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                                                                              RADIO 4
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ANALYSIS  
LOOK AFTER YOURSELF

TRANSCRIPT OF A RECORDED 
DOCUMENTARY

Presenter: David Walker
Producer:  Dennis Sewell
Editor:  Nicola Meyrick


BBC 
White City
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020 8752 6252





Broadcast Date:   04.03.04 
Repeat Date:        07.03.04
Tape Number:      PLN408/04VT1009
Duration:              27’42”


Taking part in order of appearance:

Anna Coote
Director of Public Health, the King’s Fund

Sian Griffiths
President of the Faculty of Public Health Medicine

Geoff Rayner
Chair of UK Public Health Association

Kate Fox
Director of Social Issues Research Centre, Oxford

Mike Kelly
Director of Evidence and Guidance for Health Development 
Agency

Jonathan Wolff
Professor of Philosophy at University College, London





















WALKER:	If you smoke, drink, eat fewer than 
five portions of fruit and veg a day and if your body mass index is outside 
the green zone on the nurse’s chart, you’re currently the focus of reports 
galore and frantic policy making. Anna Coote, director of public health at 
the think tank, the King’s Fund, is mighty busy.
	
COOTE:	I would say that there’s more interest 
now in improving population health than there has been at any time since 
I’ve been engaged in public policy work, which is going on for fifteen 
years now.  And before that.  I mean, as far as I’m aware - I think probably 
since they worked on the drains in London. 

WALKER:	In the 19th century?  Seriously?

COOTE:	Mmn.

WALKER:	Why?  

COOTE:	Well I think it’s to do with a moment 
where the government, the Treasury in particular, have woken up to the 
fact that they cannot go on pouring money into the bottomless pit of the 
NHS to look after people when they’re ill and that there is a link between a 
healthier population and the volume of demand on NHS services which 
will, if the health of the population is improved, help to reduce spending on 
the NHS in the future.  They’ve woken up to that. 

WALKER:	There’s an avalanche of official 
inquiries. Last week Derek Wanless told chancellor Gordon Brown how 
changing behaviour now could slash NHS costs a generation hence. The 
prime minister’s strategy unit is due to report on the demon drink. Alcohol 
is tricky. What goes on in pubs may damage health but also help regenerate 
inner cities.

For some doctors the blue light is flashing. Four out of five deaths under 
the age of 75 are down to diseases where diet, exercise and smoking play a 
major part. Two thirds of English men are overweight; one in seven 
children is obese. Those are epidemic proportions says Sian Griffiths, 
president of the faculty of public health medicine.

GRIFFITHS:	If you look at an epidemic of 
communicable disease, you see the numbers suddenly go shooting up.  If 
you just expand the timescale, the obesity picture looks almost the same; 
the numbers are going shooting up.  It’s then what’s the intervention that 
controls the disease which will make it fall again.  Now for obesity, we 
think we’re still on the epidemic curve increasing – we see no movement.  
So if you look at it just as a sort of pattern of disease, what it does it says 
there is an issue here, we need to act.

WALKER:	While new strains of influenza or 
SARS give rise to real epidemics, crisps aren’t infectious. So yes, it is 
different now says Geoff Rayner, chair of the UK Public Health 
Association.

RAYNER:	We’ve moved into the terrain of 
what’s called in the jargon non-communicable diseases – for the rest of us 
chronic disease.  And if you look at a society like America where over two 
thirds of the population is overweight, where despite their enormous wealth 
they’re having to spend more and more and more of the public purse and 
the private purse on healthcare and it’s projected that by 2011 some 17.4 
percent of the American GNP – this is a fabulous figure – is going to be 
spent on healthcare, now a lot of that is the consequence of chronic 
diseases.  Some of it is technology, some of it is ageing, but a lot of it is 
this huge influx of the new type of disease since roughly the 1960s and 70s.  
Obesity is the most visible form of it.  It’s certainly a consequence of the 
new consumer society where people get rather detached from old patterns 
of nutrition and lifestyle and enter into a new era of commercialised 
entertainment, commercialised lifestyles, if you like, and commercialised 
food.  It’s caused this thing that we refer to as the obesegenic society – a 
world all around us which makes it difficult for individuals to exercise real 
choices over their diets.  We have, on the one hand, a culture of 
individualism; on the other hand more and more difficult for people to 
exercise full individual choices.  That’s the paradox.   

