Category: Obesity

Why do we do what we do? The poverty of individualist explanations

Why do we do what we do?  The poverty of individualist explanations.

 

Photo by Sofiya Levchenko on Unsplash

We all like cake don’t we? Oh, and beer…and yes wine…and…and

 

In common talk around health issues, we hear and read a great deal about ‘taking individual responsibility for health’ or the need for ‘helping people to make better choices’  and we hear explanations for ill health based on people’s choice of unhealthy lifestyles. Papers like the Daily Mail like to focus unhealthy working class ‘chav’ cultures in a bid to promote outrage and to garner support to reduce the Welfare State. Every New Year, gym membership rises, dry January is embarked upon and resolutions to quit smoking are made. Failure often follows. The UK population is getting fatter, it drinks excessively and takes little exercise. We are also a nation consuming antidepressants as if they were smarties. Some individuals of course are ‘paragons of virtue’ in terms of health and the question is asked “if they can do it, why don’t the rest of us?”  Often this is framed within personal success stories as “I did it, so you can too (you fat lazy bastard)”. Celebrities are often promoted as role models for a “leaner, fitter, healthier you”.

Most people probably know that eating better and taking more exercise is better for health. So why do we see continuing patterns of chronic ill health, patterns which show social class differences, i.e. the  ‘social gradient’, and unequal health outcomes. Those in the lower socio economic groups die younger, experience more chronic illness and have fewer disability free years.  Is it really all down to individual moral failure? Why don’t millions of us get up off our fat arses, do something positive and take responsibility for health? Why don’t we as a population exercise our agency to act for better health? After all, we are all free autonomous people able to choose courses of action.

The complete freedom to think and act may be more complicated than adherents of the ‘autonomous sovereign individual’ may have us believe. The model of the ‘free sovereign individual’, so beloved by libertarians, neoliberals and most hues of conservatism in their political stances, is a flawed and incomplete model of human behaviour. It is a model of human behaviour that arose in Enlightenment modernity, and results in the creation of ‘homo economicus’, the free instrumentally rational being, who weighs up the pros and cons of action independently of social or cultural influences or internal psychological drivers,  and is 100% result responsible therefore for the consequences of their action.

Max Weber introduced the word ‘Verstehen’ (German for understanding, perceiving, knowing) to describe the sociologists’ attempt to grasp both the intent and context of human action. While the ‘man of modernity’ was increasingly using instrumental rationality to guide action, Weber described 4 ‘types’ of social action:

 

  1. Zweckrational – means/ends rationality
  2. Wertrational – values based rationality
  3. Affective action – emotion based
  4. Traditional action – based in custom and practice.

 

Today, many ignore or forget all but ‘zweckrational’, assuming that is our only way of thinking. We know from experience however, that we choose courses of action not because they are always meeting a certain goal, but because of a mixture of all 4 types of reasoned action. Many also think about these types (if at all) as existing independently of society. Weber’s insight was to link these types to changing social conditions. He argued that modern societies differed from those of the past because of the shift to zweckrational thinking rooted in the growth of bureaucracy and industrialism. This might explain why today, in bureaucratised, industrialised societies, that instrumental, technical, means ends thinking came to dominate. The error for many is that the ‘is’ of the dominance of zweckrational becomes the ‘ought’, the only way to think and it becomes the assumed method of human thinking. I suggest that those trained in scientific, technical and logical (means-ends) occupations are apt to think using ‘zweckrational’ but assume that is how everybody else does and ought to think. They then become one dimensional in their own thoughts, unable to grasp the complexity of human decision making.

The social theorist Margaret Archer also describes this ‘man of modernity’ as “a being whose fundamental constitution owes nothing to society” (2000 p 51) and (following Weber) who is increasingly driven by instrumental rationality or ‘means-ends’ thinking. This is the ‘ready-made man’ who turns up out of nowhere to impose his own order on the world and applies rational thought to social concerns. It is a view of humanity that believes that our ‘self’, our individuality,  exists totally separate from society, that it is not constituted at all by society or culture. The free acting self is an independent of society and culture free thinking and rational being. We will hear echoes of this man’s voice when we hear such statements as “only the individual should and can take responsibility for health”, “there is no such thing as society, just individuals and families” and “eat less  – move more” injunctions to reduce weight. Any idea of social structure or social forces is completely denied. In this view there are no social mechanisms operating ‘behind our backs’ that might be guiding free choices.

