Laudable ambitions, disappointing results

Dominic Malcolm
Loughborough University

Football as Medicine seeks to build on and extend Peter Krustrup’s 17-year project evidencing and advocating the use of football as a form of both preventative and rehabilitative medicine.  The project seeks to capitalize on football’s status as the most popular world sport and harness that popularity to engage populations in order to nudge or cajole them into adopting behaviours which an extensive body of scientific research has now shown to have health benefits. Not surprisingly this has been positively received at the highest levels of football’s administration, for it is a paradigm which enables the game to respond to the priorities of the World Health Organization, engage with the United Nations’ Sustainable Development Goals, and leverage financial support from state governments. Given the dominance of what Lupton (1995) calls the Imperative of Health in Western societies, Football as Medicine is also likely to increase or sustain participant numbers (in an increasingly competitive market place) and thus bolster the quest of the game’s administrators for greater social and political influence.

A key and interesting feature of this project has been its interdisciplinarity. For a number of years Krustrup, an exercise physiologist by training, has worked with social scientists, most notably Laila Ottesen at the University of Copenhagen. The underlying premise of this collaboration relates to the distinction between efficacy and effectiveness (Evans and Ottesen 2020) – in other words, what can be demonstrated to work in the tightly controlled conditions prescribed by the norms of natural scientific experimentation (efficacy), is difficult to translate into the fundamentally more messy and complicated social world in which individual factors (like wealth and activity levels) cannot be isolated, human life is a process rather than a time-limited intervention, and where the interdependence of politics and science is more pronounced (effectiveness). The primary intervention project to explore the effectiveness of Football as Medicine has been the development of the Football Fitness programme.

Consequently, one of the most interesting features of Football as Medicine is the attempt to embrace a mix of multiple disciplines. A variety of research paradigms are represented in this wide ranging and ambitious text, featuring 70+ contributors from at least 17 countries. The book starts by exploring the natural scientific evidence through a series of chapters discussing the physiological response to football training exhibited by patients with a variety of conditions (diabetes, cardiovascular disease, cancer patients), and considers the relevance of this for certain target populations (young, old, socially deprived), before discussing some psychological theories of motivation that could be deployed to nudge or cajole the population to increase participation in football. This is followed by a chapter on the physiological benefits of a range of team sports other than football (which seems an odd choice!), before a second half which is more social scientific in orientation. The latter chapters explore aspects of the physical activity, healthy eating and (restriction of) tobacco consumption of football fans, the relationship between football and mental health, the use of digital technologies and fitness apps to track activity levels of football fans, and issues around the implementation of Football Fitness and physical activity policies more generally.

Forums that encourage interdisciplinarity – like Football as Medicine does – are to be welcomed. It is becoming increasingly clear that the major issues confronting humanity (such as population activity and associated levels of obesity) cannot be addressed by isolated disciplines working behind exclusionary boundaries. It is as necessary that social scientists explore the material reality of the human body as it is that natural scientists recognize the social determinants of health, for the experiences of moving a ‘fat’ and a ‘thin’ body (however we might debate those definitions) are distinct, and the choices particular people make to exercise exist within a spectrum pre-defined by broader structural issues such as gender and socio-economic status.

It is becoming increasingly clear that the major issues confronting humanity (such as population activity and associated levels of obesity) cannot be addressed by isolated disciplines working behind exclusionary boundaries

But while it should be recognised that interdisciplinary research is particularly challenging, and Football as Medicineshould be lauded for attempting to bring these diverse perspectives together in one text, the degree to which they inform each other and provide a genuinely interdisciplinary collection is something of a disappointment. Frequently the physiological and the social are kept apart. The chapter on ‘Football at the Workplace’ encapsulated this sense of disappointment for me as it started with a discussion of gender, class and the social determinants of health, and then reported a series of physiological measures taken during a football intervention programme involving female hospital employees. Following a conclusion which made no reference to these previously discussed social factors but simply concluded that playing football in the workplace may be physiologically beneficial for female hospital employee’s health, is a 3-page discussion of the qualitative data derived from 5 participants in the trial. What seemed to have started as an interdisciplinary project, concludes with little knowledge exchange or paradigmatic cross-fertilization. The book as a whole, moreover, is multi- rather than interdisciplinary and the task of pulling these different strands of knowledge together is left to the reader.

