How responsible am I for my health?
The answer to that question from the dominant discourse is an overwhelming “very”.
This response sits alongside more scholarly understandings of the social determinants of health. This ‘upstream’ understanding is open to ‘Lifestyle Drift’ , ‘downstream’, responses to health. Lifestyle Drift is:
“the tendency for policy to start off recognizing the need for action on upstream social determinants of health inequalities only to drift downstream to focus largely on individual lifestyle factors” (Popay et al 2010)
McKenzie et al (2016) argue:
“Although policy documents may state that the causes of poor health or inequalities in health are to do with poverty and deprivation, the interventions which actually operate on the ground focus much less (if at all) on changing people’s material circumstances and rather more on trying to change behaviours (which are in fact heavily shaped by material circumstances)”.
Nurses might understand the concept of the social gradient in health inequalities but drift into advocating lifestyle changes for the individual, centring around smoking, diet, and exercise messages.
So why is this happening? Why resort to lifestyle approaches to health when we know health is largely socially and politically determined?
One answer is that lifestyle answers fit within the neoliberal social imaginary which individualises health and social problems and seeks market solutions to those problems. Neoliberalism is a doctrine well known to many scholars and academics but is hardly mentioned in popular discourse. To understand responses to health inequalities and poverty , we need to understand the tenets of neoliberalism underpinning much of current thinking:
- Neoliberalism sees competition as the defining characteristic of human relations. Therefore competition between service providers should be introduced into the NHS.
- It redefines citizens as consumers, whose democratic choices are best exercised by buying and selling, a process that rewards merit and punishes inefficiency. So patients can and should choose between hospitals and GP practices as consumers of health care using their purchasing power (not yet realised in the NHS). This way, poor service providers should go out of business.
- It maintains that “the market” delivers benefits that could never be achieved by planning. Therefore NHS = bad, US private health insurance = good; BBC = bad, SKY/Fox = good; British Rail = bad, Great Western/Virgin = good; Royal Mail (state owned) = bad, Royal Mail (privately owned) = good.
- Attempts to limit competition are treated as inimical to liberty. Thus socialised NHS service provision must be broken up to allow freedom in the market. The BBC must be sold off because it is unfair competition for Sky.
- Tax and regulation should be minimised, thus the use of offshore tax havens, reduction in top rate of tax, mistrust of EU environmental standards and hatred of health and safety regulations.
- Public services should be privatised. The Health and Social Care Act 2012 facilitates this, there may well be more to come for the NHS.
- The organisation of labour and collective bargaining by trade unions are portrayed as market distortions, that impede the formation of a natural hierarchy of winners and losers. Unison, RCN, BMA etc, must have their power curtailed. The Junior doctors cannot be allowed to win or else it will be a victory for organised labour.
- Inequality is recast as virtuous: a reward for utility and a generator of wealth, which trickles down to enrich everyone. Those at the bottom require incentives to better themselves, therefore benefits need cutting, those in the middle will benefit from wealth creation.
- Efforts to create a more equal society are both counter-productive and morally corrosive. The market ensures that everyone gets what they deserve. The arguments from books such as ‘The Spirit Level’ are therefore irrelevant. If there is a social gradient in health then this is the natural outcome of people’s decisions and choices and any attempt to change this invokes ‘moral hazard’ arguments; that is if people know they have a safety net (someone else takes the risk) they will not try to avoid poor choices.
(Monbiot 2016 The Zombie Doctrine)
|Tory Rituals on poverty:
· Blame the individual for their illness and poverty.
· Benefits cause dependency , repeat this ad nauseam.
· Deny any political responsibility for ill health, emphasise culture as causative.
· Deny the ‘social’ exists, there are only individuals
· Privilege wealth through tax breaks and preferential treatment.
· Deny one’s own privilege as a white affluent male.
These attitudes underpin the ideology of neoliberalism.
For a statement about what the Conservative Party should be about see: ‘Direct Democracy – an agenda for a new model party’ (2005) especially the chapter on health:
“The problem with the NHS is not one of resources. Rather, it is that the system remains a centrally run, state monopoly, designed over half a century ago”.
All of this results in the politics of blame and shifting responsibility for health fully onto individuals.
If material health assets are paramount, poverty and our response to it is a foundation for understanding health in society. Poverty can be defined as 60% of the median income or using the ‘consensual method’ it is “enforced lack of necessities determined by public opinion”.
However, the UK government’s position is that poverty is not caused by lack of income. Based on Charles Murray’s idea of the ‘Culture of Poverty’, poverty is a result of individual deficits, as Kitty Jones writes:
“the poor have earned their position in society, the poor deserve to be poor because this is a reflection of their lack of qualities, poor character and level of abilities”.
Kitty Jones has written clearly on this issue in 3 blogs, which can be found here.
The alternative view, expressed in for example the ‘Greedy Bastards Hypothesis’ is that poverty, and health inequalities, is caused by the rich, often through unintended consequences of their actions but also through design. It results from structural socio economic conditions that neoliberal governments encourage: for example, low wages, withdrawal of benefit provision and the use of offshore tax regimes. Osborne’s ‘living wage’ is a cynical political manoeuvre designed to woo middling swing voters rather than to address structural economic issues such as under and unemployment , lack of investment in a green economy, deficits in the housing stock and affordability and a zero hours, self employed precarious job structure.
Nurses offering health advice, are not immune to this dominant discourse. It suffuses health advice on such sites as NHS choices and is supported by health campaigns which focus on changing individual habits. Action on social inequalities as root causes for ill health sits within specialised public health literature, for example ‘Fair Society, Healthy Lives’, and unless nurses are exposed to an alternative perspective they will naturally draw upon dominant explanations for health inequalities. These are often either biologically/hereditarian explanations* or a ‘moral underclass discourse’ (Ruth Levitas) or a mix of the two. The politics of neoliberalism encourages the latter perspective.
Benny Goodman 2016
*See Chapter 4 in Psychology and Sociology in Nursing Goodman 2015 for explanations.
Watch Richard Wilkinson discuss inequalities at a TED talk.