Deborah Orr: The mantra of market forces blames the victims and excuses the most powerful

Alcohol-related diseases, obesity and smoking disproportionately affect the poorest and least educated
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The Independent Online

A poll by the private health company Bupa has found that a lot of people think those who smoke, drink or are obese should be charged for NHS treatment. It's easy to see where this groundswell of piously judgemental opinion comes from. Only the saintly among us has never felt the ghost of a sneer at the sight of a fat man scoffing a burger, or a grimace of repulsion at a smoker coughing her lungs up.

Such punitive attitudes are encouraged, often with the best of intentions, even by government - and charity-sponsored health campaigns that urge us to take responsibility for our own bodies. Often though, in seeking to make people repulsed by their own habits, they instead make those people all the more repulsive to most of the rest of us. Being the loser berated for smoking doesn't help you to stop. It makes you feel even more rubbish about yourself, and those around you even more impatient with your pathetic failures at control. This may be part of the reason why public health campaigns have such limited results.

The reverse psychology doesn't end there. The photographs of endless "binge drinkers", always female, sprawling on the pavements with their novelty antennae rakishly askew, has probably contributed hugely not only to the idea that such people should pay for their health care, but also that they "deserve" to be raped. The knots of smokers, huddled outside their offices, surrounded by the smelly detritus of their pointless, addictive habit, is always a good advert of the pathetic lengths such fools will go to. And the avalanche of magazine stories about people who have dropped 28 dress sizes sends out the constant message that fat people are just thin people with no will-power, even as the obesity figures swell like western tummies.

If one needs more assurance about the generalised confusion about these seemingly straightforward health issues, then look at the current public debate around them. The Cabinet recently found itself in open revolt over whether to ban smoking in public places. The police and emergency services appear quite terrified by the prospect of 24-hour licensed drinking, even though it starts tomorrow. And even Jamie Oliver has been unable to do more than dent the unhealthy eating habits of our nation's precious children.

It's at the legislative level that you see most clearly where the problem really lies. All the above clashes of opinion are about the same thing: the question of how much individuals interacting with markets should be left to decide things, and how much governments should intervene. There's plenty of money to be made from drink and fags and food, and the Government's confusion stems from its wish to strike a balance between stimulating free markets and its belief that it ought to be protecting the public health.

By encouraging such a punitive attitude in the culture, yet intervening very lightly, the Government might be said to be having its own cake and eating it. Current policy allows the exploitation of the most vulnerable, while fostering the idea that the most vulnerable only have themselves to blame. Statistics, surveys, and the evidence of our eyes tells us that obesity, smoking, and alcohol-related illness disproportionately affect the poorest, the least educated, the youngest and - increasingly - the female. Those who can best afford to pay for health care are the ones least likely to need it.

The wish for penalties to be introduced into the NHS suggests that people are open to the idea of market mechanisms regulating public services, even though there is actually little or no logic in doing so, and even though such an undertaking is likely to exacerbate rather than soothe existing problems. But there are also signs that people long for more intervention from the Government, with a whopping 84 per cent of respondents wanting "more government regulation of food manufacturers" and 73 per cent favouring a "crackdown on media advertising of unhealthy lifestyles".

Unfortunately, these latter are mere gestures, as indicative of a failure to grasp the real issues as the initial finding that a third of those surveyed wanted treatment charges to be introduced. What smoking, drinking and over-eating have in common is of course that they are addictive or compulsive behaviours - illnesses, in fact. Suggesting that people should be charged for health problems relating to their compulsive behaviours is pretty much the same as suggesting that the suicidal should pay for having their wrists stitched up.

And while these three compulsive behaviours have lately been dominating the public debate, plenty more of them are becoming more and more common. Addictive and compulsive behaviour of all kinds are on the increase, from addictions to online gambling - and online pretty much anything - to the compulsive behaviour so many people have around shopping and which exists in a symbiotic relationship with the media, thanks to its relationship to advertising, and the Government, thanks to its marvellous effect on the economy.

Increasingly, one sees that people use their cars compulsively as well, for journeys that are entirely unnecessary. It makes no more sense to make a fat person pay for his hip operation than it does to make a driver pay for their knee to be pinned together because he was driving down a perfectly good bus route, or a cyclist to pay for his brain operation because he chose not to wear a helmet (though there's a piece of legislation waiting to happen).

The depressing fact is that far from starting to charge to treat the physical symptoms of addictive and compulsive behaviour, the NHS has to start looking at its attitude to mental as opposed to physical illnesses, and stop stoking prejudice by continually presenting certain addictive behaviours as a lifestyle choice. It is telling that while most people are able to perceive the eating disorder anorexia as a mental illness - because it swims against the tide of greedy consumption that we are exhorted to join - it is harder to see diseases of consumption as anything other than self-indulgence.

Again, this is something over which we are deeply confused. It is now considered something of a throwback to the politics of envy if you berate conspicuous consumption among the wealthy, or suggest that the insatiable appetite for fuel displayed by industrial economies is killing us all. This, it seems, is the ultimate free market hypocrisy - turning a blind eye to the wholesale despoliation of an entire planet, while at the same time telling the most exploited and powerless members of this rampaging society, who are able to despoil nothing much except their own bodies, that it is they who are the problem. That's the trouble with the mantra of market forces and individual responsibility. It excuses the powerful, and blames the victim. This survey from Bupa does just the same.