Monday, 15 August 2016

Foucault's Truth - or why most public heath spending is a waste of money

I don't like what's called public health very much. Not because I think there are no environmental contributors to poor health but because what we now call public health isn't about removing things like pollution, exterminating disease-carrying vermin or making the air more breathable. It's about adopting the view that, because government funds healthcare, you have fewer rights over what you consume.

Yesterday I clicked through to a more-or-less incomprehensible blog post written (I think) by a chap called Robert Dalziel*. The post is titled "Nudge, Nudge, Public Health England and Behaviour Change" so is positioned right at the heart of what ought to be the public health debate. It even quotes a critical review of Thaler and Sunstein's 'Nudge':

Though costumed in the guise of pop economics, complete with a cute logo – Nudge is, in fact, a manifesto for the new paternalism… don’t be fooled.

So far, so good. We've a critique of nudge - what I call the sledgehammer approach to implementing behaviour insights - and the hope that the writer is going to reject such paternalism, cast aside the nannying fussbucketry of today's public health, and return the idea to its roots in making our environment more healthy. Sadly, this appears not to be the case:

So what is ‘dispiriting’ you and me Mark is an ostensibly ’arms length’ PHE resourcing and implementing a paternalistic libertarian approach to health improvement driven by the Behavioural Insights Team based on nudge theory and clearly supported by senior Tory politicians and Civil Servants.

Our writer's objection isn't a liberal objection to 'nudge' but is a belief that it's all a cunning Tory plan to undermine what's described in the previous paragraph as an "old-fashioned finger wagging approach to health behaviour change". The unmentioned issue here is the familiar one of more intervention - more bans, more taxes, more compulsion, more mandatory lessons in schools, more forced diets, more 'othering' of people who make the 'wrong' choices. All wrapped up in the cuddly pseudo-sciences of psychology, sociology and ethnography. The sneering use of the word 'libertarian' is a classic illustration of the author's ideological baggage.

This is further illustrated by the author's quoting of Foucault as his philosopher of choice:

“predicated on our societal regime of truth, the types of discourse it accepts and makes function as true; the mechanisms and instances that enable one to distinguish true and false statements; the means by which each is sanctioned; the techniques and procedures accorded value in the acquisition of truth; the status of those who are charged with saying what counts as true.”

Strip away the flash language and we have a definition of relativism. Truth isn't defined by scientific equiry but is determined by society and those who have the status to say what is true. Suffice it to say that you can't - as this author does - criticise others for using 'policy driven evidence' rather than 'evidence driven practice' and then use a post-structuralist philosopher as the supposed source of your ideology. The whole point about Foucault is that truth is defined by the prevailing ideology not vice versa - he says change the ideology not change the truth.

Looking at this, however, and we can see yet again that real scientific evidence is of no consequence to much of public decision-making in health (nudge theory, for all that I find it morally dubious, at least has the merit of some practical scientific basis). As I wrote the other day ideology - the received wisdom - is everything and no evidence that challenges this orthodoxy can be admitted:

The limited evidence we actually received was ignored in favour of signalling that we are "doing something" about obesity. This is despite that "something" being a strategy based on things like planning controls over fast food takeaways, fussing about portion sizes in restaurants and promoting inadequate dinners for primary school children. None of which ideas has any evidence demonstrating its effectiveness in reducing rates of obesity.

Put bluntly, we will (well not me but a majority of the Health & Wellbeing Board) agree to waste over £2 million of public money every year just to indulge an ideological, all-population approach to obesity that isn't justified by the data or supported by evidence. And if this is repeated across England that probably means over £200 million of your and my taxes spend to indulge the ignorant ideological vanity of public health.

When you strip public health back to its basic objectives, we're really left with one fundamental truth: the richer the society the better the health outcomes and the lower the health inequalities. Therefore, the right way to improve those health outcomes isn't nannying the hell out of us about smoking, drinking, bad sex and too many burgers but to invest in those things that make society richer. Suffice it to say that current public health spending (by local government especially) does not contribute to making us richer and is probably a complete waste of money.

I'll grant you a case for looking to improve things such as air quality and providing the means to respond to epidemics (although you'll note that epidemics are also much rarer in richer societies). Everything else. All of it. The last scrap of that nagging about salt, fussing about fags, bothering about booze and flapping about fat or sugar - all the 'interventions' beloved of the fussbuckets who make up public health. It is a waste of money.


*The post is on Mark Gamsu's blog but it's clear it's a guest posting.

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