The Myth of Free Will in Public Health
In a 2011 article on tobacco control, Robert Proctor stated clearly that: “No causes are themselves uncaused”. Discussing the cigarette epidemic, Proctor highlighted the need to address the causal chain that drives behavior, which has detrimental effects on health and well-being. This view forces us not to reduce behavior to individual choice, but to acknowledge the larger socio-structural environment at play. So, what are these social structures?
Social Structures that Shape Population Health
Young describes these structures as relationships and systems that shape how individuals experience their lives, influenced by their social standing. These structures are often insidious, self-perpetuating forces that shape societies and the inequalities that exist, as well as guide behavior. Thus, the notion of “free will” is essentially an illusion in society. Consider this: in value-laden systems that overtly and covertly shape beliefs and practices that guide behavior, and the political and economic forces that influence the environments in which we exist, how much freedom of choice do you possess?
Unhealthy Commodity Industries (UCIs) at Work in Kenya
Let’s bring this back home. Currently, Kenya is facing the rising burden of non-communicable diseases (NCDs). The Ministry of Health acknowledges the role of shifting food environments in driving the disease profile. Through the Food Environment Policy Action project (FEP-Action), APHRC’s Chronic Disease Management Unit (CDM), in collaboration with the national government, is driving the research and policy agenda for healthier food environments by regulating the ultra-processed food (UPF) industry.
The UPF industry is emblematic of the broader unhealthy commodity industries (UCIs). UCIs are corporations whose products and practices are perceived as prioritizing profit over people. Their activities present tension with principles of human rights, environmental sustainability, and the protection of population health. Again, these corporations shape the environments and structures in which political, economic, and ultimately behavioral decisions are made, especially around tobacco, fossil fuels, alcohol, and food.
Beyond the Plate: Mental Health and the Commercial Determinants of Health
APHRC’s research on the UCIs not only investigates the affordability, accessibility, and availability of unhealthy foods, but also examines how traditional and digital media influence the food landscape and shape purchase and consumption patterns. Although the work in these fields is emerging, parallels can be drawn from the tobacco industry. The learnings can somewhat guide public health strategies.
As we address physical NCDs, we cannot ignore the looming burden: mental health disorders. The bidirectional nature of mental health conditions ought to be recognized. They are both outcomes of physical disease and independent health concerns. While they may arise in response to a disease or other biological factors, mental health conditions can be independently influenced and exacerbated by commercial activities and products such as marketing and the availability of unhealthy products.
Example: Comfort Food and Emotional Marketing
To paint a clearer picture of this bi-directional relationship, consider the idea that food products are not only designed to satisfy nutritional needs, but also to offer a sense of identity and comfort. In turn, the emotional relationships that develop along an individual’s life course, whether with food, alcohol, tobacco, or other substances, contribute to a pattern of consumption and, subsequently, outcomes across their entire lives.
The concept of “comfort food” is drawn from the emotional bond individuals form with food. Often, this is shaped during childhood, reinforced during times of stress when we need to find calm, and capitalized on by the food industry. Take a look at this review on comfort food, which traces the origin of the term to a 1966 article by the Palm Beach Press. The article, titled “Sad Child May Overeat,” explains that adults turn to “comfort food” when faced with emotional stress, psychologically linking the food to the emotional safety associated with childhood meals – an example of a mother’s poached egg is given. This is not just nostalgia at play, it is a behavioral pathway that can lead to the overconsumption of unhealthy commodities, maladaptive coping strategies which can lead to addiction, criminal behaviors, and the development of chronic conditions, including depression.
What does this “comfort food” narrative do? It drives a shift in responsibility, which corporates take advantage of through their corporate social responsibility (CSR) campaigns. When looking at your favorite influencers’ pages today, you may see slogans promoting “drive responsibly” or “choose wisely” that shift the onus onto individuals, ignoring the systems and environments engineered to influence behavior. These narratives divert attention away from the systems that shape our environments towards the alleged “free will” we all possess. Ironically, these advertisements are often sponsored by alcohol companies and other UCIs.
A Dual Relationship: Mental Health and Consumption
Yes, poor mental health can drive people towards the consumption of unhealthy commodities such as alcohol, UPFs, and tobacco as coping strategies. Equally, commercial marketing and the availability, affordability, and accessibility of products can drive or worsen mental health disorders. This includes identity-related disorders, unhealthy coping strategies, and, in turn, triggers stress and guilt.
All factors considered, there is a need for early intervention, especially among young and vulnerable populations. Evidence shows that 50% of mental health conditions begin by age 14, and 75% by age 24. This presents a critical stage for intervention. Furthermore, the Ministry of Health explains that 85% of individuals with mental health conditions in Kenya remain undiagnosed. Yet, mental health disorders present the second leading cause of disability adjusted life years (DALYs) among people aged 10-24 years. This calls for us to equally direct our public health strategies on NCDs to also address the emotional and psychological patterns that develop and persist throughout the life course of individuals.
Proposed Reframe of Health Equity in Research and Policy
The point is, the ox and the cart need to move together. If we want to tackle the burden of NCDs in Kenya and promote health equity, we must transcend the traditional risk factor model and focus. Mental health must be integrated into our research, policy, and advocacy agendas. This means that we need to drive the research framework to address mental health outcomes alongside physical ones, designing and implementing population-level interventions that consider behavioral drivers of consumption, the expansion and focus on regulating marketing practices that play on mental and emotional states not just nutritional claims, and challenging corporate social responsibility strategies that frame the consumption of unhealthy commodities as a matter of individual responsibility.
A Call to Action: Integrating Mental Health
Health cannot be reduced to a matter of weight or the physical manifestation of disease – it encompasses overall health and well-being. Wellbeing encompasses mental and emotional health, which are as important and can drive physical outcomes. So, as we challenge the unhealthy commodity industries, we must ensure that mental health is brought to the table. It is a determinant, a target, and a responsibility we cannot afford to ignore, especially if we claim an interest and investment in promoting population health and wellbeing.