A fan of the snack bar

For Klasien Horstman, professor of Philosophy of Public Health, science is the “realm of freedom.” Unfortunately, reality is more intractable. She is irritated by the patronising lifestyle interventions imposed top-down on groups that have been epidemiologically classified as high risk. “The ‘you have to live healthily’ discourse doesn’t sit well with me.”

If there is a common thread in Klasien Horstman’s work, it’s social inequality. It frustrates her that lifestyle recommendations tend to ignore the everyday reality of “high-risk groups,” which often consist of people with a low income. She sees the word “intervention” as a veiled form of academic paternalism that is, moreover, directed at the individual without taking account of the environment.

Economic insecurity: a major health threat

The moment Horstman became a professor, she decided to do things differently. “We wanted to talk to people in low-income neighbourhoods and ask them how they themselves define health. Economic insecurity is a major source of stress, which is detrimental to health and wellbeing. The path forward is clear—put a stop to all these different interventions for umpteen individual health risks. Every expert comes up with their own risk, but the real world isn’t that fragmented. Make sure everyone has an adequate income. The people with low incomes we talk to know perfectly well that smoking is bad and exercise is good for you. But they have other things on their mind.”

Eight years ago, she set up the living lab UniversiteitmetdeBuurt (“University in the Neighbourhood”) in Maastricht-Noordwest, a low socioeconomic status (SES) neighbourhood. The goal was to tap into residents’ knowledge in and of the neighbourhood and connect it to scientific knowledge. With her colleague Mare Knibbe, she wrote De gezonde stad. Uitsluiting en ontmoeting in de publieke ruimte, a scholarly book focused on the nexus between health, social interaction and exclusion. “We see public spaces as social infrastructure, as places to combat exclusion and inequality. From that perspective, the local snack bar isn’t just a symbol of an unhealthy lifestyle. It’s one of the few places where people can get together in a neighbourhood with a dearth of public spaces. My health-sciences colleagues call snack bars unhealthy, but their value goes beyond the calorific value of their food. They also serve a social function. I’m a fan of the neighbourhood snack bar. As it happens, my parents ran a snack bar from home on weekends to make extra money. Once a week my grandparents would come over to peel potatoes for the chips.”

Philosophy café

The main problem in purely residential suburbs like Maastricht-Noordwest is a lack of social interaction. “We pulled at that thread. We organised a citizens’ summit, where residents told us they would like to have more places to get together. They wanted a healthcare café, an arts incubator, a community coffee shop. Just talk to people and you’ll see they know exactly what the problem is. They also told us, ‘We’re tired of people thinking we only want to play bingo. We want to have philosophical discussions.’ Residents of low-SES neighbourhoods feel stigmatised by institutions and researchers alike. Many researchers associate ‘low SES neighbourhood’ with ‘less educated,’ which they assume means ‘unintelligent.’ And this while being stigmatised increases unhealthy behaviour! Our philosophy café has been running for over five years now, with very meaningful discussions on a broad range of topics. You don’t need a degree to have a lot of wisdom. The next theme is compassion.”


Both feet in the peat

Born and raised in the peatlands of southeast Drenthe, Horstman knows what it’s like to grow up in modest circumstances. Her grandfather was a peat worker with nine children to feed. After finishing primary school, her father was sent out to work. “He used to slaughter animals at farms. When that work moved into slaughterhouses, he lost interest and got a job in a canning factory. We always had a beef cow at home. We didn’t have a lot of money,” she laughs, “but we always had good meat.” 

When Horstman was ten, her mother died of stomach and colon cancer. “I’ve blocked out those memories. She suffered terribly. Back then, in 1969, you didn’t talk about death. When she came home from the hospital, we had cake to celebrate. But I knew she wasn’t going to make it.” Her father was left behind with three young children, two girls and a boy. Horstman was the eldest. “Back then there was no pension for widowers, only for widows. He had to go back to work three days after her death. And he had to get a new wife, which he did. She gave us another brother. The marriage broke down after seven years. But she was a teacher, so she brought books into our house. That opened up a whole new world for me.”

