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There is a crisis of public health in the UK. Although public health measures are known to be effective and cost-effective, UK government has shown a reluctance to adopt those measures. Reasons for this reluctance include: the wide-ranging agenda involved in dealing with the social determinants of health; a governmental decision bias against prevention; a similar bias against precaution; the problems of interorganisational collaboration and cross-government working; and the need for political leadership. However, the reluctance also reflects a dominant libertarian way of thinking about the role of the state, which needs to be replaced by a new social contract for responsible government.
A public health crisis is gripping the UK. Improvements in life expectancy have stalled, health inequalities have widened, obesity and alcohol misuse are placing an increasing strain on health services and urban air pollution is now widely recognised as a serious health hazard. COVID-19 revealed the weaknesses of the UK's public health system, once thought to be among the best in the world.
Against this background, this book examines the organisational and political barriers to an effective public health system showcased through the UK. It urges that what is needed is a new social contract, in which health policy is truly public.
The fundamental question at the heart of public health policy is how it can be that cost-effective measures to promote the health of the population are not more vigorously implemented. The question has become more urgent as the pressures on the NHS have increased. Behind the implementation deficit, this chapter examines the role that a dominant public philosophy of libertarianism has played. That public philosophy is plagued with a number of problems, and in its place this chapter argues for a philosophy of social individualism in which the role of government-provided public goods is central to creating the conditions for effective individual choice and fulfilment. The chapter concludes with a manifesto of practical public health measures.
With the demise of Public Health England came the establishment of the UK Health Security Agency and the Office for Health Improvement and Disparities. This new settlement poses issues of process and policy. Separating health protection and health improvement poses its own problems, given the association between poor health status and susceptibility to infection. More generally, the new bodies will have to cope with the complexity of public health evidence which is essential to scientific integrity, as well as the need for independence from politically partisan control. Political leadership will be essential, and there needs to be a ruthless focus on implementation.
Devolution is a notable constitutional change in the UK. The devolution of health responsibilities has been associated over time with the establishment of public health responsibilities in the home nations other than England. Public Health Scotland, Public Health Wales and the Public Health Agency in Northern Ireland have acquired responsibilities, though the precise configuration varies among them. These differences suggest that there is no one right way of organising public health responsibilities, although it is notable that all the devolved governments have brought together health protection and health promotion. Important policy initiatives, like the minimum unit pricing of alcohol, are independent of organisational questions.
This chapter explores the organisation of public health responsibilities in England between 2013 and 2020. The establishment of Public Health England was widely welcomed in bringing together health protection and health promotion. During its lifetime, Public Health England encountered problems in addressing some health promotion issues, like vaping, as well as ensuring cross-departmental working in government and forming relations with local government. Its funding was also cut. At its abolition in 2020, long-standing issues about the lack of priority to be given to public health to protect the NHS and promote the health of the population remained unresolved.
The book’s conclusion attempts to weave together the various themes that dominate the work, cohering around three undergirding sections: Why use IPEDs?; Potsford’s local closed market structure; and market trajectory: commercialization and SNS supply. Chapters 4 to 7 are drawn upon to present a multi-layered theorization as to why the men under study were drawn towards image and performance enhancing drugs. Building out from a psychoanalytical account of bodily desire, to include meso and macro factors such as sporting and occupational context, the role of pleasure and lifestyle, and will-to-recognition on social media, the chapter offers some much-needed nuance to the question of motivation. Potsford’s offline market is then summarized, drawing heavily on Chapter 9. This is then woven into the final section, which reiterates the growth and development of the IPED market, bringing together Chapters 9, 10, and 11 to present a dual space of traditional offline, culturally embedded supply, alongside a burgeoning online market catering to an evolving consumer base. The chapter, and book, are drawn to a close with a number of recommendations for future research and policy implementation.
The health and fitness industry has experienced a meteoric rise over the past two decades, yet its slick exterior conceals a darker side: image and performance enhancing drugs (IPEDs). Using ethnographic data from gyms, interviews, and social media platforms, this book investigates the growing use and supply of IPEDs in a UK context. Various levels of user motivation are explored, from the psychoanalytic processes of desire and bodily dissatisfaction to the instrumental and pleasurable aspects of consumption, and their relationship to social media. The gym is also critically examined as a space of deviant leisure, applying cutting edge criminological theory to build links between gym culture, masculinity, and consumption. Tracking the intricate relationship between supply and demand, The Muscle Trade then studies the local offline IPED market in the city of ‘Potsford’, before tracking the commercialization, normalization, and digitization of supply. Within this, particular attention is paid to the social media platforms Facebook and Instagram as spaces of self-representation and illicit commerce. Ultimately, this book serves as a guide to the muscle trade, its infrastructure, the various key actors, and the motivations behind chasing masculine bodily perfection.
Chapter 4 is the first of four chapters unpacking the motivation to consume IPEDs. Serving as the theoretical base onto which analysis of the compulsion to engage in excessive bodywork and IPED consumption stands, this chapter draws on advanced psychoanalytic theory to make a case for the role of lack and desire as the key driving forces for the sample. First, the pivotal role of lack in human subjectivity is laid out, before an argument that the body, for the book’s subjects, represents the objet petit a is offered. This stance is then mobilized to interrogate the corporeal suffering and jouissance taken on by hardcore gym users, before the cyclical, psychically appealing nature of bodywork is explored. The notion that fitness is a never-ending journey is then leant upon to argue that IPED consumption is essentially a means to prolong bodily dissatisfaction, allowing subjects to suspend themselves in a state of corporeal desire. Finally, the relationship between IPED addiction and desire is explored, taking in both the chemical and psychic aspects of dependence present in the men under study.
Building out from Chapter 4’s psychoanalytic foundations, this chapter examines the instrumental reasons why the sample used IPEDs to build their bodies. First, the role of competitive sporting activity is considered as a driver of consumption, and the underlying competitive individualist mindset present among the men under study is interrogated. Following this, the utility of attaining a muscular enhanced body for professionals working in the health and fitness industry, particularly personal training and online coaching, is investigated. This analysis is contextualized within the post-industrial political economy of Potsford and an argument is advanced that IPED consumption ought to be viewed as a means of hyper-conformity to the edicts of late-capitalist accumulation, particularly given the precarious nature of many roles in the sector. Ultimately, the chapter concludes that both the sporting context of consumption and the insecure local health and fitness economy represent ‘dopogenic environments’.
