Category: Capitalism

Hunt’s agenda

The ideology of health care provision.

 

 

Amid the junior doctors strike of 2016, the health secretary Jeremy Hunt was embroiled in a conflict with the BMA over doctors’ contracts designed to address a 7day NHS. This is the surface issue but sits upon a deeper ideological conflict, one that many of the doctors will be unaware of but will suspect, especially if they have read Alysson Pollock’s works on the privatisation and corporatisation of the NHS. Hunt argued he has a ‘mandate’ to introduce a 7 day NHS and perhaps realises that if this policy cannot be introduced, the balance of power over the future of the NHS will swing back towards the BMA and other health professional groups. The irony is that the BMA opposed the introduction of the NHS back in 1948 but now is one of the strongest supporters. Since 2012 however, the NHS has been dismantled and been replaced with privatised and corporatized service provision, with ‘patient choice’ and ‘patient safety’ being used as the ideological veil which masks the corporate face. People have not noticed this detail because so far ‘free at the point of delivery’ is still in place, but this principle, along with universal and comprehensive cover, is under threat. The government remain the almost monopoly purchaser of health services on our behalf but for how long? The care home crisis points in the direction of travel. This will be withdrawal of state funding and reliance on private provision which will not be ‘free at the point of delivery’.

 

 

 

In 2005 ‘Direct Democracy – an agenda for a new model party’ was published, the authors include the current health secretary Jeremy Hunt. It is not government policy and does not represent the full range of conservative views. The Tory party itself is home to those of a ‘one nation’ persuasion who mix ideas of ‘noblesse oblige’ with a modicum of a social welfare, safety net, public service ethos. It is also home to ‘neoliberalism’ rooted in anti State sentiment based on freedom of the individual and free market economics. This ideology can be clearly seen in the 2012 book ‘Britannia Unchained – Global lessons for growth and prosperity’ which argues for further free market economics based on a bonfire of employment laws. The book suggests:

 

“The British are among the worst idlers in the world. We work among the lowest hours, we retire early and our productivity is poor. Whereas Indian children aspire to be doctors or businessmen, the British are more interested in football and pop music.”

 

This one quote conveys the disdain neoliberals have in general for those less well paid, less “successful” and less powerful than themselves. Boris Johnson’s speech in 2013 on the impossibility of equality being based on differences in IQ, implied some people are too stupid to get ahead. This individualises issues, while ignoring structures of class, gender, ethnicity and privilege. He said:

 

And for one reason or another – boardroom greed or, as I am assured, the natural and god-given talent of boardroom inhabitants – the income gap between the top cornflakes and the bottom cornflakes is getting wider than ever. I stress: I don’t believe that economic equality is possible; indeed, some measure of inequality is essential for the spirit of envy and keeping up with the Joneses that is, like greed, a valuable spur to economic activity.”

 

Two ideas are core here: that the working class and the poor are so because they are more lazy and stupid than the ruling class, and that the answer to this is to increase competition and to use inequality as incentives for personal improvement. Of course said like that to the electorate, it would seriously threaten voter support. Instead the discourse of market efficiency, effectiveness and choice is used to justify privatization and corporatization of public services. The message to the public is clear: take responsibility for education, health, social care and housing. It is down to individuals and families to provide by working hard and being prudent.

 

The arguments over the NHS have to be seen within this wider context. At heart, many in the current Tory party viewed the state run NHS as anathema. As such they have succeeded in dismantling the post war structure of the NHS following the Health and Social Care Act 2012. This allowed for private providers to bid for the provision of health services but keeps in place, for now, principles such as ‘free at the point of delivery’.

 

According to Alysson Pollock, the Health and Social Care Act 2012:

 

  1. Removed the duty of the Secretary of State for health to secure and provide health care for all.
  2. Introduced US style insurance schemes.
  3. Gives the secretary of state legal powers to create a market, allows providers to pick and choose which patients will get care, services to be provided and what will be charged for.

 

A market has been introduced into health service delivery, and markets operate through risk selection and appraisal resulting in fragmentation of provision. That is to say a market provider needs to pick and choose which patients are profitable in competition with other providers. We now have clinical commissioning groups modelled on insurance based lines. Those with high risk or multiple needs will be expensive to provide care for.

 

The ‘NHS’ is now fragmented in which:

 

  1. Services are broken up and put out to tender to commercial companies.
  2. Commercial shareholders have new legal powers to decide who gets care, what the get and what they pay for.

 

This current state of affairs is not enough for neoliberal thought. So what is the vision of this group of neoliberal Tories? How did this happen?

 

Direct Democracy argues:

 

“Several other countries operate political systems based on localism and direct democracy. Two outstanding examples – one much smaller than the United Kingdom and one many times larger – are Switzerland and the United States. In their different ways, both states respect the principles of the dispersal of power, the direct election of public officials and the use of the referendum as a legislative tool. Our proposals for the devolution of power directly to the citizen – notably in the fields of education and health care – have also been successfully trialled abroad, often in unlikely places. No less corporatist a state than Sweden has introduced a form of school voucher, while almost every state in Europe, at least since the fall of the Berlin Wall, now provides for an element of health insurance”.

 

This goes to the heart of the matter, note how the US and the Swiss are held up as models. The principles of localism and direct democracy are invoked as justifications hiding their argument and belief about market mechanisms. The United States is a beacon for the dispersal of power? One cannot expect anything other than this nonsense from neoliberals, wilfully ignorant as they surely must be of the work of C Wright Mills, Herbert Marcuse, Jurgen Habermas, David Harvey, Thomas Picketty, Graham Scambler, and Yanis Varoufakis? This also ignores the literature on social inequalities and inequalities in health and the social and political determinants of health. At this point we must also point to the wealth of feminist and post-colonial literature on ‘power’. In short it is an invocation of bourgeois patriarchal perspective on the exercise of power which blinds them to actuality.

 

As for Switzerland, the OECD reports that compared to the UK’s 9.3 % of GDP, the Swiss pay 11.4%. The UK used to pay under 6% but has seen a rise, not totally due to actual health spending but to cater for administration and profit for private companies. The US spends 16.9% (OECD 2014) and has introduced ‘Obama care’ to address the plight of uninsured americans. Obama care is an outcome of class struggle which has been hotly contested in the ‘land of the free’.

 

 

 

‘Direct Democracy’ claims to hold to three principles:

 

  1. Decisions should be taken as closely to the people they affect.
  2. Law makers should be directly accountable.
  3. The citizen should enjoy maximum freedom from state control.

 

 

On the face of it who would argue with that? Certainly not anarchists, socialists or libertarians. The problem is that these principles exist within a social and historical context, one characterised by imbalances of power along class, gender and ethnic lines and this cannot deal with the reality on the ground. Hunt et al are blind to the context in which ‘men of wealth buy men of power’, a world in which the capitalist class executive and the political power elite exercise a new class/command dynamic which neoliberal ‘reforms’ ushered in since about the 1980’s especially in the US and UK.

 

Yanis Varoufakis (2016) clearly discusses the effects of such things as the “Nixon Shock’ on the post war global financial settlement, the outcome being that the ‘strong do what they can and the weak suffer what they must’. Global health corporations need new markets and looked to the UK’s NHS as a source of rich pickings. This is the context in which Hunt’s bourgeois democracy operates.

 

  • Decisions about who provides health care, what health care looks like and where it is provided are taken by unelected clinical commissioning groups operating within a profit driven market context.
  • Patients do not have an electable secretary of state who has a statutory obligation to provide health care services.
  • Freedom from state control for health service provision has morphed into control via corporate decision making.

 

 

Direct Democracy (2005) argues:

 

‘The problem with the NHS is not one of resources. Rather it is the system remains centrally run, state monopoly designed over half a century ago’ (p74).

 

Clearly this is a statement that ‘the system’ needs to go. The resource issue in the context of increasing demands and costs is brushed aside. This remark now looks questionable at best in 2016.

 

“We should fund patients either through the tax system or by way of universal insurance, to purchase health care from the provider of their choice. Those without means would have their contributions supplemented or paid for by the State.” (p74).

