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‘Health’ is not fit for purpose
OPINION
Not fit for purpose The idea of “health” has become too much of a sacred cow to challenge. Time to slaughter the beast, say Jonathan M. Metzl and Anna Kirkland WHY would anyone in their right mind be “against health”? Surely the only position possible must be “for” health? Not if you talk to a growing band of dissenting academics in disciplines ranging from history and literature to medicine and law. In a new book, entitled Against Health: How Health Became the New Morality, we’ve tried to capture some of the flavour of this critique. The basic argument is that the time has come to stand against health as currently understood. Health now means more than the absence of disease or presence of a positive state of bodily flourishing. In 2010, health also describes an ideological and commercial tool, used to make moral judgements, convey prejudice, sell products, or even to exclude groups of people from healthcare. The near-sacred status of the word has protected it from criticism for too long. We should stress here that the authors in our volume have absolutely nothing against penicillin, the germ theory of infectious illness, stem cell research, bike helmets, sunscreen, enteric-coated tablets, or a host of other advances. The objections are to the ways in which the rhetoric of health is being used to promote value judgements, hierarchies, and blind assumptions that speak as much about power and privilege as they do about well-being. This has become frustratingly clear in the US political arena, where battles over healthcare plans thinly veil divergent assumptions about health, responsibility, 28 | NewScientist | 20 November 2010
and what it is to be a person. preoccupation with health and The ideological and moral the US industries that gained functions of health also percolate financially from promoting it. down to the individual level. So Health, he reportedly said, “is the when we see someone smoking, most cherished and destructive we might say: “Smoking is bad for certitude of the modern world. It your health,” but mean: “You are a is a most destructive addiction”. bad person because you smoke.” Thirty years on, the powerful Equally, with someone whose forces controlling the health body size is deemed excessive, business are stronger than ever. we say: “Obesity is bad for your From inventing and selling new health,” when we mean: “We can’t diseases to the endorsement of hire someone who looks like you.” narrow medical specialisms, We are not the first to attack the western society – especially the notion of health. In the 1970s and US – is thoroughly medicalised. 1980s, Austrian philosopher Ivan Illich famously delivered a series “The powerful forces controlling the of lectures entitled “To Hell With health business are Health”, in which he bemoaned stronger than ever” the negative effects of excessive
At the same time, despite the promise of President Barack Obama’s reforms, average Americans must manage health risks on an individual level without much of a collective safety net. The expectation is that we will insure our own retirement through market investments earned through work (rather than relying on social security), receive health insurance as part of our employment package, and take personal responsibility for our health through diet, exercise, stress reduction, and keeping watch over ourselves, our children, and our ageing parents. One of the many ironies is that at an individual level a health imperative reinforces the presumption of personal control deeply at odds with the reality of life. Cancer, accidents, Alzheimer’s disease still strike those who do everything that they are told might save them. The illusion of total self-care and independence inflates the sense of entitlement of those who think they have achieved it, putting unbearable stress on those who can barely achieve it, and conferring second-class citizenship on those who cannot achieve it at all. At this point some people may feel like arguing that health is about empirical facts, that we are just social scientists making a fuss and that we should shut up and check out the scientific literature. These would be cheap shots. We are in the tough position of understanding scientific knowledge and morality as deeply interwoven and also as deeply
Comment on these stories at www.NewScientist.com/opinion
Jonathan M. Metzl is a psychiatrist and Anna Kirkland is a political scientist and lawyer. Both are in the women’s studies department of the University of Michigan. Against Health: How Health Became the New Morality is published this month (New York University Press)
One minute with...