 

This model of the self assumes the primacy of agency devoid of social structure or cultural or language contexts. It not only assumes the primacy of agency, but elevates it into a core aspect of the political project (neoliberalism) to reduce any action on poverty or welfare beyond that of individuals, families and charities. If there is no society, then there is nothing society can or should do.

 

Those who adhere to this model might think that obese and overweight people merely freely choose to eat more than they need, that their inability to lose weight is down only to their weak moral character and lack of will power. The obese should “just say no” to a second pork pie. Against this I suggest that they eat and move within the structures and cultures of the ‘obesogenic environment’ (Foresight 2007) and within cultural practices around food that becomes aspects of who they are, that they build into their self-concept. Veganism for example has been seen as the preserve of a slightly effete (?) minority and for many men especially, just cannot be built into their own notions of self as ‘red meat eating males’. Their self-concept as a man excludes this food choice as viable. They are of course free to act as a vegan but the structural and cultural context militates against men many doing so. Some men will be able to draw upon their material, psychological, biological, social, cultural, spatial and symbolic assets to exercise their agency to become vegan. Many others will not be able to exercise the same degree of freedom to do so.

 

There is not the space to fully explore this idea of the ‘free, pre-existing, independent from society’ view of self, other than to suggest that extricating human agency and the ‘self’ completely out of the effects of language, culture and social structure is erroneous. I emphasise however, the pernicious persistence of this idea in current culture, politics and health policy as it underpins much understanding of, and pronouncements about, human behaviour towards health.

 

I also suggest that those whose knowledge is non-existent, or superficially grounded, in philosophy, the humanities or social sciences cannot exercise their agency to begin to understand this argument. Their ‘ways of knowing’ and sense of self  is in violent opposition to it. They will be so embedded in certain social structures and cultural assumptions and values that the self they experience is unable to grasp the concepts. They will read the words but will feel an instant visceral hatred of the challenge to sovereign individuality because it shakes the very foundations of who they think they are and the basis for success and failure. Current ideal types would be Boris Johnson, Peter Thiel the PayPal billionaire, Rupert Murdoch, Donald Trump, many in Silicon Valley and the alt-right. In fact most of the powerful world leaders would fall into this category including Putin, Erdogan and Modi. They all feature varying degrees of narcissism and the assumptions of what Graham Scambler calls the ‘Greedy Bastards’.

 

Part of the answer to understating why we do what we do,  will be found by exercising our sociological imaginations to gain a fuller understanding of human behaviour. We need to think beyond the action of an individual, to consider the wider actions of society and culture that provides the context for individual choices at this point in history..

Take the choice to eat insects. In the UK we are free to do so. We could exercise our ‘free agency’ as sovereign individuals. There is no biological reason why we don’t. There is no legal barrier to doing so. There is no trade barrier, tariffs or taxes in importing insects as food. What prevents us eating insects is a combination of cultural barriers with a lack of social institutions that values eating insects, no social institutions providing access to insects. Psychologically we might think that the eating of insects is not part of our ‘self-concept’, there is no social learning going on because no one is doing it, the mental short cuts bypass rational appraisal and go straight to the ‘yuk’ factor. We live in an obesogenic environment and not an ‘insectivorous’ environment.

Why do fat people eat pork pies? Why don’t thin people eat insects?

Graham Scambler in wishing to establish a theory of agency in sociology argues:

 

Humans…are simultaneously the products of biological, psychological and social mechanisms while retaining their agency…socially structured without being structurally determined

 

I think this means that if you want to know why some people can resist eating the pork pie and most in the UK resist eating insects, you have to think holistically rather than individualistically. You have to avoid the temptation to be reductionist and instead think ‘systems’.

A biologist would focus on physiological processes and raise the importance of body chemicals such as leptin, dopamine, serotonin and endorphins in stimulating behaviour. They might acknowledge the physiological role of sugar and processed carbohydrates in providing very satisfying, but unhealthy, eating habits. This is perhaps the first hurdle that ‘will power’ has to overcome.  ‘Willpower’ is of course the ‘go to’ mechanism for those with individualist understandings.