 

Holding on to a notion of ‘free at the point of delivery’ implied here, it is clear that private provision is to be introduced. The language is anodyne, context free, taking no notice of what private provision might look like, who would provide it and what the consequences of the inevitability of a market might be. The State at least has a role in providing for the poor. The writers of this document are part of the political power elite, or may wish to be, and the coherence of interests with the corporate/capitalist class executive are hidden. Those who sell insurance have not been lobbying for this change then? A bit of research into who benefits from this change might prove insightful. Are there links between corporate interest and the politicians who are driving the changes?

 

Hunt et al feared the NHS would only be second to the US in terms of % of GDP spent. This has not occurred. They report a study ranking the UK 18 of 19 countries. This is selective in the extreme, and is now way out of date.

 

Many of the critiques they evoke of the NHS are a result of the rise of new public management, or ‘managerialism, introduced into the system by previous governments both New Labour and Tory. For about three decades managerial control, targets and distrust of professionals have eroded the ability of the NHS to be the best in the world.  The judgment about the efficiency and effectiveness of health services partly depends on what criteria are being used to judge them. The % spend of GDP is a crude figure as it hides a plethora of costs and profits.

 

Other measures of success could include universality of access, comprehensiveness of cover, mortality and morbidity outcomes, and the publics’ safety and satisfaction.

 

Mark Britnall has written ‘In search of the Perfect Health System’ (2015) of the complexity of comparing health systems. Britnall is no Tory ideologue and describes his approach as more brown mud than blue sky thinking:

 

He also wrote in 2011 before the 2012 Act:

 

“[o]f course, the vast majority of care – quite rightly in the UK context – will always be provided by public sector organisations (currently, about 95% of it) and will be paid out of taxation” and “[t]he issue of competition, which now seems to be conflated with privatisation, is unhelpful and misleading and, at best, only a small part of reform. Competition can exist without privatisation and the NHS can maintain its historic role in funding care while dealing with a richer variety of providers – public sector, social enterprise and private organisations”.

 

This 2011 comment predated the 2012 Act and can be seen as a statement of intent than actuality on his part. In 2010 there was some controversy over his statements in the US about private provision.

 

One area in which private provision is facing severe challenges is the care home sector.

 

Roy Lilley, writes a daily blog, and has considerable experience in the health service and with private sector organisations. He is no left wing radical. He writes in ‘They don’t matter’ (3rd May 2016) that success in private provision in the community has been ‘patchy’, citing Circle’s loss of £5 million and the paying of another £2 million to get out of the Hinchinbrooke contract, while SERCO and Bupa ‘bailed out’ of provision leaving Virgin clinging on. He argues that the private sector can be nimble and quick to adapt, but of course needs to make a profit.

 

However, the largest care home provider, Four Seasons, is in talks to ‘restructure its debt’ as they face a 39% drop in profits. Most of their ‘customers’ have their fees paid by social services. This amounts to some local authorities paying £385 per week which is just not enough. The living wage is also an issue for them, they have over 30,000 staff but with no way of adjusting prices to pay for the increase and with no operating surplus. It has a debt of £510 million. If Four Seasons go broke they have 450 care homes at risk.

 

The bottom line is that health and social care costs money. There is not enough money in the system to pay for the care required. Some private families are paying £1,250 per week. Company Watch data which covers 20,000 homes, indicates that there is a funding black hole of half a billion pounds. This is market failure due to inadequate funding by design. It is almost as if the government is deliberately forcing people to find the money themselves either through savings, insurance or property while state funding through local authorities is slowly wound down.

 

Mark Britnall’s approach is scholarly, based in experience managing health care organisations and a deep knowledge and overview of many health systems. However, is Britnall sufficiently aware of the political economy of neoliberalism and its agenda for health?  Roy Lilley’s highlighting of the care home crisis clearly shows the political, austerity driven nature of the issue.

 

‘Direct Democracy’ and ‘Britannia Unchained’ are ideological approaches to health and social care. Whether Hunt has the temper for addressing Britnall’s insights or whether he still stands by the document he co-wrote is anyone’s guess. However, I know where the smart money would go. His face down of the doctors is more to do with power and who exercises it rather than the future of the health service as we knew it. If the neoliberals can get away with it, then free at the point of delivery will be severely challenged perhaps using spurious arguments stigmatising drug users, alcoholics, smokers, the obese, self harmers, self inflicted sports injuries, prostitutes, the promiscuous and Johnson’s ‘stupid’ as a wedge driven between the deserving and the undeserving ill. The care home crisis indicates that older people are ignored and the costs increasingly privatised as the state withdraws, or should we say abdicates, support. The NHS was to socialise risk, to spread its cost across the whole population. Instead we are rapidly moving towards individualising risk and private insurance based provision as the state withers away.

 

The neoliberal revolution and Health

Neoliberalism has various meanings, but many commonalities (Hall, 2011). Nurses in the UK’s NHS, alongside their colleagues elsewhere, may not be familiar with the term but they will be familiar with its effects on service delivery, patient care and of course their own working conditions (Abramovitz & Zelnick, 2010; Gonçalves et al., 2015; Horton, 2007; Reiger & Lane, 2013; Wright, 2014).  Stuart Hall outlines the main ideas underpinning what he calls the ‘neoliberal revolution’ (Hall, 2011). This is useful for nurses in order to first understand and then to act.

 

The main ideas according to Hall (2011) are:

  1. It is grounded in the idea of the ‘free, possessive, individual’; a concept understood in classical economics as ‘homo economicus’ – the rational actor in a market weighing up costs and benefits of consuming decisions according to price signals. Therefore:
  2. The State must not govern society or dictate to individuals how to dispose of their private property.
  3. The State must not regulate the free market.
  4. The State must not interfere with ‘God Given’ rights to make profits or to amass personal wealth.
  5. The State is tyrannical and oppressive.

 

In the health service it means:

 

  • The State should not really be running hospitals. Instead private sector companies, and health care professionals should offer their services for a fee. These providers should compete in a market
  • Patients are not really patients but consumers of health care services and so should decide what they want, when they want it and where they want it.
  • The State should not tax the public to pay for health services, instead there should be private health insurance or provision by family, charity and friends.
  • The NHS gets in the way pf private sector companies money making services by distorting the market.
  • There should not be any national pay and conditions for service providers, that should be decided by the market, so where demand outstrips supply the price (wages) should go up.

 

 

 

Abramovitz, M. & Zelnick, J. (2010) ‘Double jeopardy: the impact of neoliberalism on care workers in the United States and South Africa’. International journal of health services : planning, administration, evaluation, 40 (1). pp 97.

 

Gonçalves, F., Oliviera-Souza, S., Gollner-Zeitoune, R., Leite-Adame, G. & Pereira do Nascomento, S. (2015) ‘Impacts of neoliberalism on hospital nursing work’. Texto contexto – enferm., 24 (3). pp 646-653.

 

Hall, S. (2011) ‘The neoliberal revolution’. Cultural Studies, 25 (6).

 

Horton, E. (2007) ‘Neoliberalism and the Australian Healthcare System (factory)’. Proceedings 2007 Conference of the Philsophy of Education Society of Australasia. Wellington. Available at: http://eprints.qut.edu.au/14444/1/14444.pdf (Accessed: 7th December 2015).

 

Reiger, K. & Lane, K. (2013) ”How can we go on caring when nobody here cares about us?’ Australian public maternity units as contested care sites.(Report)’. Women and Birth, 26 (2). pp 133.

 

Wright, S. (2014) ‘Cash v compassion: underpaid care workers expose the battle between the profit and the service ethos, says Stephen Wright.(Reflections)’. Nursing Standard, 29 (1). pp 26.

 

How responsible am I for my health 2

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.

·         Divide population into:  skivers v strivers, deserving v undeserving poor, low achievers v high achievers.

·         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.

https://www.facebook.com/groups/Sociologyhealthnursing/

 

 

 

 

 

 

To the Guardian: A Political Manifesto for Nursing in unjust times

A Political Manifesto for Nursing in unjust times

 

Despite general satisfaction and support for nurses and the NHS by the public, there are continuing issues that threaten to undermine the trust given by the public, and to the health and wellbeing of the public. These issues include the health and social care needs of older people, care for people with mental health problems and inequalities in health as outlined in ‘The Spirit Level’. Junior Doctors are currently flexing their political muscles while public health professionals have been engaged in civic and political advocacy supported by such organisations as ‘The Equality Trust’.  The political ‘nursing voice’ has yet to be clearly heard.  To do this we propose an ‘Action Nursing’ which should:

 

  1. Equip all nurses with an understanding of the social, political and ecological determinants of health.
  2. Encourage and support nurses to confront vested interests through action at local, national and international level, by providing them with evidence, analysis, justification, critical concepts and theories and thus confidence to speak and to act.
  3. Create a network of clinical and academic nurses, and other co-opted health professionals, to argue and publicise the requirement to ‘speak truth to power’ and to engage in civic, academic and professional activity as part of a wider social movement from below.
  4. Seek and encourage research applications by nurses, alongside other academic colleagues, to continue to add to the body of scholarship on health inequalities and the politics of health care.
  5. To work with any of the Royal Colleges, and any interested parties, on political and civic action.