Rebecca Skloot The winner of the Wellcome Trust book prize explains why she had to write about the woman behind the first immortal cell line Tell me about Henrietta Lacks, the inspiration for your book. She was a poor African-American tobacco farmer from southern Virginia. In 1951 she was diagnosed with cervical cancer. Without her knowledge, her doctor took a piece of her tumour and sent it to George Gey, who was head of tissue culture research at Johns Hopkins University in Baltimore. Gey had been trying to grow human cells for decades and it had never worked. Henrietta’s cells became the first immortal cell line ever grown in culture, which means they live indefinitely in laboratories as long as you feed them and keep them warm. Henrietta died a few months later. What, apart their immortality, made Lacks’s cells so important to medicine? The cells, called HeLa, were used to develop the polio vaccine and went up with the first space missions to see what would happen to cells in zero gravity. They were the first cells to be cloned. Her genes were some of the first ever mapped. The scientific landmarks just go on and on. Weren’t there ethical problems in using Lacks’s cells? No one told Henrietta’s family the cells had been taken until the 1970s, when scientists went to her family, wanting to do research on them, to learn more about the cells. The book traces the history of modern medicine and bioethics, but also the story of her family struggling with the aftermath of discovering what happened to her cells. One of the judges at last week’s prize ceremony described your book as being the story of “right versus right”, rather than “right versus wrong”. Can you explain? That’s a great description. On the surface, it’s easy to hear the story and think: oh, the evil scientists who took cells from this woman without asking and did bad things to her family later. But it’s much more complicated than that. The science that was done with these cells was incredibly important, and in 1951 when the cells were taken from
Profile Rebecca Skloot has a biology degree and has taught creative writing and science journalism at several American universities. Her first book, The Immortal Life of Henrietta Lacks, won this year’s Wellcome Trust book prize
Henrietta without her permission, that was absolutely standard procedure. Researchers didn’t know in the 1950s what you could learn from someone’s cells. They didn’t know they would eventually be worth billions of dollars. What was important to me in writing the book was telling all the sides of the story, showing that there are human beings behind every biological sample in the lab, but also showing there are human beings behind the science too. Are you taking Henrietta’s story further? There’s a film about her just getting off the ground. One of the producers is Oprah Winfrey. I’m a consultant on the movie and so are Henrietta’s remaining children. They’re really excited. Your father, Floyd Skloot, is an acclaimed writer. Is there rivalry between you? [Laughs] Oh no. There couldn’t be less of a sense of rivalry. It’s like the family business. We love to talk shop. He could not be more excited by it all. Interview by Clint Witchalls
20 November 2010 | NewScientist | 29
manda townsend
human constructions, while also acknowledging them to be indispensable in the modern world. So our book is not just “against” many of the current meanings of health, but “for” encouraging better conversations in our interactions with medical professionals – both intellectually and in our daily lives. Suppose a patient is discussing test results that show borderline abnormality in bone density, cholesterol, or blood pressure. The usual presumption is that the test has detected some objective feature of the patient’s body we can treat, just as if she or he had a burn or a broken bone. Perhaps there would be more tests, some drugs, and eventually a label, such as “osteopenia” or “pre-diabetes”. Shared scepticism between doctor and the patient could be helpful in removing some of the mystery from what is bound to be a stressful encounter. What did the test really measure? Would the treatment regime require giving up something pleasurable or convenient, and if so, what would all the pros and cons look like? Bringing these questions into the discussion would mean the measure of health (the test) had been “denaturalised” – that it would no longer be taken for granted and instead become something that could be critically examined. That way, alternative notions of life and health would have entered the conversation. This can only be a good thing. A process which allows the many, disparate meanings of “health” to be articulated and challenged is more likely to lead to deeper, more productive, and healthier interactions about our bodies, our politics and our desires. n
Not fit for purpose The idea of “health” has become too much of a sacred cow to challenge. Time to slaughter the beast, say Jonathan M. Metzl and Anna Kirkland WHY would anyone in their right mind be “against health”? Surely the only position possible must be “for” health? Not if you talk to a growing band of dissenting academics in disciplines ranging from history and literature to medicine and law. In a new book, entitled Against Health: How Health Became the New Morality, we’ve tried to capture some of the flavour of this critique. The basic argument is that the time has come to stand against health as currently understood. Health now means more than the absence of disease or presence of a positive state of bodily flourishing. In 2010, health also describes an ideological and commercial tool, used to make moral judgements, convey prejudice, sell products, or even to exclude groups of people from healthcare. The near-sacred status of the word has protected it from criticism for too long. We should stress here that the authors in our volume have absolutely nothing against penicillin, the germ theory of infectious illness, stem cell research, bike helmets, sunscreen, enteric-coated tablets, or a host of other advances. The objections are to the ways in which the rhetoric of health is being used to promote value judgements, hierarchies, and blind assumptions that speak as much about power and privilege as they do about well-being. This has become frustratingly clear in the US political arena, where battles over healthcare plans thinly veil divergent assumptions about health, responsibility, 28 | NewScientist | 20 November 2010
and what it is to be a person. preoccupation with health and The ideological and moral the US industries that gained functions of health also percolate financially from promoting it. down to the individual level. So Health, he reportedly said, “is the when we see someone smoking, most cherished and destructive we might say: “Smoking is bad for certitude of the modern world. It your health,” but mean: “You are a is a most destructive addiction”. bad person because you smoke.” Thirty years on, the powerful Equally, with someone whose forces controlling the health body size is deemed excessive, business are stronger than ever. we say: “Obesity is bad for your From inventing and selling new health,” when we mean: “We can’t diseases to the endorsement of hire someone who looks like you.” narrow medical specialisms, We are not the first to attack the western society – especially the notion of health. In the 1970s and US – is thoroughly medicalised. 1980s, Austrian philosopher Ivan Illich famously delivered a series “The powerful forces controlling the of lectures entitled “To Hell With health business are Health”, in which he bemoaned stronger than ever” the negative effects of excessive
At the same time, despite the promise of President Barack Obama’s reforms, average Americans must manage health risks on an individual level without much of a collective safety net. The expectation is that we will insure our own retirement through market investments earned through work (rather than relying on social security), receive health insurance as part of our employment package, and take personal responsibility for our health through diet, exercise, stress reduction, and keeping watch over ourselves, our children, and our ageing parents. One of the many ironies is that at an individual level a health imperative reinforces the presumption of personal control deeply at odds with the reality of life. Cancer, accidents, Alzheimer’s disease still strike those who do everything that they are told might save them. The illusion of total self-care and independence inflates the sense of entitlement of those who think they have achieved it, putting unbearable stress on those who can barely achieve it, and conferring second-class citizenship on those who cannot achieve it at all. At this point some people may feel like arguing that health is about empirical facts, that we are just social scientists making a fuss and that we should shut up and check out the scientific literature. These would be cheap shots. We are in the tough position of understanding scientific knowledge and morality as deeply interwoven and also as deeply
Comment on these stories at www.NewScientist.com/opinion
Jonathan M. Metzl is a psychiatrist and Anna Kirkland is a political scientist and lawyer. Both are in the women’s studies department of the University of Michigan. Against Health: How Health Became the New Morality is published this month (New York University Press)
One minute with...