In two further senses the Football as Medicine disappoints on its ambitious goals. Firstly, much of the content of the book is far less critical than anticipated. Criticality is both implied – the book appears in Routledge’s Critical Research in Football series – and claimed, as the editors’ introduction explains to the reader, e.g., that the chapters ‘aim to provide sharp, critical analysis of key features and topics … Each chapter critically analyses its respective area’. But if there is a critical voice in the book, I could not find it. Jean-Marie Brohm’s views on sport as an opiate of the masses are dismissed as somewhat ‘alarmist’, and the use of digital technologies to track human activity is described as a ‘hot topic’ because of the ‘potential and versatility’, as opposed to any concerns about the unwarranted corporate surveillance and economic exploitation of personal data, consent for which is given in an impenetrable set of terms and conditions that few people ever read.

Indeed, the concluding chapter pretty quickly passes over the body of work that ‘challenged [ideologies regarding] the social impact of sport, claiming a lack of empirical evidence’ and states that ‘it is now beyond doubt that regular physical activity … is an important part of the foundation of a happy, healthy and longer life’. Not only is that a fundamentally uncritical statement, it’s also highly dubious. The studies in this book may show that people who exercise/playing football enjoy exercise/playing football, and that people find exercise/playing football a useful addition to the armoury of interventions needed to address underlying mental health issues, but they do not show that people who exercise are happier than those who don’t. Equally, the presence of many highly physically active populations across the world who have relatively low live expectancy would raise questions about the associations being drawn in this claim.

A study claiming to be critical should really have made some reference to the body of critical work that exists on the subject at hand, if only to try to refute it.

I recognise that my sensitivity to this point is derived from the social science bias of my perspective, but it is also informed by the basic premises of scientific investigation regarding the recognition of the limitations of any data set, and confusing correlation with causation. For a more critical reading of this broader paradigm of research, I would point readers to the recent EJSS editorial by Evans and Ottesen (2020) and the “Exercise is Medicine” special issue of Qualitative Research into Sport, Exercise and Health (Cairney et al. 2018). These voice fundamental conceptual, ethical and social concerns about claiming that any form of physical activity can be equated with medicine. A study claiming to be critical should really have made some reference to the body of critical work that exists on the subject at hand, if only to try to refute it.

Second, and despite the impressive number and international representation of contributors, the contents rarely speak to the book’s subtitle ‘Prescribing Football for Global Health Promotion’. It does not conclude as the introduction promises it will with a discussion of how Football as Medicine ‘can be taken up and applied by health workers and policymakers around the world’.  The content is largely Euro-centric with glimpses of a broader perspective. When I saw the picture of Denmark’s Crown Prince promoting Football Fitness in China, I really wanted to know more about the practicalities of that particular process of cultural diffusion. Similarly, on learning that just 20 of FIFA’s 209 national associations had adopted the 11+ injury prevention programme I would have been very interested in an explanation that went beyond simply noting the failures of individual national associations, and discussed the difficulties of implementing largely Western inspired and designed programmes into culturally diverse contexts.

Without doubt the book reports on a movement that has considerable potential to enhance the lives of significant proportions of the world’s population. Football as Medicine also represents the most comprehensive and holistic consideration of this movement to date. As the authors of the book’s Foreword write, this is an important and unique book. Like them I too support the vision of Peter Krustrup and colleagues. I also applaud the ambition. But I think a more reflective, rounded, and ultimately interdisciplinary approach is fundamental to achieving those particular goals.

Copyright © Dominic Malcolm 2020

References

Cairney, J., McGannon, K. and Atkinson, M. (2018) Introduction. Exercise is medicine: critical considerations in the qualitative research landscape, Qualitative Research in Sport, Exercise and Health. 10(4): 391-399.

Evans, A. and Ottesen, L. (2020) Football is/as medicine: the growth of a health promotion movement and a challenge for sociologists. European Journal for Sport and Society, 17(1): 1-10.

Lupton D. (1995) The Imperative of Health. Public Health and the Regulated Body. London: Sage.