The argument that health is primarily a matter of individual responsibility, and therefore that governments have little role to play in intervening to protect the nation’s health, is a longstanding trope used to oppose population-level health policies.  

This, though, is ultimately a political argument, rooted in beliefs about the role of the state and about drivers of inequality. What it is not, is an evidence-based account of what actually shapes people’s health: the system that shapes our lifestyle choices and the way in which we live, work, and age. 

This evidence for that is based on more than 50 years of research by the Institute of Health Equity’s (IHE) Director, Professor Sir Michael Marmot, and the more than 100 reports and papers published by the Institute. 

While this view has long existed in public debate, it tends to reignite when a new report discusses the causes of ill health. 

This time, it was prompted by a rather clickbait headline: ‘at least 80% responsibility for ill health in old age down to individual' - the Guardian’s coverage of the Oxford Longevity Project’s first Age-less report ‘Living Longer, Better’. 

There was one quote by the main author, Christopher Ball, that made my jaw drop: 

“We live in a culture which is always looking out for some external reason to give the blame to: ‘It’s all the fault of my genes’; ‘It’s all the fault of my parents’. No, it isn’t. If you want to play the fault game, it’s all your own fault.” 

Sure, having a drink, eating a salad, smoking a cigarette, and going on a walk, are behaviours carried out by an individual.  

But you cannot ignore the contexts in which we as individuals make these choices – the report disregards all the robust evidence over the last 200 years of the effect of social conditions on health and wellbeing. 

Focusing only on individual behaviours strips them entirely from the context in which they occur. Such victim blaming is not only uncomfortable, but it totally contradicts the evidence base.  

Evidence shows that the main drivers of health are the circumstances in which we are born, grow, live, work and age (the social determinants of health (SDH)). Recognise the science, and the school of thought that health is simply the result of genetics and individual choices starts to fall apart, as the authors of the new report well know. 

The stark inequalities in disease prevalence and life expectancy between the most and least deprived groups are clear evidence that health outcomes are shaped by system-level drivers, and cannot be simply reduced to personal decisions.  

Consider a powerful social determinant of health, often referred to as the commercial determinant of health: the ways in which industries shape the environments around us, be it through lobbying, marketing, and product placement (just to name a few). Tragically, health-harming industries have a tight grip on England and across the world.  

Taking fast food, as an example. We know that proximity to fast-food outlets is associated with a higher risk of obesity, and that there is a higher concentration of these outlets in more deprived areas. This is often compounded by limited access to supermarkets selling fresh and affordable food (commonly known as food deserts) and a lack of time, due to multiple work and caring demands, to source and cook healthy food. 

None of this is new information, including to Government. The Government’s flagship health strategy published last year (Fit for the Future, 10 Year Health Plan for England) placed ‘prevention’ at its core. This accepts that early intervention to reduce disease is preferable, both to halt clinical deterioration and to reduce pressure on healthcare services. But this stops at early diagnosis or disease management, rather than addressing the root cause of that illness (the SDH). 

True prevention isn’t the slowing down of illness, it is preventing ill health by creating the conditions for good health. Yet public discourse remains heavily centred on illness and healthcare. Until we successfully reduce demand for healthcare services by investing in the social determinants of health, the NHS budget will continue to be a leaking bucket: continuously dealing with the consequences, while the causes go untouched. 

That is why headlines like the Guardian’s matter: they fly in the face of global research and evidence, and they risk undoing progress by returning to the over simplistic understanding of individual responsibility for health. 

There has, at least, been some improvement in public understanding. Campaigns such as Health Equals, which is backed by research from FrameWorks, is helping to shift the conversation away from simplistic narratives of personal responsibility. 

Meanwhile IHE’s work in more than 60 Marmot Places is making a difference to local residents’ lives by ensuring health equity is prioritised across the social determinants of health, including education, housing and transport. 

Politically, though, commitment on the SDH is lacking by central government, which makes promoting health and wellbeing, equitably, extremely challenging. Until the Government is willing to confront the root causes of poor health, we will stay trapped in this cyclical debate: focusing on individual behaviour while the underlying drivers of ill health remain the same.  

The IHE, based at University College London, is the world’s leading policy institute that demonstrates health inequities (avoidable health inequalities) can be reversed and sustained through cross-sectional action on the social determinants of health.