WALKER:	And if Geoff Rayner’s right, we need 
to watch what’s really at stake in this new public health debate. If it were 
just the Treasury getting us to eat apples so we don’t turn up in the diabetes 
clinic 20 years hence, that’s fiscal common sense. But there’s more. At 
issue are the nature of choice, the balance of public and private, individual 
interest and collective consequence, adaptation to affluence. What I’d like 
to diagnose in this programme is public health as a symptom, maybe a 
proxy for things that dare not speak their name, class and inequality for 
instance.

Kate Fox is director of the Social Issues research centre in Oxford which, 
it’s open about this, will research questions posed by the food industry. 
Such as health scares. She’s an anthropologist and looks at behaviour over 
the long, evolutionary haul.

FOX:	The problem is that we as human 
beings are designed to in effect, programmed by our evolutionary heritage, 
to take risks, and in effect to be comfortable in our lives with a certain level 
of risk.  There’s almost a sort of risk homeostasis.  And the problem is that 
we are living longer and healthier and safer lives than we ever have before 
in human history and in a sense the fight flight muscle needs exercising.  
It’s why we take up dangerous sports … in affluent societies take up 
dangerous sports like bungee jumping and skiing and so on.  Quite frankly, 
if our ancestors back in the Stone Age had adopted the precautionary 
principle, we wouldn’t have had fire, the wheel.  All of these things 
required taking risks.  I mean now, if we looked at the invention of the 
wheel, we wouldn’t do it if we adopted the precautionary principle.  We’d 
say ooh gosh, that could cause a lot of problems.  Fire – whoah, dangerous, 
don’t do it.  But the fact is as a species we are programmed to be risk takers. 



WALKER:	Health scares pander to our need to 
frighten ourselves, she’s saying; could it even be that by diverting us from 
risky behaviour, health promoters stop us learning from error? Ubiquitous 
but not necessarily consistent diet and health messages, in the media, from 
the government, ought to carry a health warning.

FOX:	I think we need to take a step back 
from this kind of elitist moralising of the sort of making working classes 
eat up their greens and so on, assume that everyone is just as intelligent as 
you are in terms of their response to these kind of messages, take a step 
back and actually start to look rather more seriously at the causes of obesity 
because it just isn’t as simple as banning this or warning people about that.  
The rise of obesity has paralleled the rise in heavy-handed messages about 
what we should and shouldn’t eat, and to say that people are becoming 
obese in spite of all of these health messages, it might be more sensible to 
turn that on its head and look at perhaps people are becoming more obese 
because of the kind of fear of food, obsession with food that is being 
promoted.

WALKER:	And do those who link obesity (as a 
number of other conditions) with low income and social class and say that 
many of these problems are actually problems of inequality, you would 
say …?

FOX:	I would agree entirely with that.  I 
mean I think tackling child poverty is obviously a lot more expensive.  I 
mean the problem is that we’re talking about families on low incomes, 
working mothers.  These are the people who have less time and less money, 
who can’t go out and buy all these wonderful organic ingredients and so on 
that are so much better for you because they can’t afford them.  And also 
harassed, overworked don’t have the time to prepare perfectly balanced 
meals and so on every evening and simply telling them that packaged food 
and fast food and so on is bad is supremely unhelpful and isn’t going to do 
the slightest bit of good.  But the trouble is that tackling inequalities and 
poverty is a lot more expensive and less dramatic than having yet another 
health promotion campaign.

WALKER:	It’s striking how under the label of 
“health”, we talk about things -- social division for example -- that 
otherwise are considered taboo. Kate Fox’s phrase about the working 
classes eating their greens is anachronistic but also a reminder that some 
social facts don’t change, more sickness in lower income households for 
instance. Mike Kelly is director of evidence for the Health Development 
Agency, the government body charged with getting out messages about 
good practice. What is this: a health or a class debate?

