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On the constraints of behaviour and individual choice in public health: how about environmental health?

By Adithya Pradyumna
on September 30, 2021

In their recent  comment  titled “Beyond behaviour as individual choice: A call to expand understandings around social science in health research”, Nakkeeran and colleagues reminded the social science and health community about the need to scrutinize and address the underlying structural and institutional factors that perpetuate “behaviours” detrimental to health. The article was mainly a critique of the recent trend of researchers and policymakers employing lessons from behavioural economics in public health responses (for instance, nudging). They also identified reasons for the thrust on behavioural change-centred models in public health and highlighted their limitations.

As I read this piece, I remembered again a plenary talk that I delivered a few years ago on climate change and health at a large student-organised conference in India. It was still early days for me in my “environmental health” career. For weeks I wondered what I should say to these students (and faculty members) of public health about climate change and health. And while slowly thinking and drafting, the focus of the presentation somehow drifted towards individual actions and choices (monitoring personal carbon footprints, conscious use of resources, sustainable diets…the whole nine yards). I was unsure how many in the audience would relate to my life context, but I went ahead and shared about my own “behaviours” on all these aspects. These ideas and suggestions met with some resistance from the audience (especially faculty members from social sciences backgrounds) in the form of polite but sharp questions and comments on the utility of individual behavioural change, and understandably so. Looking back, while I maintain that my controversial messages had some merit, I’m not convinced they should have been the main message of my talk.

That talk was not the only time I fell back on reflecting on individual behaviour in the context of climate change and health. A few of my essays also focused on the individual, for example: An ethical dilemma for a young (environmental) health researcher: the trade-off between carbon footprint and education/networking. I was not naïve about the politics of climate action, though. For instance, at an earlier meeting with a climate change action group, I had argued against an elderly academician who focused on the need for individual change, saying that without strong policy interventions, nothing would actually change.

Among others, Nakkeeran and colleagues discuss the methodological convenience as a reason for researching and pushing individual behavioural change, that it is “more difficult to measure and address structural and environmental factors”. There may be more to this, at least with respect to behavioural and structural factors in the context of global environmental change and consequent health concerns.

Behavioural change and climate change mitigation

Here we have the classical “chicken or the egg first?” dilemma. Does one demand for strong policy/structural interventions first or look inwards first? Part of this answer may be related to the background of the individual. Coming from a privileged background, I had to do some introspection and change my own wasteful “behaviours” before I could take myself seriously as an environmental health researcher and practitioner. This became immediately necessary in my initial days in this sector, as I saw young environmental activists rolling their eyeballs when I bought packaged fruit juice during lunch. Unlike the likes of Al Gore and Erik Solheim, I wanted to practice what I preach. And ever since, despite fully recognizing its limitations, I have continued my personal “behavioural reform”, which includes since mid-2020: no more air-travel.

So, the targeting of individual behavioural change is different in general public health as compared to global environmental health problems. For instance, to control non-communicable diseases, behavioural change would benefit persons across socio-economic strata; the prevalence of hypertension, for example, was comparable across strata in India as of 2015 (9.3% vs 12.6% between the lowest and highest wealth quintiles in women aged 15-49 years of age). For mitigating climate change on the other hand, it is the privileged that are expected to change individual behaviour (most) by reducing resource use. However, individual behavioural change (even minor, rather unimpactful ones, such as throwing trash in the right bins) can also lead to a false sense of security and a feeling of having contributed, potentially making the individual less inclined to question the status quo. In addition, as it is this group that “benefits” from the status quo, that becomes another road block. Individual choices are more available to the privileged, and with the privileged being closer to policy circles, and with individual choices often not sufficing to address the problem…. As you can see, all this together could form a dangerous cocktail. Also, while Nakkeeran and colleagues state that individual behavioural interventions could be a “quick fix”, that may not even be the case in the context of problems stemming from global environmental change.

