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The dominant discourse within neoliberal health policy has been that of the autonomous individual, in which each individual is an agent, responsible for his/her own health. The ideology of individualism dictates that each person is motivated by self-interest to elevate his/her well- being with the least effort and resources possible. Deep within the ideological substratum of modern culture lurks the credo of individualism – ‘each man for himself’ – making his/her choices, and taking the consequences, as in: ‘You made your bed, now lie in it.’ Theories in health psychology are imbued with this cultural presumption. The existential truth of ‘do or die’ is embellished in polite language as ‘making informed choices’.

The cult of the individual has spawned the notion of the responsible consumer (RC). The RC is an active processor of information and knowledge concerning health and illness. He/she makes rational decisions and responsible choices to optimize well-being. The epitome of the RC is the hypothecated ‘anything in moderation’ person who eats five-a-day, never smokes, drinks alcohol in moderation, exercises vigorously for at least 30 minutes three times a week, always uses a condom when having sex, and sleeps eight hours a day. The stereotype of the more common ‘irresponsible consumer’ (IC) is the so-called ‘couch potato’ who enjoys beer and cola, smokes, eats junk food, watches TV for many hours each day, and rarely takes exercise. Accordingly, responsibility for illness relating to personal lifestyle is seen as the fault of the individual, not an inevitable facet of a social, corporate, economic environment designed to maximize shareholder profits.

Using a mixture of well-intentioned pleading, information and advice, the traditional approach to health education aimed to persuade people to change their habits and lifestyles. Information campaigns designed to sway consumers into healthier living were the order of the day. Combined with policy and taxation, health education justifiably can claim some limited success over the last 50 years, e.g., the fall in lung cancer rates. Tobacco control has become a benchmark for what may be achieved through consistent public policy, educational campaigns and behaviour change. A major public health call today is for a vigorous campaign to halt the obesity epidemic. If similar methods are deployed to those used for tobacco (i.e., voluntary controls, advertising restrictions, product labelling, health education), then the evidence suggests that it could take at least 50–70 years before obesity rates can be expected to go into any noticeable decline (Marks, 2016b).

In recent decades, appealing to the right-minded ‘anything in moderation’ consumer has been prevalent throughout health care. The prescription to live well has always had a distinctively moral tone. Health promotion policy has been portrayed as a quasi-religious quest, a war against the deadly old sins of gluttony, laziness and lust. Discourse analysis of public health policy statements makes this fact all too clear (Sykes et al., 2004).

The demise of the construct of the RC is imminent within health policy. Common observation and decades of research show that people are really pushed and pulled in different directions while exercising their ‘freedom of choice’. Emotions and feelings are as important in making choices as cognition. The beneficial satisfaction of needs and wants must be balanced against perceived risks and costs. Health policy is beginning to acknowledge both the complexity of health and the power of the market. Human activity is a reflection of the physical, psychosocial and economic environment. The built environment, the sum total of objects placed in the natural world, dramatically influences health. The ‘toxic environment’ propels people towards unhealthy behaviours, directly causing mortality and illness (Brownell and Fairburn, 1995).

Government policy documents in the UK indicate that the reliance on consumers as responsible decision-makers has been waning, but it remains a primary strategy. The environment and corporations are being given a larger role. In Healthy Lives, Healthy People: Our Strategy for Public Health in England (Department of Health, 2010: 29), the government stated:

2.29 Few of us consciously choose ‘good’ or ‘bad’ health. We all make personal choices about how we live and behave: what to eat, what to drink and how active to be. We all make trade-offs between feeling good now and the potential impact of this on our longer-term health. In many cases, moderation is often the key.

2.30 All capable adults are responsible for these very personal choices. At the same time, we do not have total control over our lives or the circumstances in which we live. A wide range of factors constrain and influence what we do, both positively and negatively.

2.31 The government’s approach to improving health and wellbeing – relevant to both national and potential local actions – is therefore based on the following actions, which reflect the Coalition’s core values of freedom, fairness and responsibility. These are:

 strengthening self-esteem, confidence and personal responsibility;

 positively promoting ‘healthier’ behaviours and lifestyles; and

 adapting the environment to make healthy choices easier.

In the above policy document, personal responsibility remains at the top of the agenda. The statement that ‘we do not have total control over our lives or the circumstances in which we live’ is a small step forward but, unfortunately, taking two steps back negates this. Only holistic public policies can lower the toxicity of the environment, and to declare otherwise is a cop-out. Yet large corporations are engaged as the new allies of health promotion in the twenty-first century. The UK government enlisted the food industry, including McDonald’s and Kentucky Fried Chicken, among other corporations, to help to write policy on obesity, alcohol and diet-related disease (MailOnline, 2010). Processed food and drinks manufacturers, including PepsiCo, Kellogg’s, Unilever, Mars and Diageo, were contributors to five ‘responsibility deal’ networks set up by then Health Secretary Andrew Lansley. In a similar sponsorship arrangement to previous Olympic Games, McDonald’s and Coca-Cola sponsored the 2012 London Olympics. This is putting foxes in charge of the hen house!

In the USA there has been a similar shift in thinking: the ‘anything in moderation’ philosophy of responsible consumption is no longer the principal foundation for public health interventions. The Surgeon General’s Vision for a Healthy and Fit Nation states:

Interventions to prevent obesity should focus not only on personal behaviors and biological traits, but also on characteristics of the social and physical environments that offer or limit opportunities for positive health outcomes. Critical opportunities for interventions can occur in multiple settings: home, child care, school, work place, health care, and community. (US Surgeon General, 2010: 5)

In twenty-first-century health care, the opportunities for health psychological interventions to assist within the major settings has never been greater. But one must ask whether the discipline is fit to meet these challenges. Alternative methods must be tried and tested if we are to make in-roads into the massive scale of issues on the public health agenda.

Economic analyses use gross domestic product (GDP) as a measure of output and, to a degree, an indicator of welfare also (Oulton, 2012). GDP measures the value of goods and services produced for final consumption, private and public, present and future. Across countries, GDP per capita is highly correlated with important social indicators. GDP is positively correlated with life expectancy and negatively correlated with infant mortality and inequality. One of the most traumatic events in anybody’s life is the loss of a child, and infant mortality rates might be thought of as a proxy indicator of happiness. Figure 4.1 plots infant mortality against per capita GDP for a large sample of countries. The graph shows that richer countries tend to have greater life expectancy, lower infant mortality and lower inequality. As always, it is important to state that correlation is not necessarily causation, although there is strong evidence that higher GDP per capita leads to improved health (Fogel, 2004).

Figure 4.1 Infant mortality versus household consumption per head across 146 countries

Source: Oulton (2012)

A key component of subjective well-being and quality of life is employment. A strong relationship exists between these factors. Unemployment brings stigma, lowered self-esteem and mental health problems, especially depression and feelings of low self-worth (Warr et al., 1988). In some cultures, for example in Japan, a particularly strong correlation exists between the suicide rate and unemployment rate among men (Chen et al., 2012). Under a blanket of statistics lies a multitude of individual calamities.

Population growth and the scourges of unhealthy commodities, unemployment, poverty and inequality place their fingerprints over human existence. In charting the macro-social environment for health, we consider the transitions that have accompanied the globalization of unhealthy commodities, population growth and widespread poverty; we briefly discuss inequalities both within and between societies, and the inequities that exist between genders and ethnic groups. In the following chapters, we take up social justice issues in more detail (Chapter 5) and explore the significance of culture (Chapter 6).