KELLY:	While over the last fifty years we’ve 
seen the health of the population of Great Britain improve as a whole, 
generally speaking, on whatever measure you use – quality of life, early 
death or anything else – at the same time, especially in the last thirty years, 
we’ve seen the gradient in inequalities – in other words the difference 
between the most advantaged and the least advantaged in health terms 
getting worse.  And that’s the key conundrum in public health: the overall 
improvement – things getting better and better – but, at the same time, for a 
significant proportion of the population things either not getting better at all 
or actually getting worse.

WALKER:	If a principal source of bad health is 
associated with economic circumstance, shouldn’t one attend to the socio-
economic condition of people – how much money they’ve got basically – 
rather than worry initially about their health?

KELLY:	Oh certainly.  There’s no doubt that 
the relationship between the economic circumstances is more or less a 
direct one, but  - as always - the picture’s slightly more complex than that.  
When you have a situation in which the causes of death are directly 
attributable to the extremes of poverty and therefore to things like 
infectious disease, then the broader social structural factors, which can be 
led by direct government policy in housing and social circumstances, have 
a very significant and big effect.  When you move into an environment 
where the causes of death are attributable to non-infectious diseases – and 
presently that, of course, means death rates from coronary heart disease and 
cancer – the social conditions still are very important but they seem to play 
a less immediate and less direct role than they did in an earlier historical 
period.  So as we move into the 21st century, we have to take on board not 
just the structural factors but also the factors relating to the way we deliver 
healthcare, access to healthcare and of course individual behaviour.

WALKER:	Here we’re not just into politics but 
the texture of consumer society. Sociologists tell us some young people 
derive their very identity from leisure and what they do on a Friday night: 
that means they are what they drink. Should government stop them? Can 
we, at one and the same time, extol people’s right to choose how they live, 
what they buy, the proof of the alcopops they consume and say the State 
should step in when choice harms health?

KELLY:	Yes of course we’re all capable of 
making choices and yes of course to suggest otherwise would be 
patronising, but there is a sting in the tail of that which says you know 
when we make those choices for some of us it’s a great deal easier and we 
can draw upon a great many more resources both economic, intellectual 
and otherwise in order to make those sorts of things effective.

WALKER:	Are we in danger of being mealy-
mouthed here? Is the link between income and ill health causal or are 
cultural factors at play? Does anyone dare say that low income households, 
formerly called working class, can’t be trusted in the supermarket aisles or 
the off licence cabinets? Anna Coote of the King’s Fund.

COOTE:	Why do people so-called choose to 
have McDonalds every day?  What are all the things that you would need 
to do if you wanted to give a family in a disadvantaged neighbourhood the 
choice, a real choice to choose something other than cheap junk food?  
Now if you think back along the pathway that would lead to that choice, 
there are plenty of things that government and organisations in the 
community could do to make that choice an open choice and not a closed 
one.  It’s certainly not only about the price of the food.  It’s about what you 
know, it’s about how much time you’ve got, it’s about how far away from 
your home the food is, about the convenience of being able to buy it and 
cook it.  So all those things.  It’s about the way that children’s tastes are 
developed in their early life.  So all sorts of things can be done to affect 
that - the most obvious being school meals.  Most schools do not feed 
children very nutritious meals.  Most schools do not for, often for 
understandable reasons, put a lot of energy into giving children the 
education that they might need that would enable them to choose healthier 
food to eat because it’s not a priority.

WALKER:	Some people might say that’s 
idealistic. It certainly tells us that doing anything about health-related 
behaviour is going to be hugely complicated. It will involve communities 
(assuming they exist), school meals, buses to shops, women’s time and so 
on. 