These boots are made for walking

In primary school, Horstman proved to be a good learner. “I was offered extra French lessons, and once I’d finished all the maths workbooks of the year I was in, I’d move on to the next year’s. I had to go and fetch the workbooks from the next classroom myself, which was difficult. I was a shy child, but people saw me as an overachiever and a know-it-all.” She was glad to move on to high school in the city of Coevorden. “Every step I took outside the village was a relief. It was easier to be myself in high school. I loved learning. And I was into the alternative look—Afghan coats, ripped jeans, sturdy boots. It was my way of rebelling against the conventions of village life.”

Communist stronghold

She became the first in her family to attend university, studying philosophy in Groningen. “I enjoyed reflection and discussion, and I’d loved doing a history project on Jean-Jacques Rousseau. Philosophy seemed like a good fit for me. My father was proud. He wanted us to learn as much as we could so we’d always be able to take care of ourselves, no matter what life threw at us. ‘Knowledge is power’—that was one of his slogans. He’d have liked to have gone to university himself.”

But she soon became disillusioned. “I felt intimidated by the political ideology in the faculty. A lot of the students were older than me, and the faculty of philosophy was a stronghold of the local student union, dominated by communist ideology. Many of the professors were Marxists or communists. My social-democratic views were ridiculed. I developed an aversion to peer pressure and dominant social codes. After a year, I switched to historical and philosophical sociology, which was a breath of fresh air. I learnt all about the historical context and philosophical critique of totalitarian and dogmatic thinking. Philosophy of science, the relationship between science and democracy—all themes I’m still involved in. The lecturers were wonderful; I had a great time there. After 2000, when our FHML began to idealise evidence-based medicine and allow only one kind of knowledge, I sometimes felt like I was back in that faculty of philosophy.”


The emergence of preventive healthcare

One of her professors pointed her to a PhD position in Maastricht under Louis Boon. They met at a traditional café near Amsterdam Central Station. She’d been out late the night before, so when Boon asked her where she wanted to sit, she said, “Away from the light, please—I’m a bit hungover.” He appreciated her honesty. The PhD position involved research on health philosophy. “After my mother’s death, I’d avoided anything related to health and healthcare. But I was handed a blank cheque. I spent three months in the library, poring over all issues of the Dutch Journal of Medicine published between 1865 and 1920 to identify the social themes and debates in healthcare. I saw how preventive healthcare emerged during that period, how the concept of risk was introduced, the social debates about vaccination and the ethics of double-blind studies—fascinating sociological-philosophical themes.”

She also explored the role of insurance companies, which were the first to distinguish high-risk groups and introduce screening tests. “They screened healthy people to predict whether they would live longer or shorter lives. I analysed how this way of thinking developed and how it affected people who were refused insurance. Even then, the theme of social inequality was close to my heart: who is included in or excluded from collective care arrangements, and on what grounds?”

Single mother

Her PhD research coincided with a difficult time in her personal life. Her first child unexpectedly died at birth. “I was really out of it for a long time. But I badly wanted a child, and two years later, my son was born. My relationship didn’t survive, so I suddenly found myself a single mother. I’m now happily together with someone else, but back then, I was finishing my dissertation. I scrapped half my chapters and wrote like crazy during my pregnancy leave. I submitted my dissertation on a Friday; my son was born on the Sunday. I defended my PhD a year later.” One thing she didn’t have to worry about was putting food on the table. “I was doing a lot of teaching —philosophy and women’s studies—and I was made assistant professor within two years.”  

A good life

What does living a good and healthy life mean to her? After a moment’s thought, she says, “To be able to mean something to a few people. To have meaningful relationships; that’s what matters to me. To have the freedom to think and do what you want. To take things as they come and not make yourself too important. I don’t believe we can control our lives. You never know what will happen. Most people do their best, but you can be unlucky, and everybody makes mistakes from time to time. Let’s not judge one another too harshly, but help each other out when things go wrong. Of course we have to take responsibility, but it’s an illusion to think we can foresee and control everything. That’s why good healthcare arrangements are crucial to society.”

Text: Annelotte Huiskes

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