Are we creating a health pariah class?

BMJ 2004; 328 doi: (Published 06 May 2004) Cite this as: BMJ 2004;328:1141
  1. Des Spence, general practitioner (destwo{at}
  1. Glasgow

    When I was a boy my parents smoked—as did most adults who I knew. People lived and then they died. I lived in a council house and went to a comprehensive school. I ate pies, cakes, and pastries, all washed down with full fat milk. When we could afford it we ate butter, but most of the time it was Stork Special Blend margarine. We had free school dinners and I loved spam fritters, sausage pie, stew, corned beef, or meat loaf, followed by pink custard and sponge. I loved our dinner ladies, and I often had third helpings. All my spare money went on Cabana bars, crisps, and a “quarter” of boiled sweets. My first McDonald's burger sent me delirious with its flavour.

    I found that my nagging was patronising and pointless

    Regardless of the weather, we fought and played outside. When I was 16 years old I started to have the occasional cigarette, and from about 17 I drank at weekends. I tell you this not to project myself as some crazed, working class hard man from the slums, as that wouldn't be true. I do not seek your pity or sympathy but merely wish to make it clear that my childhood was like that of most other ordinary people.

    I am now educated, live in the suburbs, and am well off. I am, however, still the product of my childhood. I work as a GP in an inner city Glasgow practice in an area with some of the worst health statistics in the Western world. People in this community are either berated for their lack of self control or seen as bastions of the underclass, battling against government oppression. Neither is true. Well meaning outsiders proffer sympathy and pity. The goal of living to 85 to die on the ski slopes of Val d'Isère is beyond my poor deprived patients. Not for them the joys of low fat yoghurt, cholesterol lowering spreads such as Benecol, tofu, jogging on a treadmill, Mediterranean holiday resorts, “protected” sexual intercourse, piano lessons, Duke of Edinburgh awards, private tutors, the pride of seeing their children entering a profession, or the fun of half starving themselves to keep themselves thin. Never will they have the benefit of voyages of self discovery with a psychotherapist to try to bring meaning to their lives.

    Embedded Image

    Eschewing the joys of low fat yoghurt


    Blackpool, alcohol, chips, cigarettes, and recreational drugs beckon my patients. Obesity, chronic obstructive pulmonary disease, diabetes, ischaemic heart disease, and premature death are the few certainties in their “deprived” lives. However, many of my patients willingly choose this lifestyle and laugh loudly at people living in the suburbs. When I ask my patients what they would do if they won the lottery they say that they would buy a bigger house and car and stay in their own community.

    In my early days in practice I remember telling a patient that smoking causes serious illnesses. She picked up her packet of cigarettes, pointed to the health warning that almost obscured the entire packet, and exclaimed sarcastically, “Never!” Other responses have been “What the hell! You've got to die of something,” “I enjoy it,” “I don't care,” and a multitude of similar expressions. I found that my nagging was patronising and pointless.

    The health messages are well meaning but are projections of the values of middle class people—concerned missionaries seeking to save the poor noble savages from themselves. I worry that we are operating in a two dimensional model of medical correctness, where lifestyles that differ from the prescribed health utopia model are simply seen as wrong. Will health apartheid soon follow, where smokers, drinkers, drug users, and obese people are denied treatment? Some health professionals already think this way.

    I believe that if people choose to live their lives in a way that jeopardises their health and life expectancy, then so be it. We should stop patronising and blaming these so called deprived communities and respect the different choices they might make. We middle class people would be better spending our time addressing our self obsessed desire to make everyone else conform to our lifestyle and should confront the consuming and distorted vanity that underlies this.