 

Acknowledging that many health professionals have been engaged in political action already, Action Nursing should encourage the wider body of nurses, and their health colleagues, into organised, confident civic and political action on their own working lives and the lives of the people they work with and for. Without this action, nursing and nurses may continue to be largely ignored, and thus relatively powerless, to change the experiences of vulnerable groups in society, i.e. most of us, the 99%, at some point in our lives.

Choose your parents

Alejandro Nieto.

Bernal Heights. San Francisco.

What has the death of a young man, shot by four police officers in a park in California got to do with with understanding health outcomes in the United Kingdom?

Mary Sue and Miriam. Two women born at similar times whose grandparents came from the same small town in the United States. One will be going to an Ivy League University while the other struggles with drugs and hopelessness writing on her Facebook page ‘Love hurts, Trust is dangerous’.

What links them is that Alejandro and Mary Sue ‘chose the wrong parents’, while Miriam chose wisely, a Harvard professor for a grandfather (Robert Putnam), and University educated parents.

Their cases illustrate that health and well being is ‘structured but not determined’, that to truly understand their life chances we have to consider the transformations in society that impact on the choices made and opportunities open to individuals and their families.

Alejandro was born to Mexican immigrants who came to San Francisco in the 1970’s. His mother worked all her life while his father took on most of the child care duties. San Francisco has a history of immigrants from other parts of the US as well as from elsewhere. Being Hispanic in California is ‘normal’ but not to the white, male, educated tech engineers from Silicon Valley who have moved to the area en mass ushering in gentrification and myopia. Alejandro was described to the Police as probably ‘foreign’ who had a gun, his red jacket marking him out as a gang member. All of this was supposition and assumption. Alejandro had lived in Bernal Heights all of his life, the gun was a taser, carried because he worked as a security guard. His red jacket was a sports jacket, the colour of the local sports team the 49’ers. Those doing the describing were white tech engineers making assumptions about behaviour. Indeed, Alejandro was holding a taser, but he had just been harassed by a dog barking and jumping up at him to get at his chips. The dog owner was 40 feet away, distracted by a ‘jogger’s butt’ and unable to keep his dog under control.

The police arrived, and shot him, one unloading over 20 bullets and had to reload.

Alejandro, Mary Sue and Miriam live at a time when the United States is experiencing growing inequalities in wealth, segregation in its communities, family instability and a collapse of both good working class jobs now being followed by a squeeze on middle class opportunities. While the wealth of the 1% has increased based on their increased share of wealth being created – they are getting an even bigger slice of the pie, working class incomes have stagnated. Mary Sue’s grandfather used to have a decent income from a solidly working class job, now gone leaving ‘flexible’, low paid insecure work.

As economies restructure, as cities adapt to new social conditions, people experience changing social structures that enhance or diminish their chances. The white Ivy League tech engineers are likely to know only other white Ivy Leaguers, to come from Ivy League parents, went to the same schools and know only their own kind in a networked bubble of privilege, social myopia and self satisfying smugness. They don’t know the ‘other’ and can thus label a sports fan as a gang member with in this case lethal consequences.

Perhaps representing their views:

“I know people are frustrated about gentrification happening in the city, but the reality is, we live in a free market society. The wealthy working people have earned their right to live in the city. They went out, got an education, work hard, and earned it. I shouldn’t have to worry about being accosted. I shouldn’t have to see the pain, struggle, and despair of homeless people to and from my way to work every day.”

 

So ‘free market society’ justifies the breakdown of community, segregation, inequality, fear and mistrust. Wealth is ‘earned’ rather than a result of circumstances (right time, right family, right ethnicity, right gender, right neighbourhood, right education, right opportunities and often the inheritance of not only financial but social and cultural capital). Indeed, no one should have be be accosted, no one should see pain and struggle and despair, but don’t blame the victims of unjust social, political and economic systems. Don’t blame the dog for barking when someone’s kicked it.

Alejandro’s ‘personal trouble’ (being shot) is now a public issue. When only one young man is shot by police, we might consider the character of the man and look to him as an individual for reasons and solutions. When hundreds of young men are being shot by police this individual analysis is no longer useful, we must look to social structures, to link personal stories to this point in time in this particular society.

Miriam can look forward to a bright future, she experienced great parenting, great education backed up of course by well resourced material assets. Mary Sue, is a single parent with no education, self harm, a drug habit and abusive partners. Her child will very probably not go to Harvard. Alejandro made the mistake of being born Hispanic and thus a potential threat to the White denizens of a newly gentrified neighbourhood.

If you are struggling to apply this to the UK context, you don’t know the truth and you lack the ‘sociological imagination’.

Alejandro’s story is in Rebecca Solnit ‘Death by Gentrification’. Opinion. The Guardian. March 22nd 2016.
Mary Sue and Miriam’s story is in a talk by Robert Putnam to the RSA in London, March 2015, on ‘Inequality and the Opportunity Gap’. https://www.thersa.org/discover/videos/event-videos/2015/10/robert-putnam-on-inequality-and-opportunity/#

The missing two C’s – commodity and critique

http://tinyurl.com/the-missingtwoCs   This is the link to the published article in the Journal of Research in Nursing.

This discussion paper argues for understanding nursing care as a commodity within capitalist relations of production, ultimately as a product of labour, whose use value far exceeds its exchange value and price. This under recognised commodification of care work obscures the social relationships involved in the contribution to the social reproduction of labour and to capital accumulation by nursing care work. This matters, because many care workers give of themselves and their unpaid overtime to provide care as if in a ‘gift economy’, but in doing so find themselves in subordinate subject positions as a part the social reproduction of labour in a ‘commodity economy’. Thus they are caught in the contradiction between the ‘appearance’ and reality. A focus on the individual moral character of nurses  (e.g. the UK’s 6Cs), may operate as a screen deflecting understanding of the reality of the lived experiences of thousands of care workers and supports the discourse of ‘care as a gift’. The commodification of care work also undermines social reproduction itself. Many nurses will not have tools of analysis to critique their subject positioning by power elites and have thus been largely ineffectual in creating change to the neoliberalist and managerialist context that characterise many healthcare and other public sector organisations. The implications of this analysis for health care policy and nursing practice is the need for a critical praxis (an ‘action nursing’) by nurses and nursing bodies, along with their allies which may include patient groups, to put care in all its guises and consequences central to the political agenda.

 

NHS Dissatisfaction levels are perhaps not yet high enough to embolden the political power elite to further uncouple NHS principles from actual delivery, but they might be going in the right direction.

How satisfied with the NHS are we? The British Social Attitudes Survey has been tracking satisfaction levels since 1983. In 2011 it reached the highest it had been (64%), much higher than the 39% recorded in 2001. In 2000 there was a large rise in funding and according to John Appleby (Kings’ Fund) the change upwards might reflect that extra funding. In 2010 the rate had hit 70%, while in 2015, 65% stated they were quite or very satisfied, with dissatisfaction at a low of 15%. Now, in 2016, dissatisfaction rates have hit a 23% ‘actively dissatisfied’.

 

For trends see the graph at:  http://www.bbc.co.uk/news/health-35527318)

 

 

So, should we read anything into these figures? The “NHS’ is a complex set of organisations and services, and is affected by such external factors such as social care. It is probably foolish to peg changes in attitudes to any one factor (such as funding or waiting times). The survey does provide some information as to why those who are dissatisfied say so:

 

The stand out reason is taking too long to see a GP (60%). Interestingly only less than 5% state ‘stories on TV or radio’. However, 6 reasons above that are also gained by reading the press, watching TV as well as being supplemented by actual experience of friends and family.