A psychologist might explain eating patterns from a variety of perspectives: cognitive psychology might outline the role of mental short cuts that bypass rational thinking; behavioural psychology emphasising the conditioned nature of responses; social psychology which asks us to consider the power of social learning upon choices and psychodynamic psychology which would raise deep seated emotions as drivers for behaviour e.g. food playing the ‘comfort’ role. All have explanations that down play the power of rationality.  Key concepts within psychology which could be linked to why we eat as we do include:

  • Self-Efficacy.
  • Body Image.
  • Locus of Control.
  • ‘What the hell’ effects.
  • Future Discounting.
  • Classical/Operant Conditioning.
  • System 1 and System 2 thinking.
  • Self and self-awareness.
  • Adult, Child, Parent Ego States.

 

Both biology and psychology examine the individual body and mind. They seek explanations for human agency within ourselves. For some people, that is enough. Yet both disciplines cast huge doubt on the idea of ‘free thinking sovereign individuals’ who use rational thought, and the exercise of sheer willpower in achieving their aims.

If you have not eaten for three or four hours, and you pass a shop selling freshly baked bread or pasties, or foodstuffs you very much enjoy, your will power to lose weight is severely challenged first by your biology as the body reacts to sight and smell of delicious food and then by your psychology as the ‘what the hell effect’ kicks in supported by ‘future discounting’. Your future self as a slim lean athlete is discounted by your immediate self’s need for food.  As you go through your day you are immersed in social and cultural invitations and opportunities to eat and to eat too much. Against this is will power, unless you can actively design your social and cultural environment every single day to support will power, you may well crack. Do you have the material, psychological, social, cultural, spatial and symbolic assets to do this day after day after day for years? For the rest of your life? Some also have poor biological health assets in this regard as in utero processes may well have pre-set a certain weight for you that your body will always want to get to.

We are not completely free autonomous agents beloved of neoliberal ideology. Our lives are highly structured, but not determined. We are the result of a complex interplay of our biology, our psychology and the social. Underpinning much of the common discourse in our media is the idea of the ‘liberal human self’, and failures to live healthy lifestyles are to be found in the individual. This belief, and it is a belief not a scientific fact, often leads to a ‘Moral Underclass Discourse’ (MUD) to explain health inequalities. The MUD focuses on cultural and behavioural explanations, rather than sociological, for health inequalities. It is a discourse that leads easily to victim blaming.

We need to think a little more critically about this explanation, particularly as it has a great deal of political and social force in terms of policies we design to tackle health. We need to bring the social (structure) into the individual (agency). We need to ask to what degree are we free agents who can take 100% responsibility for our lives, we need to examine what social structures exist in which that agency operates.

Margaret Archer has published a series of books on this central problem of structure and agency, i.e. the relationship between our personal actions as free agents and the societies and social structures we are born into.

We know that smoking is linked to illness and disease, we also know there are patterns to smoking which show prevalence is not spread equally across class or age. If we want to more fully understand smoking behaviour we require not only the sociological imagination but also why people as ‘free agents’ continue to smoke despite knowing the consequences. The answer is of course complex, situated in and mediated by a matrix of the biological, social and psychological. Smoking occurs in a social context in which people are enabled or constrained in their behaviours by the structures of society and mediated by their and others’ ‘reflexive deliberations’ and to a degree, their biology (the ‘substance’ (nicotine) theory of addiction).

Archer’s theory suggests that our individual actions are predated by the existence of social structure of, for example, class relationships. Class structure, and the culture associated with it, are transmitted to individuals. In smoking’s case, the culture of smoking was once widespread across all social classes and therefore to take up the habit was not to be seen as a social pariah. Quite the opposite. George Orwell in both ‘Homage to Catalonia’ and ‘The Road to Wigan Pier’ describes vividly the valued place of tobacco in people’s lives. Today however, smoking has a class characteristic to it, the middle classes apparently are more open to health warnings than those lower on the social scale. This ‘predates’ any individual coming into puberty today. The ‘cachet’ associated with smoking, or its status as a rite of passage, has to be factored in to understanding why some people shun the habit while others embrace it.

Archer however does not wish to over emphasise how such social structures affect action, rather there needs to be a focus on how agents respond and act to those circumstances. There is a causal efficacy to agency, we are not automatons responding to class structures or obesogenic environments. We can make choices to act in certain ways to not buy the pork pie.  We do so by having internal conversations which are mediated by our ‘mode of reflexivity’ which at this point in history is particularly salient.

