Like many of us, I grew up with the idea that health was an individual responsibility and a moral good. It was “good” to exercise and restrict food, “lazy” or “self-indulgent” to rest and eat for pleasure. In the era when there was still a smoking section on planes (what can they have been thinking?) and we didn’t wear coats on nights out because it would have taken weeks to get the cigarette stench out, people with lung cancer “had only themselves to blame”.
The blame narrative runs deep, partly because it allows us to make false sense of an unfair world. If people with cancer or diabetes brought it on themselves, if ill-health is mostly the logical outcome of poor choices, we reduce our obligation to tolerate the way bad things happen to good people and increase the dream of control.
You’d have to be an outright fantasist to believe that everything happens for a reason or that any amount of gym-going and cake-refusal brings eternal life, but we can certainly reduce the cognitive load of living and loving by imagining that bad things happen to other people and mostly through their own negligence, weakness and deliberate fault, with the corollary idea that if only we ourselves exert sufficient strength and willpower the bad things will stay away. It’s a seductive fairy tale, and hugely profitable, especially at this time of year, for people claiming to sell us new regimes of self-discipline and willpower. But it’s not true.
According to the World Health Organisation, 30-55 per cent of health outcomes are socially determined, which means beyond individual control and set by factors including income; social protection; insecurity of housing, food and employment; social inclusion; education.
You can see in the decline of Britain’s health under Tory austerity that people get sicker and die earlier as they get poorer and have reduced access to under-resourced healthcare. Life expectancy fell. Metabolic disease and tooth decay increased. Childhood rickets is back. British children’s height is falling as their weight increases, because they’re getting a lot of energy but missing the nutrients needed for development.
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It should be obvious that this isn’t because individuals across the nation suffered a simultaneous loss of willpower which coincided with the decline of public services and widening divide between rich and poor. Across the world, in North America and Australia and Ireland and the rest of Europe as well as the Global South, poorer people live in areas with the highest levels of pollution, the least access to fresh food, safe water, good healthcare and education.
More of our health is genetically determined, and constrained or nourished by family circumstances. Regardless of socio-economic status, “adverse childhood experiences”, including all forms of abuse, neglect and parental substance misuse, mental illness and incarceration, make it harder to thrive in later life. And then bad things happen: grief can make you ill. So can becoming an unpaid carer, losing your home or career, experiencing or witnessing violence, living through natural disaster, war and civil unrest.
So we can, some of us, those privileged to be spared most of this and to live in able, unstigmatised bodies, close our eyes and insist that health is a choice and that we can control and exert our way to long life, but I can’t see how doing so constitutes “being good”. Exercise, for sure, if it feels good. I do. Eat your kale (I like it with ginger and soy sauce). Do yoga and meditate your way to serenity – it’s all fine, and doubtless will nudge you towards longer life than lying on your bed doom-scrolling and eating doughnuts, partly because if you can afford the yoga and have time and energy to wash, chop and cook the kale plus whatever else is on the plate, the social determinants of health are already in your favour.
If we really wanted to be good and healthy in 2025, we’d resolve to pester our politicians for universal access to affordable fresh food, clean water, secure housing, safe infrastructure for active transport. We’d take to the streets over the pollution of air and water. We’d be demanding well-funded public healthcare, preventive as well as reactive, and publicly raging over social injustice and health inequality. The rest of it is just more individual solutions to structural problems, and it won’t change anything.