But have we answered the jibe about public health being essentially an 
elitist business in which those who know what’s right tell others how to 
behave?  The people who make it often also say choice is unbounded. And 
of course it isn’t: diet depends on income; in a market society resources 
constrain choice all the time. Why not make a virtue of controlling choice, 
asks the philosopher Jonathan Wolff, a professor at University College, 
London

WOLFF:	If government wants to change 
people’s behaviour, what it needs to do is to make it easier for people to act 
in the ways that they want those people to act.  It takes incredible self-
sacrifice for a young kid to buy salad rather than fish and chips at 
lunchtime, but if salad was all that was on offer then it would be much 
easier for them to do the right thing.  So it’s a matter really of creating the 
sort of structures in which people can make the right choices without 
sacrifice rather than giving them a wide array of things and then expecting 
them to choose in a sacrificial way.

WALKER:	Government is increasingly trying to 
set an example. Prison and NHS food is being scrutinised and ‘healthy 
choices’ flagged up. But for the public at large a precondition of a 
government-ordered diet of lettuce is confidence that Whitehall, or local 
authorities or primary care trusts do know better. In other words we accept 
medical expertise, experts’ superior knowledge and the state’s veracity. 
Better them, some might say, than the makers of that soup found the other 
day to be saltier than the ocean. Geoff Rayner listens to a cacophony of 
voices, advertisers among them, seducing us with biscuits and crisps.

RAYNER:	I see that there are two types of health 
promotion in the country.  There’s the sort of the anti-health promotion – 
the negative health promotion, which is this mass, this wall of information 
projected at children and everybody to consume this, consume that, 
particularly crisps, sugary drinks, fatty foods, salty this, salty that.  All of 
these things have constituents in them we don’t know about, we’re not 
informed about.  We don’t know how much salt there is in a loaf of bread, 
but it’s likely to be twice as much as we actually should have.  So while 
we’re told we’re making informed choices, it’s quite the opposite.  These 
choices are made in laboratories.  You know , they’re made by marketing 
people and they’re sold to us as all we have to is exercise our choice in the 
marketplace and our problems are solved.  That’s a fantasy world really.  If 
we really looked into it and looked into our souls, we know it’s very 
difficult to actually take the healthy choice.  And we’re all affected.  I am 
tempted by a packet of kettle fried whatever crisps as much as anybody 
else and it is difficult to resist.  So I don’t think we should make the 
separation of the middle classes, who are well informed, except the middle 
classes have more control over their lives.  They feel more secure.  They 
are less tempted because they feel ‘we’ve actually achieved something.  
We can control that, therefore we can control this’.  So often they can’t.

WALKER:	But what is he saying about those 
tempting crisps. Should they just tell us how much salt and fat they contain 
(and packets these days are pretty informative) or is he saying that 
government should ban them from the shelves? That could sound not so 
much like nanny as big brother. The proposal here is for a significant 
extension of the State’s remit and a corresponding reduction in individual 
autonomy and market discretion. Anna Coote thinks we’re at a tipping 
point.

COOTE:	I don’t think we should underestimate 
the value of getting really strong messages from central government, which 
we are now beginning to hear.  I don’t know how long this is going to go 
on for, but while it’s here let’s be optimistic.  I do think government could 
be a lot more bold about it and what it does about some of the commercial 
interests.  For example, if you take food producers and retailers, the 
government should put more pressure on them by saying, look, if you 
haven’t got your house in order, if you’re not going to reduce the content of 
fat and sugar and salt in your products by let’s say two years, we’ll give 
you that length of time to do it voluntarily; if you don’t do it , we’re going 
to legislate.

WALKER:	Here’s a muscular prescription for 
state intervention. If leaks about a “fat tax” are at all accurate, it’s  one Dr. 
Blair is at least considering. But I wonder if there’s anything yet like a 
consensus on the public’s part to underpin such an extension of the welfare 
state.  Some medics are unabashed advocates of action. And they don’t just 
mean posters and television advertisements. Our crusader is the public 
health doctors’ president, Sian Griffiths.