You and I are confronted in our daily lives by social circumstances, and we have a choice of action. We bring to that choice of action our own priorities, our ‘projects and concerns’. What we then do is mediated by the type of internal conversation, or reflexive deliberation,  we have. Archer’s thesis is that in the past social structures were such that little self reflexivity occurred. We ‘knew our place’, we knew what our role was and what status we had.  However, as societies modernised, cultures and structures confronting us are far more open to change and critique, and are so by the actions of the people involved. Women for example, no longer took for granted that their place was to rear children and to engage in domestic labour. They thought about the franchise and employment and some decided to act differently to ‘break the mould’. Why do some act to challenge social structure and why do others conform and thus replicate social structures?

“The subjective powers of reflexivity mediate the role that objective structural or cultural powers play in influencing social action and are thus indispensable to explaining social outcomes’ (Archer, 2007: 5).

In other words, your inner voice is confronted by the facts of the obesogenic environment or of social class or of gender relationships in the work place, but that fact can be acted upon so that action can for example be fatalistic towards that circumstance or instead might confront it in an attempt to overcome any perceived or actual disadvantage.

Agency is necessarily contextualized, it occurs in a context of social structure and culture. That is the objective fact the people confront every day.

Archer’s (1995, 2003, 2007) way of articulating this is in terms of a three-stage model.

  • Structural and cultural properties objectivelyshape the situations that people confront involuntarily; the structural and cultural possess powers of constraint and enablement in relation to
  • People’s own constellations of concerns, as they define them.
  • Courses of action are produced through the reflexive deliberationsof subjects who subjectively determine their practical projects in relation to their objective

 

Think about the social structures that produce, advertise and market and then distribute food  – how that this currently characterised by the industrial production of delicious, tasty and cheap foodstuffs packed with sugar, salt and calories. The objective cultural context might include aversion to walking and cycling as we perceive these as impractical, dangerous or too slow.  Think about the culture of eating food and the sociability that surrounds certain foodstuffs. What currently does wine play in the cultural life of many women and beer for men? These objective conditions provide ‘enablements’ to eating easily too many calories. It is made easy to do so. What constraints do we have in eating too much? Well, against the above we have health injunctions not to do so, we have body images that emphasise thinness with attractiveness. If the various constraints to eating too much are not as strong as the enablements, then the individual has to work hard  on clearly identifying their ‘concerns’ – one of which is to lose weight. This has to be turned into a project, something that they focus on every day to combat the many opportunities to fail at achieving the goal. People will tell themselves if the daily project of losing weight is achievable given the reality of their working and social lives. They will draw upon their health assets to help them do so. If their health assets are very poor across the board success is not impossible (they are after all free agents) but it will be harder.

 

Agency operates within certain social and cultural contexts, so consider how agency operated by an A list actress and a struggling in debt mother. What social ‘forces’ propelled them into two very different circumstances and how much is down to personal achievement, luck or circumstance? Consider they now give birth to daughters. What are the chances of either girl using personal agency to radically alter their circumstances. Yes, it happens (e.g. Oprah Winfrey) but who will have the easier path?

 

The following table are ideal types to illustrate just some of complexity of the interplay between biology, psychology and sociology in understanding health choices and health outcomes. These factors are not be thought of as a simple cause effect relationship, there are feedback loops and emergent properties from the whole. Nothing is predestined, all is possible. The list is not exhaustive either. There may be other confounding variables that will change outcomes. The actress may develop a cocaine habit, Vicky may become an ‘Educated Rita’.

 

Asset A list celebrity Actress Vicky Pollard “yeah but no”
Biological Ectomorph

Non variant FTO gene

No chronic illnesses

Endomorph

Variant FTO gene

Diabetic

Psychological High self-efficacy

High self esteem

High body image (body reality matches body ideal

Internal locus of control

Emotional and sexual support

Depression free

Positive outlook

Low self-efficacy

Low self esteem

Poor body image (body reality far from body ideal)

External locus of control

Emotional and sexual abuse

Bouts of depression

Suicidal ideation

Social Similar looking thin peer group

Network effect positive

Social support for domestic needs

Child care easily affordable

Food prepared by nutritionist

Supportive parents and spouse

Socially popular

Wealthy successful peers

The 0.01% Global elite

Private School and Drama school paid by parents

Similar looking fat peer group

Network effect negative

No social support for domestic needs

Child care expensive

Food prepared by Greggs

Parents both dead, absent partner

Social pariah

Poor just about managing peers

The local Precariat

Left at 16 with no qualifications.