See reasons at http://www.bbc.co.uk/news/health-35527318)

 

The figures cannot be directly tracked to funding or political party. The background of the Health and Social Care Act 2012 has not on the face of it made a difference to people’s attitudes. The high rate of satisfaction in 2010 of 70% has dropped to around 60% since, while dissatisfaction has only just started to rise again from the 2011 level.

 

If you want to change the way the NHS is funded, this survey is still an issue. Too many people like it the way it is, “free at the point of delivery” is a possible reason. Social Care (means tested) ranks the lowest on these satisfaction scores and might indicate that funding is a real issue for people.

 

 

The context for this includes 4 assumptions held by governments over the past 25 years: Neena Modi in the Guardian writes:

 

  • Personal responsibility for health supersedes government responsibility.
  • Markets drive efficiency.
  • Universal healthcare is unaffordable.
  • Healthcare is a business.

 

For example, Christopher Smallwood wrote ‘Free at the point of use’ has had its day and argues for private health insurance.

 

Each one of these assumptions are questionable and draw upon a certain view of the role of the state vis a vis the private individual (neoliberalism). Alongside that there are profit making health care organisations looking for new business opportunities that the relatively closed NHS used to block. Graham Scambler’s ‘Greedy Bastards Hypothesis’ suggests that health inequalities are the unintended consequences of the actions of a core cabal of the ‘capitalist executive’ who, aided by the ‘political power elite’ engage in business activities aimed at capital accumulation which includes commercialisation of health services for profit. The Health and Social Care Act 2012 provided an opportunity for just such private sector involvement. A problem for the private sector is that much demand for services comes from an increasingly ageing population whose needs are difficult to make a profit from.

 

 

There are very real discussions to be had about the sort of health service we want and the principles that should underpin it. There is now increasing argument for a rolling back on its founding principles of universal access, comprehensive coverage, equity of service and free at the point of delivery all in the name of ‘affordability’ underpinned by an ideology that deplores public sector provision. Dissatisfaction levels are perhaps not yet high enough to embolden the political power elite to further uncouple NHS principles from actual delivery, but they might be going in the right direction.

 

 

 

For discussion on health services globally see:

 

  1. Which country has the best healthcare system?
  2. Britnall, M (2015) In Search of the Perfect Health System. Palgrave macmillan .

 

 

 

 

 

Developing the Concept of Sustainability in Nursing

“NOTICE: this is the author’s version of a work that has been submitted for publication in Nursing Philopsohy. If accepted, changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication.

 

Developing the concept of sustainability in nursing.

 

Abstract

 

Sustainability, and the related concept of climate change, is an emerging domain within nursing and nurse education.  Climate change has been posited as a serious global health threat requiring action by health professionals and action at international level. Anåker & Elf undertook a concept analysis of sustainability in nursing based on Walker and Avant’s framework. Their main conclusions seem to be that while defining attributes and cases can be established, there is not enough research into sustainability in the nursing literature. This paper seeks to develop their argument to argue that sustainability in nursing can be better understood by accessing non nursing and grey literature and, for example, the literature in the developing web based ‘paraversity’. Without this understanding, and application in nursing scholarship, nurses will have a rather narrow understanding of sustainability and its suggested links with social and health inequalities and the dynamics underpinning unsustainable neoliberalist political economy. This understanding is based on the social and political determinants of health approach  and the emerging domain of planetary health.  However, this is a major challenge as it requires a critical reflection on what counts as nursing knowledge, a reflection which might reject this as irrelevant to much of nursing practice.


 

Introduction

 

Sustainability, and the related concept climate change, is an emerging domain within nursing (Adlong & Dietsch, 2015; Allen, 2015; Aronsson, 2013; Goodman, 2011; Hunt, 2006; Polivka, Chaudry & Mac Crawford, 2012; Sattler, 2011) and nursing education (Goodman, 2008; Goodman, 2011; Goodman & East, 2013; Goodman & Richardson, 2009; Johnston et al., 2005; Richardson et al., 2013). Climate change has been posited as a serious health threat (Costello, Grant & Horton, 2008; IPCC, 2014; McMichael, Montgomery & Costello, 2012)  requiring action by health professionals (Costello et al., 2011; Gulland, 2008; Harding, 2014; Patton, 2008; Reale, 2009; Thomas, 2014) and action at international level (Durban Declaration on Climate and Health, 2011; WHO (2016) . The status of climate change as health threat has however been contested (Goklany, 2009a; Goklany, 2009b; Goklany, 2012; Goodman, 2014), but it remains an important determinant of health (Barton & Grant, 2006; Griffiths, 2009). In this context, Anåker & Elf (2014) undertook a concept analysis (Walker & Avant, 1982)  of sustainability in nursing. This paper seeks to develop their argument to argue that sustainability in nursing can be better understood by accessing non nursing literature, to address the socio-political context in more depth. This should include going beyond accepted peer reviewed nursing journals and include literature such as that written by Wendell Berry (Berry, 1995) who writes eloquently on human health and our relationship to the natural environment.  There is also a growing body of work online and of an academic standard to qualify for what might be called the ‘Paraversity’ (Goodman, 2015a; Rolfe, 2013). Without this understanding, and application in nursing scholarship, nurses will have a rather narrow understanding of sustainability. There is a need to link social and health inequalities (Dorling, 2013; Marmot, 2015) and the dynamics underpinning unsustainable neoliberalist political economy (Harvey, 2005; Harvey, 2014; Sayer, 2015) with the concept of sustainability. Climate change is just one aspect, albeit a very important aspect, of that linkage. This understanding is based on the social (Davidson, 2015; Raphael, 2004; WHO, 2013) political (Ottersen, Frenk & Horton, 2011) and ecological (Goodman, 2014; Goodman, 2015b; Lang & Rayner, 2012; Lang & Rayner, 2015; Rayner & Lang, 2012) determinants of health (Barton & Grant, 2006).  However, this is a major challenge as it requires a critical reflection on what counts as nursing knowledge, a reflection which might reject this as irrelevant to much of nursing practice. Before addressing the definition of sustainability in nursing, the socio-political ‘pattern of knowing’ will be outlined to form the justification for the ensuing discussion.

 

The fifth ‘Pattern of knowing’ in Nursing

Jill White (White, 1995) added a fifth pattern of knowing in nursing to Barbara Carper’s four (Carper, 1978): the ‘Socio-Political’. White argued the other four patterns provided answers to the ‘who, how and the what’ of nursing practice but not the ‘wherein’, the context. This, White argued, is the pattern of knowing essential to an understanding of all the other four. Socio-political knowing that is gained from a fuller understanding of the ‘sustainability literature’, might lift the ‘gaze’ from introspective nurse patient relationships at the bedside and requires the situating of that relationship within the wider socio-political context. This may result in challenging the taken for granted assumptions about practice, health, the profession and wider health policy. To that could be added the raising of questions about political economy and engaging in philosophical enquiry about such concepts such as ‘non duality’ (Loy, 1988), a concept Wendell Berry implies in his essay ‘health is membership’ (Berry, 1995).

White quoted Chopoorian who suggested:  “nursing ideas lack an archaeology of the social, political and economic worlds that influence both client states and nursing roles’ (White 1995 p84). This ‘archaeology of ideas’ still seems relatively poorly uncovered. Davies argued that ‘some of our concepts are missing’ in a critique of the Sociology of Health and Illness (Davies, 2003).  By that is meant that there had been a lack of a ‘sociology’ of organizations in the sociology of health and illness, a sociology which is able to reveal concepts such as discourses of managerialism (Gilbert, 2005; Traynor, 1996; Traynor, 1999; Traynor, Boland & Buus, 2010), or to reveal patterns of power and accountability for policy and its consequences (Freudenberg, 2014; Scambler, 2012; Schrecker & Bambra, 2015). Davies argued that

“sociology needed to take seriously the politics of NHS modernisation” (p183)

It is suggested here that many nurses also don’t have such a set of critical concepts to give them a more critical discourse upon which to base critical action or ‘praxis’ (Cox & Nilsen, 2014). There are a few papers addressing political activism in nursing, providing critical theories and concepts (Antrobus, Masterson & Bailey, 2004; Hewison, 1994; Phillips, 2012; Racine, 2009; Shariff, 2014) and other papers which discuss politics and nursing (Davies, 2004; Masterson & Maslin-Prothero, 1999; Salmon, 2012; Traynor, 2013).  These works suggest an interest in the interplay of the socio-political context and nursing practice and provide some evidence of relevance of this ‘pattern of knowing’.  White argued that nurses must “explore and expose alternative constructions of health and health care, find means of enabling all concerned to have a voice in care provision and develop processes of shared governance for the future” (p85). Exploring sustainability, climate change and health assists in that work. Indeed a focus on global governance for health in the context of climate change and environmental challenges is a key theme of recent reports  (Ottersen, Dasgupta & Blouin, 2014; Ottersen, Frenk & Horton, 2011) in non-nursing literature. This leads us onto consider how nurses are to understand what sustainability means.

