People are good.

I believe this wholeheartedly. Without question. And yet, in my 48 years exploring this particular time, space and reality, I have noticed something rather peculiar. People are also very good at making limited choices. We are blinded by shiny things, burdened by obligations that seem to serve nobody and have a knack for constructing surprisingly limited horizons for ourselves, which we then populate with beliefs, commitments, possessions, mortgages, careers and responsibilities until there isn’t much room left to breathe, never mind see beyond them. Yet, wonderful as people are, it is a rare treat to meet somebody with a genuinely long-sighted view of the world. Someone capable of looking beyond their own immediate needs, perhaps even beyond their own lifetime. They do exist. I know it. I’ve met some of them, and you know, there are more than you might have been led to believe! They’re often the quiet voice of wisdom in a noisy room. Perhaps because they’ve discovered something rather useful:

If you don’t need the credit, you can get a great deal more done.

Which brings me, rather ambitiously, to medicine, pharmaceuticals, food and social care. Four mighty pillars of our society. Individual leviathans in their own right, yet so intertwined that it can sometimes be difficult to see where one ends and another begins. And all, ostensibly, virtuous. Medicine wants us well. Pharmaceuticals make medicines to help us become well. Food nourishes us. Social care catches us when we fall.

What could possibly go wrong?

HA!

Well…

People.

Not bad people.

Good people making limited choices.
See medicine. Here in Britain we quite rightly hold the NHS as one of our great achievements. Healthcare, free at the point of delivery, is an extraordinarily bold idea. An enormous collective agreement that if one of us falls ill, the rest of us will help pick up the bill. That’s rather beautiful. But more than 75 years after its creation, I wonder if something peculiar has happened. Somewhere along the way, have we slowly handed over responsibility for our health to the people who are there to help us when we become ill? The distinction matters.

If I come off my bicycle and break my leg, please take me to hospital. I have absolutely no intention of setting it myself with two sticks, a copy of Private Eye and a sugar pill. Modern medicine really can be extraordinary. But medicine and health are not the same thing. Health happens in kitchens and gardens. On walks. In friendships. Through sleep and movement and purpose. It happens through the thousands of mostly mundane decisions we make when there isn’t a doctor anywhere in sight.

Perhaps one of the unintended consequences of building such an extraordinary institution is that we have gradually outsourced some of our personal health obligations to it, and the doctor now becomes the custodian of our health rather than someone whose expertise we call upon when necessary. We risk becoming patients seeking magic pills rather than participants exercising sovereignty.

Prevention is difficult to see. Intervention is wonderfully visible. Prevention might be somebody walking every morning for thirty years. Intervention is a surgeon replacing their knee. One is almost impossible to photograph; the other is miraculous. And so we build magnificent systems for putting people back together while perhaps paying rather less attention to why quite so many of us keep arriving at the door.

Then there are the medicines.

Doctors and pharmaceuticals fit together like hand and glove. On the face of it, there is nothing particularly troubling about this. We develop substances capable of relieving suffering and extending life, and doctors use them. What’s not to like?

Well, fundamentally, the two institutions aren’t driven by the same thing. The foundations of the NHS are altruistic. The pharmaceutical industry is commercial. Again, this doesn’t make pharmaceutical companies evil. Profit isn’t evil. Nor are the scientists, researchers, pharmacists, salespeople or shareholders involved secretly rubbing their hands together hoping everybody gets sick. But it does create a rather interesting contradiction. A medicine that cures an illness is a triumph for humanity. A patient requiring treatment indefinitely is, commercially speaking, a rather more reliable customer. That doesn’t require a conspiracy. It simply requires us to acknowledge that the incentives are different.

So what happens when a system built around human need becomes increasingly dependent upon another whose continued existence requires a market? Nobody needs to be plotting anything. Everybody can simply turn up for work …

Which brings us to food.

Another extraordinary human achievement. Most of us can walk into a brightly lit building at almost any hour of the day and choose from foods gathered from every corner of the planet. Strawberries in December. Avocados in Cumbria. A £1 pineapple — once a status symbol roughly equivalent to use of a helicopter or private jet — whenever you fancy one.

Kings couldn’t eat like this. Starvation, once commonplace, is now for many of us something encountered through history books and charity appeals rather than lived experience. That is an astonishing achievement. And yet the business of feeding people is, once again, a business. And businesses need us to consume. Preferably today. And again tomorrow. So food becomes a product. Products compete for attention. Attention rewards novelty, sweetness, convenience, colour, packaging, shelf life and the magical ability to make us want another one. Something designed primarily to nourish a human being is gradually required to perform another task: To sell.