Cultural Ambitious

Health high priority

Non smoker

Gym membership

Non violent

Survivalist

Health discounted

Smoker

Daytime TV

Emotional, verbal and physical violence common/expected

Spatial Beverly Hills, Sunshine, Sea View and palm trees Concrete high rise, Rain, Industrial Units and burned cars
Symbolic ‘A’ list Chav
Material

This asset is paramount as it feeds into the others

High Net worth

 

In debt.

 

 

 

 

 

Graham Scambler, emeritus professor at UCL, has written a series of blogs based on the work of Margaret Archer. His work can be found here: http://www.grahamscambler.com/sociological-theorists-margaret-archer/.

Archer,M (1995) Realist Social Theory: The Morphogenetic Approach. Cambridge; Cambridge University Press.

Archer,M (1998)  Realism in the social sciences. In Eds Archer,M, Bhaskar,R, Collier,A, Lawson,T & Norrie,A: Critical realism: Basic Readings. London; Routledge.

Archer,M (2003) Structure, Agency and the Internal Conversation. Cambridge; Cambridge University Press.

Archer,M (2007) Making our Way Through the World. Cambridge; Cambridge University Press.

Archer,M (2012) The Reflexive Imperative in Late Modernity. Cambridge; Cambridge University Press.

Archer,M (2014) The generative mechanism re-configuring late modernity. In Ed Archer,M: Late Modernity: Trajectories Towards Morphogenetic Society. New York; Springer

 

 

 

The Sociological Imagination

“The sociological imagination enables us to grasp history and biography and the relations between the two within society. That is its task and its promise” C. Wright Mills

Photo by Lance Anderson on Unsplash

This is a key work in the sociological literature and provides a way of thinking about our experiences as individuals in society at any given point in time. The argument is that to fully understand ourselves we have to apply the ‘sociological imagination’ to our ‘personal troubles’.

The relevance for health is that this takes us beyond making overly simplistic analysis of our health behaviours, experiences and decisions. If our analysis is too simplistic then we come up partial answers to health care issues at best and irrelevant, judgemental or dangerous answers at worst.

C Wright Mills wrote:

‘…men (sic) do not usually define the troubles they endure in terms of historical change…’ (p3).

So, what is a ‘trouble’?  That might be an episode of illness.

 

 

Personal troubles:

 

  • Having type 2 diabetes and thus having to manage that condition
  • Living alone
  • Being overweight
  • Worries about changes in the benefits system

 

 

We may not consider that our issues (as personal troubles) are better or more fully understood as being linked to living in the 21st century, or that the roots may lie in current society. We are

‘…seldom aware of the intricate connection between the patterns of their own lives and the course of world history.’ (p4).

We do not

‘…possess the quality of mind essential to grasp the interplay of man and society, of biography and history…’  (p4).

In addition we:

‘…cannot cope with their personal troubles in such ways as to control the structural transformations that lie behind them.’  (p4).

What ‘structural transformations’ might be behind living alone, diabetes, weight gain and money worries?

What is a ‘structural transformation?’

If we think of society has having ‘structures’, which vary from society to society and which varies within the same society over time (history), we may begin to understand that society is but the outcome of individuals, groups, communities and populations deciding to act out their relationships one with another. In doing so they create (and are created by) society and its social ‘structures’. We have family structures, gender role structures, work organisation and employment structures, educational structures, health care delivery structures, food manufacture, marketing and delivery structures, economic structures…..  A commonly experienced social structure today is the baking or buying and eating of cake and coffee as a social event. In response to, or perhaps to encourage this, we now have both small businesses in town centres and global corporations (Nestle, Starbucks, Costa Coffee) oriented to selling us high calorie non essential  food and drink.