 

Defining Sustainability in Nursing

 

Anåker & Elf (2014) argue that the “term is not clearly defined and is poorly researched in nursing” (p382). This applies not only in nursing.  Sustainability has diverse and contested meanings in many disciplines (Thompson, 2011; Williams & Millington, 2004). The quest to tie down the concept is possibly futile, as Anåker and Elf themselves suggest that: “a concept analysis is never a finished product” (p388). They provide a definition which is a helpful contribution to the discussion, and their model and contrary case illustrate for clinical nurses the value of trying to understand sustainability in practice. Throughout the paper they provide attributes and definitions from various sources and refer to, but do not foreground, social and health inequalities arising from wider determinants of health including political economy, which also underpins understandings of sustainability and climate change (Goodman & Richardson, 2009; Sayer, 2015).

The defining attributes identified in Anaker and Elf’s concept analysis were:  ecology, environment, the future, globalism, holism and maintenance. The attribute ‘globalism’ indicates that they are getting close to discussing and emphasising political economy underpinning such issues as climate change, ocean acidification and soil erosion which are three of the nine planetary boundaries which, it is argued, delineate a ‘safe operating space for humanity’ (Rockstrom et al., 2009; Steffen et al., 2015) . Nonetheless, the analysis misses something important, i.e. the neoliberal (Freudenberg, 2014; Harvey, 2005) and environmental, socio-political context of health (Barton & Grant, 2006; Ottersen, Frenk & Horton, 2011; Sayer, 2015; Scambler, 2012; WHO 2015) characterised by social and health inequalities (Dorling, 2013). This is the link between capitalism, climate change and sustainability (Goodman, 2014; Griffiths, 2009; Klein, 2014; Sayer, 2015). Various writers (Hamilton, 2010; Jackson, 2009; Marshall, 2014; Sayer, 2015; Urry, 2011) suggest or imply, that it is our political orientations (Douglas & Wildavsky, 1992), moral intuitions (Haidt, 2012) and our social and economic relationship with carbon which are foundations upon which we as communities and individuals assess environmental issues and our reactions to them.

Urry particularly on this point, (2011) coins the term, ‘high carbon economy-society’ to describe capitalism. He argues that the starting point for an analysis of why society engages in particular practices and habits is the observation that energy is the base commodity upon which all other commodities exist. Thus, community behaviours are implicitly locked into high carbon systems that are taken for granted aspects of our lifeworld. Urry suggests that much of social science has been carbon blind and has analysed social practices without regard to the resource base and energy production that we now know are crucial in forming particular social practices. It is these social practices that provide the structure within which our agency operates.

most of the time people do not behave as individually rational separate economic consumers maximising their individual utility from the basket of goods and services they purchase and use given fixed unchanging preferences…(we are) creatures of social routine and habit…fashion and fad…(we are) locked into and reproduce different social practices and institutions, including families, households, social classes, genders, work groups, schools, ethnicities, generations, nations…. (Urry 2011 p4).

 

These social practices arise out of our ‘lifeworld’ (Husserl 1936, Habermas 1981), i.e. our internal subjective viewpoints as well as the external viewpoints of the social and political ‘system’.  A high carbon economy society thus provides the backdrop for values, assumptions and social practices that are taken for granted in everyday life. Defining sustainability therefore requires acknowledgment of such lifeworlds and the socio-political systems in which they ‘operate’.

 

Nursing, sustainability and acontextual Concept Analysis?

 

The wider body of literature, including that in the social and political sciences and philosophy, may give nurses tools and concepts to further develop their understanding of sustainability and its relationship to human health. Importantly this could include an understanding of the political economy of capitalism (Harvey, 2011) and its link with growth, climate change and sustainability (Hamilton, 2003; Jackson, 2009; Johnson, Simms & Chowla, 2010; Sayer, 2015). Without this understanding, and application in nursing scholarship, nurses may miss the arguments linking the growth dynamics underpinning the neoliberalist capitalist political economy (Chomsky, 1997; Harvey, 2005; Sayer, 2015), climate change (Klein, 2014; Sayer, 2015) and unsustainable lifestyles (Hamilton, 2010). This sits within the social and political determinants of health approach (Barton & Grant, 2006; Davidson, 2015; Ottersen, Frenk & Horton, 2011; Scambler, 2012) and the emerging domain of planetary health (Lang & Rayner, 2012; Lang & Rayner, 2015).  This paper argues that to fully develop the concept in nursing, an analysis or at the least an understanding, of the political economy of neoliberal capitalism could be a component of nurses’ understanding of sustainability and health. This is because political economy relates to both health and social inequalities (Dorling, 2013; Dorling, 2014; Marmot, 2015; Schrecker & Bambra, 2015; Stiglitz, 2012; Wilkinson, 2005; Wilkinson & Pickett, 2009)  and to issues around sustainability and climate change. However, this is a major challenge as it requires a critical reflection on what counts as nursing knowledge (White, 1995), a reflection which might reject this as irrelevant to much of nursing practice.

 

Anåker & Elf’s (2014) inference that nursing misses foregrounding political economy and society might be a result of the method employed to search the literature, as well as their acknowledged lack of discussion in the nursing literature of political economy. Of course there might be very little reason currently for nursing literature to discuss political economy, based as it is on knowledge (biosciences, biomedicine) that may well be largely antithetical to critical social and political science. Adult nurses in particular might face a real challenge in accepting this idea in practice as Ion and Lauder argue:

 

“For very good reason, adult nursing remains committed to a biomedical vision of illness which, while cognisant of the importance of a holism, is tied to a physical approach to care” (Ion & Lauder, 2015).

 

In addition, Walker and Avant’s method was originally published (1982) before the development of academic blogs and websites such as academia.edu and therefore may not be explicit in its direction to search beyond accepted channels. This emerging literature, which may contribute to the construction of the ‘paraversity’ (Goodman 2014, Rolfe 2014), will therefore be missed as source of information and discussion on topics such as linking sustainability, health, climate change and capitalism.

 

There are several key papers discussing the link between human health, political economy and the environment. Goodman and Richardson (2009) explicitly link Sustainability, Climate Change and Health conceptualizing them as three sides of a triad. To fully understand one requires an understanding of the other two. The three, in this conception, are indivisible. Further, the link involves political economy and socio-economic behavior as crucial underpinnings for climate change and sustainability issues. Barton and Grant’s (2006) health map discusses key determinants for health including Biodiversity, Global Ecosystems and Climate change. Each one of those of course involves human activity and disruption to create what some are calling a new geological era, the ‘Anthropocene’ (Zalasiewicz et al., 2010). Lang and Rayner (2012) discuss the concept of ‘Ecological Public Health’, while the Canadian Public Health Association (2015) has just published its own report on ‘Global Change and Public Health: Addressing the ecological determinants of health’ which on page 1 argues:

“…changes in the earth’s ecological systems are driven principally by our social and economic systems, and by the collective values and institutions that support them”.

This echoes the World Health Organisation’s definition of the social determinants of health which explicitly mentions distributions of resources, money and power (WHO 2015). The report does not name, or analyses, in any more depth what that economic system is, as it seems to take for granted that it is capitalism. Ottersen et al emphasize the political determinants of health (Ottersen, Dasgupta & Blouin, 2014) which, alongside the WHO’s (2008) social determinants of health approach, acknowledges the role of powerful global actors and the lack of global governance for health. Health equity and social determinants are now a crucial component of the post 2015 sustainable development goals (WHO 2015).

