Introduction

Public health history is inherently linked to the history of state power and concerned with social, economic and political relations between classes, social structures and states (Porter, 2011). Arguments for health as a social right are based partly on the causal relationships between socioeconomic inequality and differential distribution of health and disease. In the 19th century, some modern states translated health citizenship into a universal equal right for their populations to receive protection from epidemic disease. From there, states developed healthcare coverage providing some form of health benefits to their citizens, ranging from little to universal coverage. In those days, infant mortality was one strong measure that demonstrated how economic inequality caused clear health differential gradients according to class. In the 20th century, however, perhaps especially when the relationship between lung cancer and smoking was established, a shift towards lifestyle explanations began to complement or replace traditional social structural concerns in public health. The new emphasis on behavioural approaches to public health was more political than it may have looked at the time. Blaming and changing individuals contrasted with improving social circumstances, and bio-psychosocial models of health focused thinking on disease prevention through the control of individual lifestyles. As time passed, victim-blaming of already disadvantaged groups developed, rather as an adjunct of the support for healthy lifestyles in public health politics (around smoking, obesity, alcohol consumption and so on).

In the 21st century, politics and policies often seem to reflect this kind of ideological standpoint, although strategies may take multiple and sophisticated forms. In a marriage of convenience, research quite frequently focuses on demonstrating the role of individual behaviour in reducing morbidity and mortality, and many academic debates broadly centre around exploring individuals’ responsibility for particular health outcomes. In the UK, the balance between the rights and responsibilities of the state and the individual has been a longstanding interest of the two main political parties (Dwyer, 2004). This chapter explores two public health programmes implemented in the UK under the 2010 coalition government, to illustrate how individualistic behavioural ideologies are embedded in them. Discussion also indicates the importance of social contexts and health service complexities when appraising policies built around ‘nudge’ ideas, and notes that such programmes may fail to relate effectively to health inequalities.