GBH: Greedy Bastards and Health Inequalities by Graham Scambler. Find it here: http://linkis.com/wp.me/Iv4tk Posted on November 4, 2012
Student nurses will be introduced to the Social Determinants of Health (SDoH) approach as outlined by the World Health Organisation (2008) and in the Rio declaration in 2011. The reason for this is that the UK’s Nursing and Midwifery Council state in their standards for education (2010):
“All nurses must understand public health principles, priorities and practice in order to recognise and respond to the major causes and social determinants of health, illness and health inequalities. They must use a range of information and data to assess the needs of people, groups, communities and populations, and work to improve health, wellbeing and experiences of healthcare; secure equal access to health screening, health promotion and healthcare; and promote social inclusion”.
The World Health Organisation states: “The Social Determinants of Health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries”.
I think this introduces an ethical imperative and a socio-political role for nursing (Falk-Raphael 2006) as the NMC explicitly state that nurses are to “work to improve health….”. If health has social determinants based on the ‘distribution of money, power and resources’ then nurses are required to understand what this means. Indeed public health principles are now embracing concepts such as the SDoH and going further in the Ecological Public Health approach (Lang and Rayner 2012) than traditional biomedical approaches to public health.
So what is the connection between this and the ‘GBH’?
The GBH asserted that health inequalities in Britain are first and foremost an unintended consequence of the ‘strategic’ behaviours at the core of the country’s capitalist-executive and power elite. This is where health gets political. The strategic behaviours include getting governments to reduce state regulation, tax, control, ownership and provision for public services in order to facilitate the transition to corporate ownership, provision and control of public goods such as health and education. These corporations include Mitie, Serco, GE, Virgin and Capita. They are currently negotiating the Transatlantic Trade and Investment partnership (TTIP) between the US and the EU in order to make it easier to engage in business across the Atlantic. The TTIP will also allow corporations to sue national governments if they try to block renationalisation of health services, or if they engage in environmental or social regulations that is perceived to hurt business.
Scambler argues that the ‘capitalist class executive’ (CCE) are a core ‘cabal’ of financiers, CEOs and Directors of large and largely transnational companies, and rentiers. This ‘cabal’ has come to exercise a dominating influence over the state’s political elite including those in government. Quoting David Landes, Scambler suggests:
“men of wealth buy men of power” who then enact state policy which supports their activities and interests.
The GBH suggests that the activities of capitalists and politicians result in ‘homicide’. Indeed Stuckler and Basu (2013) argue that the government policy of ‘Austerity kills’. Michael Marmot makes similar claims about government policies.
The GBH is based on an analysis of social structures, the class relationships, which benefits the core members of Britain’s rapidly globalising capitalist class executive. Scambler argues:
“financial capitalist Britain is characterized by a revised ‘class/command dynamic’ whereby class interests exercise greater sway over state policy and practice than hitherto”.
In other words, a ruling class can now exercise power and control, and can command the political state, in a way that they could not previously do so. Since the advent of the Welfare State, with its vanguard the Attlee labour government in 1945, the power and control of the CCE was tempered by social democratic forces acting below. However, the Thatcher-Reagan victories paved the way for an assault on social democratic control of the state and opened up a path for the CCE to further their interest through the capture of political levers of control.
Scambler argues that:
“anyone who doubts the thrust of this argument (should put forward) a more telling macro-analysis of the journey of the (English) Health and Social Care Bill into law in March of 2012. This Act is re-commodifying health care. Without mandate…the ConDem coalition is turning the NHS over to predatory US-style for-profit companies”.
So, the CCE are acting strategically to create a health environment conducive to corporate interests and profit; they are not interested in the social conditions of everyday life. Their activities result in the slow withdrawal of health and welfare provision by governments to allow them to provide services so that they can make money. They are helped in this by government ideology that abhors state provision for public goods such as health, education and transport, and is focused on deficit reduction through a reduction in the welfare bill. The CCE do not exist to address inequalities in income or wealth or to better the circumstances in which people are born, grow, live work or age. Their primary purpose is capital accumulation which results in periodic financial crises.
He goes on to suggest that the type of health care organization (private hospital or public hospital) and delivery (e.g. GP access) available to people is not decisive for health inequalities. In other words, differential health outcomes (mortality and morbidity rates) are based in the conditions and experiences of everyday lives, and this shows a social gradient – i.e. the lower down on the socio-economic scale you are, the worse your health outcomes.
Thus current arguments over the structure, funding and function of the NHS, is only part of the story for people’s health. We must also look to the actions of the CCE and social class relationships. It is in class relationships, and the power and action of the CCE, that we see ‘asset flows’ working in people’s lives and affecting their morbidity and mortality rates.
