It has become almost a commonplace to note that though we live longer and healthier lives, we are also more concerned about our health than ever before. Whilst many commentators have written on different aspects of this paradox , there has until now been no satisfactory survey of the whole. Fitzpatrick gives us, from his perspective as a GP, the most penetrating analysis yet published of the rise of the New Public Health, and of its dangers for patients, doctors and the relationship between them.
Fitzpatrick presents a history of the way that health has become a major personal and political topic, by looking at the different health scares of the last few years, the screening tests and 'healthy living' recommendations that have been introduced and accepted in spite of dissenting academic criticism We are all familiar with instructions to eat healthily (just why is it five or six portions of fruit or vegetables per day anyway?), drink a certain number of units of alcohol a week, take exercise, and subject ourselves to screening tests of dubious efficacy . However, it is only when we are confronted by the whole panoply of measures that we realise how far things have gone and how rapid the pace of change has been. The result is that we now tolerate, if not actively seek out, a level of interference in our personal lives which would have been unthinkable even ten years ago.
How to explain the astonishing success of the new public health amongst doctors and the public? A cynic would say that there is a straightforward financial motive for many doctors' enthusiasm for these measures, and though there is some truth in this, it is not the most important part of the story. Fitzpatrick provides an excellent account of the gradual process by which the medical profession has lost confidence in itself, as the old arrogance has been replaced by acute self doubt. The crisis of modern medicine is graphically illustrated by the volte face of the BMA in its attitude to alternative medicine: from a defiant defence of the 'demonstrable and reproducible benefits' of orthodox medicine in 1986 to a posture of 'abject relativism' in response to 'complementary ' approaches only seven years later .
Fitzpatrick also considers why health has become such a public concern over the last decade or so. This section is short and thus appears
somewhat schematic but does provide the basis for further work. Many commentators have noted that the ending of the Cold War has thrown up massive problems for the old ideologues of the West, as the initial triumphalism rapidly evaporated to be replaced by a general feeling of stagnation. Fitzpatrick notes that '[c]hanges in society now appear no longer to be the result of conscious or planned human activity , indeed things appear to be out of control'. At first sight this may seem exaggerated, but then think of the almost mediaeval suspicion with which GM food has been greeted. In these circumstances, any hope of achieving progress in society is just not on the agenda , and the retreat to narrow concerns about health is understandable. It is also understandable that the government should take advantage of concerns about health to strengthen its grip over an increasingly fragmented society The result , as Fitzpatrick puts it, is that 'when health becomes the goal of human endeavour it acquires an oppressive influence over the life of the individual'.
In the short term, the trends identified in The Tyranny of Health are likely to get worse . Only last week a distinguished cancer specialist was advocating that men over 50 (a category in which I have recently acquired a vested interest) should abstain from sexual intercourse and thus cut their risk of cancer of the prostate . Indeed the prostate looks set to become the organ of the decade, although I fear that until we have acquired our own distinctive ribbon we cannot compete with the other cancers.
How then to reverse the tyranny of health ? Fitzpatrick recognises that this book is very much a preliminary work , but it does lay the basis for future work which should be aimed at defining the links between, on the one hand, the tyranny of health and the crisis of medicine, and on the other, the stasis of the new world order. The medicalisation of life and the politicisation of medicine should both be resisted, for as he puts it '[i]n the absence of a forceful movement from below, medical intervention becomes a vehicle of government policy, not politics writ large, but politics on a small scale, petty, intrusive and moralising'. Fitzpatrick is certainly not against the idea of doctors being involved in the politics of health , but he emphasises the importance of maintaining clear boundaries. Doctors should reassert their autonomy from the state and '[d]octors who aspire to a wider political role, would be best advised to pursue this, not in their surgery, but in the public sphere. At a time when health has become such a political issue, he insists that 'the first responsibility of a doctor as a doctor is to provide medical treatment for individual patients'.
On first inspection, this book appears similar to Petr Skrabanek's The Death of Humane Medicine (1994). But Skrabanek's' critique, though often perceptive, was that of a cynical, detached libertarian,. Mocking his gullible medical colleagues and expressing a certain contempt for the general public, his approach was ultimately sterile. In contrast, Fitzpatrick's is a much more serious work. It is a major contribution to our ideas of health and disease at the begining of the 21st century, which deserves to be considered alongside contributions by writers such as Susan Sontag and John Berger .