It’s a question that I’ve asked myself throughout my life. When your thighs chafe together on a hot day, the sweat dripping from between the folds of your stomach down the front of your t-shirt and pooling between your polyester pants and the rash that has haunted you all summer, it’s always hard not to blame someone, even if it is yourself.

So who should we blame?

There is a very strong push in society to provide a ‘free will’ explanation. That is, I am fat because I chose to be that way. I lack self-control, I lack discipline, and if I just stopped swimming in a pool made entirely from chocolate mousse I’d be thin and happy like the rest of the people who live in ads.

The local pool

It’s not a very good argument. There are 1000's of reasons why you might be unhealthy that have nothing to do with your self-control and have everything to do with your environment. This doesn’t mean that you have no control over your health, so please remember throughout that you are the ultimate arbiter of your fate. You can change your life. But the environment you live in can make it many times harder.

We’re going to look at 2 major elements of public health that we know can be improved through good policy, but which are often impeded when people say “well, if you just did (x), you wouldn’t be unhealthy”.

Suicide is a tricky one. It’s hard to argue that people make a choice to commit suicide; killing yourself is not a choice anyone else can make for you. However, when we look at the environmental cues for suicide, there are some truly astonishing things to see. Bridges are a great case study.

Look at the barriers. Those save lives.

If the free will argument was our main concern, you’d expect that putting up barriers around bridges would do nothing; after all, it’s just as easy to jump into traffic in the road as it is to jump off the side of a bridge. But the fascinating thing is that putting up barriers not only stops suicides on the bridge itself, but also prevents these people from committing suicide at all.

We can literally save people’s lives with a fence.

There is extremely good evidence that people with suicidal thoughts tend to choose a single method, and if denied access to that method they often won’t go on to commit suicide at all. This holds true for other methods, particularly in the case of guns. A suicidal person in a suicidogenic environment will be more likely to die. Someone who doesn’t have a gun or a bridge at hand (or other cultural method; suicide is very culture-specific) is less likely to follow through. And this can all be changed. Suicides fell after Australia implemented strict gun legislation. We’ve significantly reduced the harm caused by pill overdoses with some fairly strict sales legislation regarding number of pills purchased. We know policies that are effective, but all too often it comes back to people who say that we can’t do anything because suicide is a choice.

Good mental health policy only takes us halfway; changing the environment is also key.

You may have heard the term ‘obesogenic environment’ before, and assumed that the person making the statement had a silly preference for making up words. However, there is a massive pile of evidence indicating that your environment goes a long way towards explaining your weight. For example, areas with more active transport (particularly bicycles) have lower levels of obesity. Lower socio-economic status areas, particularly those without adequate parks and recreation facilities, have higher rates of obesity. There are literally healthy food deserts where you have to travel 4+km in any direction to get anything that isn’t deep-fried.

Not to be confused with Health Food Desserts, which are an abomination unto the Lord

From a personal perspective, this doesn’t mean much. My flabby thighs? Still mostly my problem. But from a public health perspective, this makes a huge difference. When people say that overweight people just need to exert more strength of character, or that the obesity epidemic is all down to weak-willed fatties, they are completely ignoring how deterministic health can be. Not everyone is fat because of their environment, and taking responsibility for your own weight is a great thing to do, but as a community our weight problems are more about our environment than about our mentality. When push comes to shove, I’m fat through my choices. I’m also fat because my favorite method of exercise (cycling) isn’t really an option for me daily, because it is cheaper (in time as well as money) to eat unhealthy food; for a thousand tiny reasons that all come together to chafe my thighs on a hot summer day.

The worst part of all this is that we know any number of ways to fix an obesogenic environment. Active transport is a well-understood public health measure, and places such as The Netherlands have taken this idea to heart. The Mexican sugar tax is already proving extremely effective at curbing obesity-related diseases. And yet we keep insisting on implementing education-only measures, or programs that require active participation with no environmental change.

All this comes back to the political landscape. When most government policies focus on ‘free will’ interventions to our increasing obesity epidemic, it’s important to understand why. Listen to most politicians talk about obesity; they’ll mention getting people active; they’ll talk about getting us to eat more healthily. Rarely do you hear a leader of the country calling for more investment into active transport. Both major parties have backed off from a proposed sugar tax that has a great potential to change the environment and save lives across the country. The same is true of suicide. No one ever mentions that changing reporting methods for suicides in the media can prevent deaths. There is some good policy out there (for example limiting the number of pills you can buy in pharmacies), but all too often the environmental role is completely swept under the rug because a) it’s too expensive and b) we want to blame people for their problems. Giving extra money to mental health organisations is great, but if we don’t change the environment all we are doing is treating the symptoms.

Telling fat people to get out and exercise doesn’t work. Telling suicidal people to go see a psychologist is equally ineffective. It’s time to stop blaming people for their poor health, and instead work on changing the environment to make it healthier for everyone.

As always, if you think these are important issues, take action. Write to your local MP, no matter which side of politics you are on. No one is taking the environment seriously when it comes to public health. Complain. Make your voice heard.

And next time someone tries to blame you for your poor health, tell them to fuck off. It’s never all your fault.

Epidemiologist. Writer. Podcaster. Twitter https://twitter.com/GidMK FB www.facebook.com/gidmkhealthnerd/ Email gidmk.healthnerd@gmail.com