Once again, nobody needs to be evil. The food scientist is doing their job. The supermarket buyer is doing theirs. The marketing department theirs. The shareholder expects a return. The customer wants something cheap, tasty and convenient. Every individual decision can be perfectly understandable. And somehow the whole thing can still become absurd.

Then there is social care.

Poverty. The enormous network of charities, government departments, voluntary organisations, professionals and well-meaning people devoted to helping those who have fallen through the cracks. I want to be mindful here, because when somebody is drowning, you pull them out (it’s not terribly helpful to stand on the riverbank delivering a lecture on swimming — however much you might enjoy it). Sometimes people need feeding. Housing. Money. Protection. Medicine. Advocacy. Someone to sit beside them and say, I’m here. But then what?

There is an old and wise saying about giving someone a fish or teaching them how. Yet one is convenient and the other requires a much more committed investment. Help can alleviate suffering. But does our help also restore agency? Does it gradually make itself unnecessary? Because there is an uncomfortable possibility here too: entire systems can grow around the existence of the problem they were created to solve. Co-dependence becomes the new normal. Jobs appear. Departments grow. Buildings are purchased. Funding streams develop. Careers are established. Mortgages depend upon salaries. Pensions depend upon careers. Eventually an institution can acquire an interest in the continuation of the very problem it exists to address.

Not consciously.

That’s the important bit. There needn’t be a meeting. No twelve men in grey suits sit around a billiards table in a London gentleman’s club, saying, “How shall we keep the masses poor, sick and eating Tesco bourbon biscuits?” It would almost certainly be easier if they did. We could lynch them, hang ‘em high and absolve ourselves of the burden. Another familiar, tried and tested pattern. Strange fruit indeed. It hasn’t worked before. “This time it’ll be different,” said the pig.

Instead, there are millions of ordinary people getting up in the morning. Packing lunches. Dropping children at school. Going to work. Following protocols. Meeting targets. Paying mortgages. Protecting careers. Saving pensions. Navigating the boss. Trying, mostly, to do a decent job. Good people.

And perhaps this is how the strangest monsters are created. Not through malevolence, but through millions of perfectly reasonable, short-sighted decisions. Medicine needs illness. Pharmaceuticals need patients. The food industry needs consumption. The poverty industry needs need. Each feeds quietly into the next. Nobody designed the machine. Nobody is driving the train. Yet somehow the locomotive keeps moving. Which brings to mind another common sentence, perhaps broadly understood but not commonly acted upon:

The road to hell is paved with good intentions.
Well, perhaps good intentions aren’t enough. Maybe we need intentions with longer horizons.

Imagine, for a moment, that thirty years became our baseline. Not your next promotion. Not this year’s holiday budget. Not the rise of Count Binface. Not Friday. Thirty years. A sizeable chunk of a human life.

Before making an important decision we might ask: What happens if we keep doing this for thirty years?

When helping somebody: Will what I’m doing increase their ability to live well without me thirty years from now?

When producing food: What happens to a population that eats this for thirty years?

When prescribing: Where might this person be in thirty years?

When working: What happens if I do my job exactly as instructed for thirty years? Where does the cumulative effect of my ordinary obedience lead?

When building institutions: Are we solving the problem, or slowly becoming dependent upon it?

We spend an enormous amount of time, often self-righteously asking whether people are doing their jobs properly. What if a slightly more nuanced question was asked?
“What is the collective sum of all those well-performed jobs and where are they taking us?”

Perhaps even thirty years is terribly short-sighted. What if we extended the horizon beyond ourselves entirely? What choices would we make today if our great-great-great-great-great-grandchildren had a seat at the table? What would we grow? What would we stop doing? What would we preserve? What would suddenly seem ridiculous? How much would more matter?

Perhaps we’d plant forests whose susurrations we knew we’d never hear. Perhaps we’d build things designed to outlive us. Perhaps we’d become less interested in being seen to do good and rather more interested in whether good actually came of it.

People are good.

I still believe that. Wholeheartedly.

Perhaps the challenge isn’t to make people better.

Perhaps it is simply to help people see a little further.

And to ask, occasionally,

Whether the small choices we make today are cultivating an Eden for the children we will never meet.