GRIFFITHS:	I don’t think just relying on people to 
change their behaviour will improve health because I think that we know it 
doesn’t work.  I don’t think just providing information will change 
people’s behaviour in terms of health consequences upstream because, 
again, well so far we haven’t seen it working.  What we need is to have 
environments that are health promoting, and to have an environment that’s 
self-promoting you have to address issues around social inequalities as well 
as issues like advertising on television which is sort of generic and not 
particularly class biased.  But there are particular issues, if you’re looking 
at the public’s health, where you have to look at the impact of disadvantage, 
be it for an age group like older people or be it for an ethnic minority group 
or be it for unemployed people or be it for people who are just less well off.  
From a public health perspective, I would find it very hard to say to you 
that inequalities don’t matter, social factors don’t matter.  And I think that 
it may be seen as inherently Left Wing.  However, for me it’s just an 
analysis of how you improve the population’s health. 

WALKER:	State activism, so the doctor orders, is 
of two kinds: direct intervention in markets and over consumer choices 
plus measures to address inequalities. That, as Sian Griffiths admitted, is to 
take a distinct political position, which many doctors of course don’t. 
There’s an argument about political hygiene here, too. Health should not be 
used as an excuse. If it’s about the size of government, control of markets 
and constraint of individualism, let’s confront those old and big questions 
directly. 

But all that may be premature. There are distinct limits to what 
governments can do even if they wanted to. If we don’t trust them, why 
pay attention to public health broadcasts? Sex, drugs and chips may even 
acquire allure when they urge us to say no. Kate Fox of the Social Issues 
Research Centre looks quizzically at what the record shows about our 
willingness to heed safety advice.

FOX:	We found three quite separate and, to 
some extent, contradictory side effects.  The majority of people suffer from 
what I call warning fatigue – in other words they become desensitised, 
habituated to these kinds of messages.  And that is a dangerous effect in 
itself because obviously it’s like crying wolf: when there is really a wolf, 
sorry you’ve lost your audience.  If you think about it, if the Doll Peto 
research on smoking and lung cancer were to come out now, how would 
anyone be able to distinguish that from the background noise of mobile 
phones are going to fry your brains, GM foods are going to turn you into 
Frankenstein’s monster, etcetera, etcetera, that are coming out everyday?  
It’s impossible for most people, myself included a lot of the time, to 
distinguish between sensible messages and background noise of over 
zealous and over productive health promotion.  But there’s a second effect, 
which is almost the opposite of that – a slightly smaller group of people, 
largely middle class, who seem to suffer from something we call risk factor 
phobia.  In other words rather than being desensitised they, if anything, 
become hyper sensitised to these kind of messages and start becoming 
neurotic, hypochondriac, worrying about the risk factors inherent in 
everything that they eat or drink or breathe or touch. And these are the kind 
of people who would have responded when there was in 95 the pill scare.  I 
think there was a nine percent rise in the abortion rate and that was you 
know your risk factor phobics seeing one scary headline about the pill, 
going off the pill and getting pregnant.  Also something that doctors call 
muesli belt malnutrition – you know mothers who are sort of feeding their 
children low fat, high fibre diets that are quite inappropriate for young 
children, so actually becoming malnourished in this land of plenty.  The 
third side effect is well known – the forbidden fruit factor – and this is one 
of the main reasons why a lot of these kind of heavy-handed campaigns 
simply don’t work.  It’s because people – myself included – tend to 
become defiant.  Rise in teenage smoking is almost parallel with a rise in 
heavy-handed anti-smoking campaigns.  I would put myself firmly into that 
category.  I don’t like being told what to do and I tend to do the opposite 
almost out of a sense of perverseness.  

WALKER:	The prime minister’s own strategy 
unit has just published a report noting how even when offered information 
and guidance a significant proportion of people don’t choose the healthier 
option. Their lives are just too complicated or they are downright perverse. 
So while experts, the government, know more in general, they may lack a 
prescription for individual circumstances. Philosopher, Jonathan Wolff.

WOLFF:	The State or state scientists can know 
things that the rest of us don’t know.  Knowledge about sexually 
transmitted diseases, for example, is perhaps the modern equivalent – that 
there are sexually transmitted diseases that are initially symptomless and 
without publicity campaigns the public simply wouldn’t have known about 
this, which would have led to – and perhaps is leading to – massive 
increase in infertility among a generation.  And so there is technical 
knowledge that the government can have and that we still need public 
health measures to protect us, so there are very large areas where the 
government can claim some sort of superior knowledge still.  I think that 
we still don’t know enough about nutrition and fitness to know what is 
good for people in the long-term.  I mean when I think about my own 
medical problems, most of these are the result of trying to keep fit and if I 
hadn’t tried to keep fit I probably wouldn’t have had half the physical 
problems that I have had, so in my own case I might have been better just 
smoking and drinking rather than trying to take exercise and that could 
have been cheaper for the state as well. 