Rebecca Skloot The winner of the Wellcome Trust book prize explains why she had to write about the woman behind the first immortal cell line Tell me about Henrietta Lacks, the inspiration for your book. She was a poor African-American tobacco farmer from southern Virginia. In 1951 she was diagnosed with cervical cancer. Without her knowledge, her doctor took a piece of her tumour and sent it to George Gey, who was head of tissue culture research at Johns Hopkins University in Baltimore. Gey had been trying to grow human cells for decades and it had never worked. Henrietta’s cells became the first immortal cell line ever grown in culture, which means they live indefinitely in laboratories as long as you feed them and keep them warm. Henrietta died a few months later. What, apart their immortality, made Lacks’s cells so important to medicine? The cells, called HeLa, were used to develop the polio vaccine and went up with the first space missions to see what would happen to cells in zero gravity. They were the first cells to be cloned. Her genes were some of the first ever mapped. The scientific landmarks just go on and on. Weren’t there ethical problems in using Lacks’s cells? No one told Henrietta’s family the cells had been taken until the 1970s, when scientists went to her family, wanting to do research on them, to learn more about the cells. The book traces the history of modern medicine and bioethics, but also the story of her family struggling with the aftermath of discovering what happened to her cells. One of the judges at last week’s prize ceremony described your book as being the story of “right versus right”, rather than “right versus wrong”. Can you explain? That’s a great description. On the surface, it’s easy to hear the story and think: oh, the evil scientists who took cells from this woman without asking and did bad things to her family later. But it’s much more complicated than that. The science that was done with these cells was incredibly important, and in 1951 when the cells were taken from
Profile Rebecca Skloot has a biology degree and has taught creative writing and science journalism at several American universities. Her first book, The Immortal Life of Henrietta Lacks, won this year’s Wellcome Trust book prize
Henrietta without her permission, that was absolutely standard procedure. Researchers didn’t know in the 1950s what you could learn from someone’s cells. They didn’t know they would eventually be worth billions of dollars. What was important to me in writing the book was telling all the sides of the story, showing that there are human beings behind every biological sample in the lab, but also showing there are human beings behind the science too. Are you taking Henrietta’s story further? There’s a film about her just getting off the ground. One of the producers is Oprah Winfrey. I’m a consultant on the movie and so are Henrietta’s remaining children. They’re really excited. Your father, Floyd Skloot, is an acclaimed writer. Is there rivalry between you? [Laughs] Oh no. There couldn’t be less of a sense of rivalry. It’s like the family business. We love to talk shop. He could not be more excited by it all. Interview by Clint Witchalls
20 November 2010 | NewScientist | 29
manda townsend
human constructions, while also acknowledging them to be indispensable in the modern world. So our book is not just “against” many of the current meanings of health, but “for” encouraging better conversations in our interactions with medical professionals – both intellectually and in our daily lives. Suppose a patient is discussing test results that show borderline abnormality in bone density, cholesterol, or blood pressure. The usual presumption is that the test has detected some objective feature of the patient’s body we can treat, just as if she or he had a burn or a broken bone. Perhaps there would be more tests, some drugs, and eventually a label, such as “osteopenia” or “pre-diabetes”. Shared scepticism between doctor and the patient could be helpful in removing some of the mystery from what is bound to be a stressful encounter. What did the test really measure? Would the treatment regime require giving up something pleasurable or convenient, and if so, what would all the pros and cons look like? Bringing these questions into the discussion would mean the measure of health (the test) had been “denaturalised” – that it would no longer be taken for granted and instead become something that could be critically examined. That way, alternative notions of life and health would have entered the conversation. This can only be a good thing. A process which allows the many, disparate meanings of “health” to be articulated and challenged is more likely to lead to deeper, more productive, and healthier interactions about our bodies, our politics and our desires. n