Relationships between people evolve as humans live their lives and develop their capacities and these relationships then act as structural patterns for others to follow. This process of ‘evolution’ and ‘pattern’ changes over time and between societies. An individual thus is both shaped by these (structural) patterns of living, and in living their lives they in turn shape the patterns (structures). Our lives are thus ‘structured’ but not determined by these structures.

What social structures are there and what are those structures that lie beneath the personal troubles outlined above?

To help answer that question Wright Mills argued that

 

what they need…is a quality of mind that will help them to use information and to develop reason in order to achieve lucid summations of what is going on in the world and of what may be happening within themselves… this quality…(is) the sociological imagination.” (p5).

 

What information do we have about Type 2 diabetes – its rate, prevalence, risk groups, epidemiology, aetiology, and the wider determinants? To fully understand why anyone now has Type 2 we need to get this information and consider for example that:

 

We might be ‘overweight’. What exactly does that mean and how much of an issue is it? The fact that we might now have type 2 diabetes suggests that previous diet, levels of exercise and lifestyle may have contributed. What do we know about weight gain and the link to diabetes?

Our personal story of being overweight is linked to various structural and technological changes in society over our lifetime. These changes include the abundance of fossil fuels to use for energy (a technological change) instead of food, so that cars replace cycling/walking. Active travel is replaced by driving, while the social meaning of driving and car ownership underpin our unwillingness to cycle, walk to the bus stop or railway station.

So, to what degree are we responsible for gaining this weight? Many of us have lived through a time when the public’s understanding of diet was perhaps rudimentary, constrained as it was by rationing and availability and the social norms that construct a ‘healthy’ diet. Many of us experienced ‘socialisation’ which involves learning the values, norms and beliefs of our culture regarding what is appropriate food. To what degree is  vegetarianism, veganism or the mediterranean diet, popular and or promoted as healthy option?

We need to consider what a healthy diet is and how the public get to know. Currently the eatwell plate is a suggestion, but to what degree do the public know about it, how much are they guided by it and what is the evidence base for it? We might want to consider if there are any vested interests in selling us high calorie, sugar dense foodstuffs?

Exercising a sociological imagination also asks what social changes occurred so that we have now an abundance of sugar in the form of high fructose corn syrup?

Our early lives would have been guided by social norms and what shops could provide, as well as cost. the ‘personal trouble’ is weight gain but it is also a public issue as the whole UK population has gained weight. So we need to connect changes in social structures and historical events to the personal story that is a diagnosis of diabetes, to fully understand current health.

The role of sugar in the diet is an issue, what is the history of the dietary advice regarding fat and sugar? We may well have been consuming sugar in amounts that seems normal and indeed is hidden. This could be part of what is called an ‘obesogenic environment’ in which we are immersed and have been for several decades. What do we believe and think about sugar in the diet? To what degree does rational thinking about the risk to weight from eating a ‘normal’ UK diet, feature in buying, cooking and meal preparation decisions?

 

The sociological imagination enables its possessor to understand the larger historical scene in terms of its meaning for the inner life….’ (p5).

This is what Wright Mills refers to when he argued that:

The first fruit of this imagination…is the idea that the individual can understand his own experience and gauge his own fate only by locating himself within his period, that he can know his own chances in life only by becoming aware of all those individuals in his circumstances’ (p5).

 

Wright Mills outlines:

‘The personal troubles of milieu and the public issues of social structure’. (p8).

Troubles:

These occur within the individual’s immediate experience and relationships. They relate to the individual self and to those areas of social life of which the individual is immediately, directly and personally aware. The description of what the trouble is and what the solutions are, come from the individual and within the scope of their ‘social milieu’. A trouble is a private matter; they are values that we feel are threatened.

One of our personal troubles may be feeling and living alone and feeling that whatever we does makes no difference (learned helplessness). The value being threatened here is the value of social relationships being missed.

 

 

Learned helplessness is a state of mind which results in the inability or the unwillingness to avoid negative experiences as a result of thinking that those experiences are unavoidable (even if they are avoidable). This arises because one has learned that one does not have control over the situation. Learned helplessness theory is the view that clinical depression and related mental illnesses may result from a perceived absence of control over the outcome of a situation.