For example, powerful global actors, i.e. the Fossil Fuel Industry, may be acting in a way to either downplay the risks to human health from rising atmospheric carbon dioxide, or engaged in protecting their assets’ (coal oil and gas) value for the short term over and above longer term risks to climate. Exxon Mobil have argued that world climate policies are highly unlikely to stop the production and selling of fossil fuels (Exxon Mobil shrugs off climate change risk to profit – BBC News, 2014) while Shell have been accused (Macalister, 2015) of accepting a 4 degree rise in global mean temperatures. This is in the context of a reported $5 trillion annual subsidy in fossil fuel subsidies (Coady et al., 2015)  while the Bank of England considers a ‘carbon bubble’ (Carrington, 2014)  i.e. the drop in value of assets if fossil fuels are kept in the ground through the imposition of any global governance regimes to curb carbon emissions. This is an aspect of the political economy of capitalism that must be understood as a driver underpinning human health. At the time of writing, world leaders and delegates are meeting in Paris for COP 21. At this meeting there will be another meeting of the The Sustainable Innovation Forum (SIF15) which is a business focused event held during the annual Conference of Parties (COP). The two day Forum will convene  participants from business, Government, finance, the United nations, Non-governmental organisations, and civil society to “create an unparalleled opportunity to bolster business innovation and bring scale to the emerging green economy” (COP21 Paris 2015). This forum operates within the paradigm of capitalism rather than seeking radical reform. However, it illustrates the complexity of players dealing with sustainability issues.

 

Scambler (2012) outlines ‘The Greedy Bastards Hypothesis’ to describe how the Capitalist Class Executive can ‘command’ the Political Power Elite to enact policies in their favour, with the unintended consequences of exacerbating health inequalities. Evidence that corporate activities impacts on political decision making is provided by the delays to air pollution standards, Euro 6 (Archer, 2015; Neslen, 2015).  Volkswagen’s use of software to cheat emissions testing in the United States (Topham, 2015) indicates the lengths corporates will go (Freudenberg, 2014; Oreskes & Conway, 2011) to avoid externality costs resulting in the externality of for example, increased air pollution. Therefore any concept of sustainability in nursing that does not understand political economy misses something important in understanding both the concept of sustainability and of health.

 

Anaker and Elf’s definition of sustainability:

“…a core of knowledge in which ecology, global and holistic comprise the foundation. The use of the concept of sustainability includes environmental considerations at all levels. The implementation of sustainability will contribute to a development that maintains an environment that does not harm current and future generation’s opportunities for good health”. In this it echoes the Brundtland commission’s definition of sustainable development (WCED1987) which has been critiqued for being uncritical of business and growth based capitalism (Sinclair 2009).

 

This definition is a good start but requires development. Nurses, particular nursing scholars interested in health and public health, need to consider the argument already suggested around the dynamics of capitalism as a major driver for both carbon emissions and unsustainable practices. It is perfectly possible to begin the study of sustainability and environmental health within taken for granted paradigms, but what is required is a cultural critique of the values and systems that support environmental damage (Martusewicz 2014) and a better understanding how the economy and sustainability issues such as climate change, interact (Better Growth, Better Climate, 2015). Nurses, if they stick to nursing journals and literature, will not find a large amount of material that discusses this. For example the Royal Society of Arts has a wealth of papers, presentations and works streams addressing climate change (Hahnel, 2015; Rowson, 2015)  which address causes, behaviour changes, political economy and culture change.

 

Conclusion

 

Anåker & Elf (2014) argue that there is a need for theoretical and empirical studies of sustainability in Nursing. This could include accessing literature unknown to most nurses.  Writers such as Aldo Leopold, Wendell Berry, Paul Hawken, Mike Hulme, John Urry all provide insights into human wellbeing, health and the social context. Related concepts include ecojustice education, education for sustainability, dualism, anthropocentrism, anthropocene, neoliberalism, modernity and capitalism. A problem for nursing scholars is that these related concepts are not readily seen as relevant to nursing and thus there may be a reticence of nursing journals to publish them, and a reticence in nurse education to discuss them. There may be a need to resort to both non nursing peer reviewed journals but also to web based materials open to all. Anaker and Elf acknowledge in their limitations (p387) ‘the lack of research literature available for review in which sustainability was the major topic and in which sustainability was not linked to other concepts’. This paper goes further in trying to make those wider links for nurses. A problem however for nurses, is the sheer scale of literature and concepts that are involved. The task for nursing scholars is to consider just what is feasible, useful and relevant as part of their scholarly development and curriculum work.

 

 

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Health and Capitalism again.

Health and Capitalism.

 

Resistance is futile” and if you heard those words uttered by the Borg, it often was. However, that did not deter the crew of the starship ‘Enterprise’ from carrying on resisting. And so it is with our current predicament on his planet. The Borg, for the global population, is the capitalist class executive supported by their political power elite. We could just call them the capitalist class or what Graham Scambler refers to as the “Greedy Bastards”.

 

One issue is the globalised ‘capital surplus absorption problem’ (Harvey 2010) which drives capital across the globe looking for profit and cheap labour. If capital cannot make a decent return it moves on, as it did in Cornwall’s mining regions in the 20th century.

The resistance to the current global capitalist system is legion (Hawken 2009), but it is disorganised, fragmented, unfocused, without a clear plan and often unsure of who or what the real threat actually is. Some of the resistance movement of course would misguidedly seek to replace one form of exploitation and crisis generation with another, but with a kinder social democratic or green face. But, while capitalism exists it never resolves its crises, it merely moves then around the globe.

 

I seek in to cut through the mess of analysis as to why we are heading for continued economic disaster which is in tandem with the ecological one, a disaster in which we are lied to by a feral elite as being ‘all in it together’, while the distribution of wealth remains in very few hands and is then turned to exploiting the planet’s natural and social capital with often deadly results.

 

This analysis has emotional elements to it, given what the science is telling us about the crossing of planetary boundaries, how could it not? It is not however based on an emotional analysis but an attempt to understand how social worlds change and upon what basis current societies are organised. It is a complex interdependence of economy and ideology shaping social relationships, which in turn shape who we are. In the coming together as individuals to trade, work, exchange, distribute, sell, buy, advertise we bring our hopes, values and ideals to that process and in turn that process shapes our hopes, values and ideals.

 

This is an agenda that brings together  ‘inequalities in health’ (Marmot 2010), the social determinants of health, Ecological Public health (Lang and Rayner 2014) and critiques of political economy. It is a realisation that education has failed us on a grand scale. It is a realisation that a few powerful men, and it is usually men, have been bought by men of wealth and have commandeered the levers of power for their own benefit, arguing as they do that it is for our own good. It is a realisation that only when populations wake up to the fact of this old fashioned class war and demand a better way of social organization that we will we have a hope of bequeathing to our children a better world. It is a realisation that well meaning individual action that does not challenge the fundamental driver is at best useless and at worse a distraction from the real battle.

It is a realisation that the war is very possibly already lost and the best we can hope for is managed decline in human welfare before restructuring of the social economy is forced upon us. There remains optimism of the will but pessismism of the intellect.

Some are more optimistic about our ability to use technology and our transformation of economic models. The Global Commission on the Economy and Climate suggest that economic growth and combating climate change can be done together. In their “Better Growth, Better Climate “ Report (2014), the starting point for this “New Climate Economy” has been to see the issue from the perspective of economic decision-makers. By this they mean government ministers, particularly ministers of finance, economy, energy and agriculture; business leaders and financial investors; state governors and city mayors. None of these decision makers will be anti capitalist and probably have been schooled in either neoclassical economics or economic orthodoxy. I suspect few have read deeply or understood Tim Jackson, David Harvey, Steve Keen or Thomas Picketty, let alone volume’s 1 and 2 of Capital. I suggest that capital accumulation and the contradictions within capitalism is the base issue upon which climate change rests. Naomi Klein has recently (2014) linked these two and brought them into the public sphere in her book “This Changes everything. Capitalism vs Climate”.

Health

Upon what is human health based? It is largely social in nature, determined by the social relationships in a material world. No one lives alone and so it is in the coming together in communities and societies that we fashion the determinants of health. There is a biological basis for some individuals, and this may account for 30% of premature deaths. However genetic determinants (e.g. in cystic fibrosis) operate at this individual level and are manifest in a relatively minor way. This is not to deny that for the individual the medical condition is anything but minor, but health on population levels are not determined thus. Even genetic manifestations are at times made worse or better by the social conditions in which the individual finds themselves. Poverty has a knack of making underlying biological problems much worse.