Interplay between inside and outside change

The challenges appear so daunting, they can be paralyzing. There is a sense of loss of control. Just a few days ago we learned about the results of a survey indicating an epidemic of “climate anxiety” among youth (16–25-year-olds) from across the world. Many of them worry that not enough is being done to address global environmental change. The prevalence of this ‘very worried’ state was highest in countries that are highly vulnerable to and impacted by climate change, such as the Philippines (84%) and India (68%).

These youth may routinely be ridiculed by older college-educated persons, whom I’ve heard say things like “the government knows the urgency better, no need to tell them”, or bringing nationalism into the arguments. This is related to the phenomenon of “othering” experienced by the youth as discussed in the survey report. The only sense of control one may seem to have in these anxious times, when time itself seems to be slipping away for meaningful collective action, is to resort to changing individual behaviour. This may also stem from the “guilt” reportedly being experienced by a large proportion of these youth. And now with social media, there is a possibility of showcasing individual actions to wider audiences, which may also add to the temptation of focusing on this.

Given all this, it is great to witness the Fridays for Future campaign/movement which pushes for urgent policy and structural reforms at international and national levels, while also providing an opportunity for introspection and change of individual action. This movement has also shown how individual actions can lead to a groundswell, and question the underlying structure and goals of policies and institutions.

At the other end of the spectrum of environmental health action in India, individual behavioural change in the form of toilet construction has been a hallmark of the sanitation campaign (Swachh Bharat Abhiyan) towards eliminating open defecation. This has been highlighted as an example by Nakkeeran and colleagues. Long-standing structural problems such as manual scavenging, deeply linked with caste and with occupational deaths, remain relatively neglected despite the fact that regulations and prohibitions have existed for decades. The same with handling of municipal waste, where the focus has been on waste segregation (if at all) in cities in India, but not enough on the systems that lead to generation of these volumes and types of waste.

One size doesn’t fit all

Nakkeeran and colleagues also raise the important point that it is presumptuous of policy makers to claim they know what is in the best interest of vulnerable populations. This is again related to the distance between policy makers and vulnerable populations. Recently, the hot topic has been on sustainable diets and the UN Food Systems summit. Health activists from low-and-middle-income countries have expressed concerns about the need to focus on the structural drivers of food systems and take into account the needs and aspirations of marginalized communities. A colleague of mine also wrote an important and timely critique of the inappropriate quantitative comparisons that have informed the global conversation on sustainable diets, and the lack of contextualisation of these conversations. Not that there is no scope for improvement in the agricultural sector from a health and sustainability perspective (indeed a lot can and needs be done), but such analyses show the major potential negative consequences of pushing particular “one size fits all” behaviours in the context of countries such as India for health and nutrition of marginalized communities, and also the paternalistic and privileged positions of institutions and individuals that push such options. 

Impact of Covid?

It is possible that the COVID-19 pandemic experience will itself somehow reinforce the idea that public health is primarily about individual behaviours, because of the continuous messaging on masking and physical distancing. However, the impossibility of distancing in resource poor settings was immediately clear, among other critical challenges faced.

In addition, while the pandemic unintentionally led to temporary mitigation of greenhouse gas emissions due to shutdowns and lockdowns globally, nations are back on track to catch up with lost GDP. Indeed, COVID-19 is being used as an excuse to further focus on economic growth rather than strengthen public health and reduce the vulnerability of the population in a number of countries (see a forthcoming paper). Such thinking will weaken structures, unfortunately, and again put the onus on individuals, while not all individuals are in the same position to cope, and the scope for individual coping is often very limited.

And so, though it is difficult, there is an urgent need to focus beyond individual behavioural change, and the social sciences can unravel the connections between the individual, choice, institutions and structural factors. This is also the case in environmental health action, while fully recognising the importance and utility of individual level actions. The focus on determinants of health, and the underlying structural and institutional drivers fostering behaviours and choices needs to be strengthened.

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