WALKER:	Gone are the days, it seems, when 
generic messages hit the spot. People may talk about the visual impact of 
those TV pictures of arteries oozing goo, but the moment your hand 
reaches for the cigarette packet or opens the fridge another, intensely 
personal calculus applies, way beyond the reach of propaganda. Public 
health is, paradoxically, a private matter.  But combinations of individual 
advice, from GPs say, group support and billboards can change behaviour. 
Mike Kelly has the evidence.

KELLY:	What we do know in terms of the 
sorts of things that work with respect to smoking or to exercise or to diet is 
that interventions which are tailored to the particular needs of the groups in 
question, to the people in question, which are targeted very specifically, 
which are soundly based upon good psychological principles are much 
more likely to be effective than broad brush approaches, talking to the 
whole population.  You can pick out a range of things which have been 
specifically quite successful – recent initiatives on nicotine replacement 
therapy and smoking cessation, for example.  Very good evidence that that 
works.  On exercise – very, very good evidence that brief interventions by 
general practitioners during routine medical consultations, talking about the 
benefits of physical activity, that that’s effective.  And with respect to 
obesity, there’s very, very good evidence that family based approaches 
work.  So there’s a knowledge base, actually a deep and strong knowledge 
base, which can highlight specific things which we know, if they’re 
implemented properly, will work. 

WALKER:	But I wonder if the public health 
advocates mustn’t confront the political point. Their agenda, conceived in 
concern for public welfare, is interventionist. That’s no longer the old 
welfare state sense of cod liver oil and nit nurses; these days it’s about 
community involvement, product labelling and encouraging food 
manufacturers to cut salt content. Health advocates are also strong 
egalitarians. They want to turn society upside down, in terms of what they 
see as unfair health outcomes. Are political conditions now right, that is to 
say left, for this more active agenda? Ministers, John Reid the health 
secretary, do talk more about social justice but has the public bought the 
statism of the public health movement? Yes, says Mike Kelly of the Health 
Development Agency

KELLY:	We have a contract, if you like, with 
the state and with government.  The government provides certain services 
and in return we give up certain of our freedoms to receive those services - 
whether it’s education or the franchise, whatever it is. And the same is true 
with respect to health.  Now we could make choices, I suppose, as a society 
in which we said well we want to maintain that private sphere and the role 
of the state in helping to make it better should be limited.  The 
consequences of making that decision in an extreme form would be to 
continue on the path in which we’re going.  And the path on which we’re 
going is not one in which just there is a kind of moral or social justice issue 
about inequalities in health, which there undoubtedly is, but I think we 
need to move beyond that because if we continue with the same pattern of 
inequalities that we currently have and we do nothing about arresting the 
early mortality and more specifically even than that the prolongation of 
morbidity - the lengthy periods of ill health in old age that some people can 
expect to experience as a consequence of the kind of current trends we 
have -  it’s unsustainable in terms of our National Health service to cope 
with it.  The costs of that into the long run are unsustainable.  So it’s not 
actually just a question of a nanny state interfering for our own good.  In 
the long run, if we’re to make sense of this financially and politically, we 
have to do more and we have to do better than we’re doing now.

WALKER:	But it’s not going to be easy. It’s one 
thing for the state to provide health care, including statins for 
cardiovascular disease; it’s quite another for the state to intervene much 
further along the food chain. Maybe people’s anxiety about their waistlines 
will trump their distrust of government, and besides there’s no great public 
affection for food producers.  Yet before this public health agenda really 
gets going, don’t we need some ideological readjustments, some new limits 
to individualism, justifications for government to constrain choice? In other 
words, the public has to assent to a definite shift in the political balance 
before its long run health improves.



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