 

Social Conditions and Relations

Marx (1859) wrote “In the social production of their existence, men inevitably enter into definite relations, which are independent of their will, namely relations of production appropriate to a given stage in the development of their material forces of production. The totality of these relations of production constitutes the economic structure of society, the real foundation, on which arises a legal and political superstructure and to which correspond definite forms of social consciousness. The mode of production of material life conditions the general process of social, political and intellectual life. It is not the consciousness of men that determines their existence, but their social existence that determines their consciousness”.

 

In other words, capitalism as an economic system is formed by particular social relationships which give rise to our laws such as private property, our political system and our ideas about how society should be. The current ‘mode of production of material life’ is capitalism in its various forms and is the basis for our social life and our social relationships. Simplistically, this means economic factors – the way people produce the necessities of life (mode of production) – determine the kind of politics and ideology a society can have.

If health is socially determined by social relationships, what are the current forms of social relationships that give rise to certain patterns of health, illness and disease? We know from studying inequalities in health that socio-economic conditions and relative social status determine populations’ health status including measurable outcomes such as life expectancy and the under 5 mortality rate. Other social relationships such as gender and ethnicity also affect health status. However, these are subservient social conditions to the socio-economic in the last instance. Thus material conditions and poverty are prepotent conditions for health. That is not to deny that affluent women and affluent BME’s may also experience ill health disproportionately in certain medical categories. However, the major driver for global health are the socio-economic relationships which are based on a certain forms of capitalist political economy.

Graham Scambler argues that a way to understand health is to see ‘asset flows’ operating throughout the life course:

“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. A healthy child born in Redruth in 1960 starts with good biological assets.

psychological: e.g. your self-efficacy, locus of control, learned helplessness. This same child grows up in social world in which she learns that female roles are pretty much limited, her belief regarding her ability to achive anything she wants is limited by the role models and messages around her. Her ‘self efficacy’ is thus reduced to acting within strict and socially moulded goals. Her self belief does not stretch to being Prime Minister. Her psychological asset is not weak but it is certainly not as strong as a young boy at Eton.

social:  family network, community networks, friendships. All her friends do not pass the 11 plus and so her network ‘learns’ a factory fodder secondary school education hell bent on training the local girls for the local textiles factory. Father drives a bus, mother works part time at the local electronics factory. No one goes to university out of the county. This girls position on the social gradient is not the worse but it is not the best either. Her social asset is low to medium.

cultural, your lifestyle choices such as smoking. Cigarette smoking is very common, all the adults around smoke, it is a rite of passage at school and fags are relatively cheap. A 20 a day habit is soon formed. This is a very weak cultural asset.

spatial: where you live, leafy Surrey or inner city Glasgow? Thankfully Camborne is a rural small town lacking the street and environemental dangers of a Toxteth or Lewisham.

symbolic: status as a ‘chav’ or as member of the elite. Thankfully growing up in rural Cornwall in the 60’s, the word ‘chav’ is not known, the demonisation of the working class has not started and there is no talk of benefit cheats and scroungers as the girl grows, she is spared this symbolic humiliation, but the ‘gippoes’ at Carn Brea are not.

material: income and wealth. As an adult, the girl ‘marries well’, her husband has a decent job and they live in a nice part of town. The house is not damp, they can afford to heat it and provide adequate food for the children.

In addition, Scambler suggests that we need to understand that:

  1. 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.
  2. Flows of assets tend to vary together (i.e. mostly strong or weak ‘across the board’);
  3. 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’…….
  4. 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);
  5. 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 ‘greedy bastards’ are of course not the 1%, they are part of it, but their wealth puts them more into the 0.01% of income earners.

What are the current dominant socio economic conditions therefore that give rise to the health and illness patterns we note, are affect the asset flows in people’s lives?

 

Political Economy.

A feature of modern capitalism, which in its neoliberal form especially has now gone global, is that it determines in the last instance forms of social relationships that are exploitative and unequal. The material conditions of life are shaped by these unequal and damaging social relationships. Thus, how much land you have to feed your family and where that land is, is determined by systems of private property, commodity prices and the rules of the state. The same goes for water and shelter. The fundamental building blocks of life, including eco systems services, e.g. fresh water, waste recycling, are subsumed within capitalist social relationships. Nature, the air, water, livestock et, upon which we depend has been fashioned into a mere instrument for human survival and development. There is very little ‘nature’ left untouched by human hand. All of nature has been turned into natural capital and is being used up as if it is limitless.

Capitalism has to continue to do what it does because of the ‘surplus capital absorption problem’ (SCAP). As surplus value accrues to the ruling class, those who own and control the means of production, it has to be reinvested or it is lost. Thus capital continually seeks new markets and new profits. It cannot stand still and so it looks to exploit more and more natural capital in the process. The drive for capital accumulation is the engine of this whole process.

When capital comes up against a barrier to this process e.g. strong labour organisations who demand living wages and pensions, it either designs a solution, e.g. strict labour laws that outlaw strikes and unions, or finds other investment opportunities. It takes manufacturing to countries where there is weak, cheap or surplus labour. This is one of the foundational contradictions of capitalism – the capital and labour conflict. An economy that is not returning 3% growth is seen as sluggish and, as we are experiencing in the UK, recessions which result from lack of aggregate demand and lack of surplus capital investment result in unemployment and social unrest.

Capitalism has proved to be dynamic and inventive. It has taken on many forms – mercantile, industrial and recently financial and consumer based. Apologists for capital accumulation argue it is good for societies, pointing to the jobs and wealth created while ignoring the social misery that often follows in its wake and various waves of ‘creative destruction’ as it comes up against barriers to accumulation and then seeks new forms. In this manner whole cities, e.g. Detroit, are nearly laid to waste as old forms of capital accumulation, e.g. car manufacturing, becomes unprofitable and shifts across the globe. In Cornwall, capital fled following its inability to make a profit from mining and engineering leaving a service and tourism sector characterised by low wages and precarious seasonal contracts. Camborne and Redruth are hollowed out towns still trying to recover from the creative destruction unleashed by the forces of globalisation that resulted in tin being cheaper in South East Asia.

Meanwhile whole populations have been ‘bribed‘ by the baubles and cheap credit that capitalism produces which, as the recent credit and consumer led boom and bust has proved, are merely will o’ the wisps. The phrase ‘wage slave’ resonates with many in so called ‘advanced’ societies who are trapped in alienating forms of work ameliorated only by the lures of consumer products and services. The promises of ‘you’ve never had it so good’ turning sour on sovereign and private debt while the ruling class run away with the spoils in ‘Richistan’.

 Wealth

We have heard the mantra “we are all in this together” which is supposed to reassure us that everyone in society is shouldering some of the burden of the consequences of the financial crash of 2008. We also hear that the UK’s debt has to be reduced quickly and that means cuts in public spending. This is an international phenomenon affecting the United States as well as Europe. Many other countries are not quite so indebted. Global capitalism is still working very well in certain localities and everywhere for the capitalist class.

Forbes has been reporting global wealth for 25 years and states that 2011 was a year to remember. For positive reasons. The 2011 Billionaires List breaks two records: total number of listees (1,210) and combined wealth ($4.5 trillion). This amount of money is bigger than the gross domestic product of Germany, one of only six nations to have fewer billionaires that year. BRICs led the way: Brazil, Russia, India and China produced 108 of the 214 new names. These four nations are home to one-in-four members, up from one-in-ten in 2006. Before 2011, only the U.S. had ever produced more than 100 billionaires. China in 2011 has 115 and Russia 101. While nearly all emerging markets showed solid gains, wealth creation is moving at an especially breakneck speed in Asia-Pacific. The region now has a record 332 billionaires, up from 234 in 2010 and 130 at the depth of the financial crisis in 2009. High performing stock markets are behind the surge. Three-fourths of Asia’s 105 newcomers get the bulk of their fortunes from stakes in publicly traded companies, 25 of which have been public only since the start of 2010.