“The noun ‘flows’ is significant here. People do not either have or not have assets positive for health and longevity, rather the strength of flow of these assets varies through the life-course”.
So it is not about the static acquisition of wealth or material deprivation that is at work. It is about what assets flow in and out of people’s lives over the course of their life, and this is particularly important in childhood and older age.
The ‘assets’ are:
- biological, your ‘genetic inheritance’, sex, your disabilities, your long term conditions.
- psychological, your self-efficacy, locus of control, learned helplessness.
- social, your family network, community networks, friendships.
- cultural, your lifestyle choices such as smoking, or ethnic background
- spatial, where you live, leafy Surrey or inner city Glasgow?
- symbolic, your status as a ‘chav’ or as member of the elite.
- Material, your income and wealth.
It is important to stress that a strong flow of one asset can compensate for the weak flow of another.
Scambler provides examples: ‘a strong psychological asset flow (i.e. high personal resilience) can cancel out the negative propensities of a weak flow of social assets (i.e. an absence of close-knit social networks); and a strong flow of symbolic assets (i.e. high social status) can mitigate the damage liable from a weak flow of spatial assets (i.e. living in a deprived neighbourhood).
In addition, Scambler suggests that we need to understand that:
- the strength of flow of material assets (i.e. standard of living via personal and household income) is paramount. This links with the material deprivation thesis explaining the link between health inequalities and socioeconomic status.
- flows of assets tend to vary together (i.e. mostly strong orweak ‘across the board’);
- weak asset flows across the board tend at critical junctures of the life-course (e.g. during infancy and childhood) to have especially deleterious effects on life-time health and longevity: a child born with a chronic illness, into the lowest decile of income distribution, in an abusive psychological and social environment, living in damp squalid housing in which both parents smoke, in an area of high unemployment and poor access to health care and a proliferation of fast food outlets, in a culture that demonises ‘chavs and benefits cheats’…….
- weak asset flows across the board, and I daresay strong asset flows across the board, tend to exercise a cumulative effect over the life-course (negatively and positively respectively);
- the ‘subjective’ evaluation of the strength of an asset flow can exert an effect over and above any ‘objective’ measure of that flow (e.g. a symbolic asset flow perceived as weak relative to that enjoyed by an individual’s reference group can be injurious in its own right). That is, how we perceive how good or poor our ‘asset’ is, affects us even if that asset is not in itself injurious. This is the social comparison thesis or psychosocial hypothesis.
Scambler regards the material asset flow as vital or ‘prepotent’. Of all assets it is the material conditions of life that underpin much of our health outcomes. In this, Scambler is adopting a Marxist take on health inequalities. To argue that material conditions underpin all other asset flows is not to diminish their importance for health inequalities. This is only highlighting the key point of Wilkinson and Pickett’s The Spirit Level, in that that action on the reduction in income inequality is a precondition for tackling health inequalities.
Danny Dorling (2014) points to the rising levels of inequality and argues that being born outside the 1% has a dramatic effect on a person’s potential – their asset flows – reducing life expectancy, limiting educational and work prospects and adversely affecting mental health. The CCE are of course not the 1%, they are part of it but their wealth puts them more into the 0.01% of income earners.
“This last point takes us back to the GBH and the class/command dynamic that underwrites it. Our society, one in which income and health inequalities are rapidly rising, and in which policy…has allowed a Health and Social Care Act to deliver a proven cost-effective publicly-owned NHS into the hands of transnational profiteers, is slipping into a post-welfare-statist, neo-liberal abyss”.
In other words, UK society is losing its NHS as it is being sold off piecemeal to private sector providers who seek to make a profit, losing its welfare provisions, is experiencing increasing social and economic divides and which are the ‘circumstances shaped by the distribution of money, power and resources’ impacting on population health. The CCE of course do not need the welfare state or the NHS as they inhabit ‘Richistan’ providing them with private health and ‘concierge’ doctors.
Finally, a nurse argues;
“Considerable evidence suggests that neocolonialism, in the form of economic globalization as it has evolved since the 1980s, contributes significantly to the poverty and immense global burden of disease experienced by peoples of the developing world, as well as to escalating environmental degradation of alarming proportions. Nursing’s fundamental responsibilities to promote health, prevent disease, and alleviate suffering call for the expression of caring for humanity and environment through political activism at local, national, and international levels to bring about reforms of the current global economic order”. (Falk-Rafael 2006)
So there you have it, a call to engage politically to address the actions of the CCE and the political power elite to call them to account and to change social and economic conditions that result in inequalities in health.
©Benny Goodman 2014