Forbes argues that the reason they track this wealth is because these billionaires have the power to change the world. For example, Telecom billionaire and prime minister Najib Mikati supports the Lebanese government. Ernesto Bertarelli, is now focusing on saving the oceans from eco disaster. Bill Gates and Warren Buffett have already traveled to three continents working to change giving practices among the ultra-rich. This is feudal ‘noblesse oblige’, the power of the divine right of kings by dint of wealth with little democratic control. Meanhwile the UK’s Candy brothers like to boast of their wealth and how little tax they pay in the context where “only the little people pay taxes” and in which the rich are winning the class war.

Meanwhile nearly half of the world – 3 billion people – live on less than $2.50 a day and 80% of humanity live on less than $10 a day (2008 figures from the World Bank Development Indicators).

In the UK, the inequality briefings report that  the richest 1% of the population have as much wealth as the poorest 55% combined; Oxfam report the 5 richest families are wealthier that the poorest 20% combined.

“We are all in this together”. Right.

Green thinking

One way to confront this machine is to get off the consumerist treadmill and hope that through collective consumer choices, i.e. not to buy stuff, that the ruling class will mend their accumulative ways, invest in health, education, the conditions of social life and design products that are ‘green‘ and ‘environmentally friendly’. This is already occurring. The plethora of products from hybrid cars to organic and locally sourced food products indicate that some companies are basing their business models with sustainability in mind. What this does not do however is change the underlying dynamic of the surplus capital absorption problem which demands growth in the economy and the overuse of natural resources.

This means there is a race on between developing goods and services that are carbon neutral and environmentally friendly and the supply of goods that are killing ecosystem services and wreck social relationships through alienating labour and growing inequality. This race occurs within the context of the SCAP which will seek to overcome any barriers to the investment of that surplus value and will not wait until all goods and services become eco friendly. If investment in eco friendly products can be found, and is profitable, capitalism will do so, but it is not fussy in this regard. Canadian tar sands exploitation is an example in which demand for oil and the chance for investing surplus capital to turn a profit cannot be overlooked.

Thus, living the good life runs up against globalised capital accumulation, especially in the form of the subsidized Fossil Fuel industry.

Green thinking is also a minority sport as it is up against other forces as well. The idea of human progress and technological advances to solve our problems runs in tandem with those who have the capital to invest. This also includes some forms of religious ideology, which affirms man’s right to dominate nature and an anthropocentric and dualist world view.

Greens need a critique of political economy or risk being sidelined in the Shire as Mordor advances its deathly grip.

So what?

It is unlikely that human populations under globalised capitalism will stop the SCAP dynamic. They don’t understand it. What they do understand is that there are winners and losers in the current system. If you win, you win big. Many also feel impotent to prevent the investment decisions being made by suits in the financial districts of first world countries. Politicians have let their electorates down or more likely could not deliver as they are merely apologists for the ruling class. Democracy is under challenge, more than ironic given that many are currently dying for a democratic ideal.

Many shrug and say ‘nothing can be done’. They may be right. The ruling class may have too powerful a grip and ‘enjoy’ too much of the spoils to change. Meanwhile the political economy of SCAP produces social relationships that determine our current unequal patterns of health.

To date, not enough people are discussing the underlying dynamic of capitalism that produces periodic crises and which may eventually allow Gaia to take revenge. We are locked into a cluster of high carbon systems underpinned by this capitalist dynamic and we don’t have a key. There is an urgent need to design one but our so called elite Universities are currently so wrapped up in producing technologies for capitalist production and equipping people with skills fit for capitalist purpose that they are ill placed to produce radical thinking, challenges and alternative plans. Education is not the solution, it is the problem. Politics is not the solution it is the problem. Ecology is not the solution it is the problem.

And as for a voice? In the UK it takes a comedian to rattle cages in tandem with a few commentattors such as Owen Jones.

“Philosophers have hitherto interpreted the world in many ways, the point however is to change it”.

That means confronting Capital. Changing the light bulbs ain’t enough and may give a false sense of ‘doing something’.

The ruins of Cornwall’s mines stand in silent testament to the destructive forces of globalisation, mirroring the ruins of people’s lives in the sunken inland towns of Cornwall’s backbone, connected together by a road that fails to take them to the golden reaches of England’s South Eastern metropolis 300 miles way.

So:

  • Join/start an anti capitalist social movement.
  • Use social media to connect for example 38 degrees.
  • Confront your elected representatives in writing.
  • Identify and contact the ‘suits’.
  • Find someone who knows what campaigning is all about and share skills.
  • Focus on your core skills, attributes and role and fashion a response that suits them.
  • Identify a sphere of influence and work within that.
  • Consider direct civic action, e.g. ‘Occupy’.
  • Read and understand the issues.

…or realise that no one gives a toss about any of this, go home and get pissed or pregnant.

 

The unlearned, fed by the unscrupulous, led by the clueless.

The unlearned, fed by the unscrupulous, led by the clueless.

 

 The economies of Europe and the US are still feeling the after effects of the financial crisis of 2007/8. Next week midwives go on strike for the first time in their history, other NHS workers have been denied a 1% increase in pay. In the US over 13,000,000 foreclosures, i.e. banks taking back property on mortgage defaults, were filed since 2007. There is evidence that China is following the US in experiencing housing bubbles. Although ‘growth’ has resumed in the UK, the nature of recovery is weak and is still based on the system that crashed in the first place. For the first time ever the majority of people in poverty are working while the government subsidises business to the tune of £85 billion. Britain First has 500,000 ‘likes’ on Facebook; neonazis in Neasden, Northampton and Newcastle.

 

Meanwhile UKIP preach that our salvation lies in curbing Immigration and getting out of the EU. That has about as much credibility as waiting for the Messiah, and is as useless as a bible in a whorehouse. It would be government by ‘white van man’ who doesn’t like ‘darkies’ coming over here and stealing our right to petty nationalistic ignorance.

 

The political response is weaker than pissed gnat and only half as intelligent. It is predicated upon assumptions and theories about how the economy works that either focus on the supply side (neoliberal economics) or the demand side (Keynesian). In other words, one side see that policies are put in place to revive the supply of jobs and products through low taxation, cutting back public spending to reduce government debt, removing state regulation and curbing the power of labour in an attempt to unleash the creative forces of capitalism. This is the neoliberal response and has been dominant since about the 1980’s. The other side, Keynesian demand management, focuses on more public spending, increasing worker’s wages, investments in new technologies, education and infrastructure to stimulate demand. Demand then stimulates growth with which to pay back the governments’ borrowing. This was dominant from about the late 1940 until the 1970-80s. However each attempt produces a crisis in the system that requires a resolution. This is economic orthodoxy, which is only now being challenged by post crash economics in Manchester. However, way back in the 1980’s the humble Plymouth Polytechnic was teaching unorthodox political economy (Marx, Veblen, Galbraith) while Russell group elites were mired in neoliberal classical economic theory.

 

Orthodoxy has not analysed the underlying contradictions of capitalism or understands it as a dynamic system. Crises in capitalism, e.g. too much worker power or too much Capital power, do not get solved as much as moved around the globe.

 

So if we want to understand the current economic mess we are in, we need to try and understand the underlying dynamic and systemic processes at work.

 

I don’t think this is going to happen in the short to medium term because the general population likes its politics in bite-sized chunks based on slogans and soundbites and a bit of showbiz. The myopic media know this and pander to this tendency by presenting us with a woeful lack of analysis and baking.

 

Political parties in the UK: Tory, Labour, Lib-Dem, UKIP are all united in accepting economic orthodoxy either in its neoliberal form or its Keynesian form. All accept growth as the key objective indicator of success, and growth measured in GDP terms. Only the Green party challenges growth but even then are often hazy on the underlying dynamics of capitalism and so are in danger of ‘greening the capitalist machine’ which is of course an oxymoron. It cannot be done.

 

What is required is hard work. We need to get our heads around how capital goes about its business, to understand that contradictions are inherent within it and that right now there are three dangerous contradictions that could wreak havoc on civilised societies around the globe:

 

  1. Endless Compound growth (exponential growth).
  2. Capital’s relationship with nature (consumption is killing us)
  3. Universal Alienation: the revolt of human nature.

 

 

So for now, know that you are being fed bullshit, lies and myopic analysis leading to the Clacton bell being rung for the victory of the disenchanted, uneducated and alienated ‘consumer citizen’ looking for a scapegoat.

 

 

 

 

See: David Harvey 2014 ‘Seventeen Contradictions and the End of Capitalism’.

 

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