 

Public Issues:   

These are matters that go beyond the local environment of the individual and their inner life. They result as an ‘organisation’ of many such situations into the structure and institutions of society. The countless individual social milieux (i.e. ‘all the lonely people’ in the UK) overlap and create society at points in history. An issue is a public matter; issues threaten values held by the public. When this happens there may be public debate about what that value is and what really threatens it. There is some evidence that loneliness is becoming a public issue as the scale of the issue becomes clearer and its health effects become known.

One of Wright Mill’s examples to explain the use of the sociological imagination is unemployment:

‘When…only one man is unemployed, that is his personal trouble, and for its relief we look to the character of the man, his skills and his immediate opportunities. When…15 million…are unemployed, that is an issue, and we may not hope to find the solution within the range of opportunities open to any one individual. The very structure of opportunities has collapsed. Both the correct statement of the problem and the range of possible solutions require us to consider the economic and political institutions of society and not merely the personal situation and character of a scatter of individuals’. (p9).

What the individual unemployed man (out of the 15 million) experiences is often caused by the structural changes in society. When global economics means that steel can be produced more cheaply in a foreign country (a structural change) then a UK steel works shuts down. To be aware of the idea of social structure and to use it, is to be able to trace links among a great variety of individual social milieu which, as Wright Mills’ states, ‘…is to possess the sociological imagination’ (p11).

There is more than one person who lives alone, is overweight, struggling with diabetes and has money worries. Therefore these personal troubles are also public issues of society if we use the sociological imagination.

To fully understand our life means understanding how society has changed and the opportunities and threats to health that arise as a consequence. It means understanding that our personal agency, the freedom to act, operates within particular social structures that constrain action as well as providing enablements. So, what constrains our action, what enables us to take control of our lives?

Understanding obesity using the sociological imagination links the personal trouble of weight gain with the public issue of whole population shifts in BMI within the context of the obesogenic environment. A fuller understanding of ‘fatness’ goes beyond overly simplistic calculations of calories in = calories out type equations, and simplistic exhortations to “eat less move more”.

Implications:

Health and illness is to be thought as arising from social structure as well as, if not more than, biology. The knowledge that diabetes results not just from the individual’s choice of diet, but also from the social environment, should indicate a  public health and socio-political role. Health education is not just an individually focused issue, based on a biomedical understanding. Health itself has social origins. The concept of an ‘obesogenic environment’ suggests just that.

Therefore strategies that will assist people to move towards health must take into account the social and political context in which they live. Society has to change as much as the individual. Individualised models for change that ignore this will have less chance of success.

Understanding that illness, although at first may seem self-inflicted and out of free will, may result from the social milieu of the individual.  Victim blaming of the unpopular patient, the obese, the self-harmer, the drug addict, the alcoholic, is not only poor practice but is theoretically myopic. That is to say it does not understand the wider determinants of health. This realisation should change the language around health into a more open, less judgemental stance towards the people. For example, the label alcoholic implies the trouble lies within the individual when the roots may also be social.

To summarise: 

  • Health and Illness both derive from socially structured human agency, societal as well as biology.
  • The patterns, experience and causes of health and illness has to be understood in the context of history and culture.
  • The meanings that people attach to health and illness not only are built by social structure but go towards creating social structures.
  • Professionals need to acknowledge the complexity of health and illness and adopt a more open, non judgmental viewpoint.
  • There is a social/political and public health role.
  • Models for change have to go beyond individualised biomedical understandings of health and illness, realising that ‘education’ is not a universal panacea.

 

Benny Goodman      September 2017

 

Public Health and Health Inequalities: why is progress so slow?

Public Health and Health Inequalities: why is progress so slow?

 

This is one question contained in the 2009 report: Learning Lessons from the past: Shaping a Different Future written by the Marmot Review Working Committee 3 – Cross-cutting sub group report. (November 2009).  Hunter D, Popay J, Tannahill C, Whitehead M and Elson T.

The Marmot Review was published in the following year 2010. ‘Fair Society Healthy Lives’ described a mass of data on inequalities in health. A key concept was the ‘social gradient’ which suggests that one’s social position indicates one’s health outcomes at every point on the scale of socio economic status. It thus affects everyone.

The Social Gradient

http://www.who.int/social_determinants/thecommission/finalreport/key_concepts/en/

 

Hunter et al’s (2009) paper considered sources of evidence for ‘Fair Society’ and asked why better progress has not been made to reduce health inequalities and to suggest clear messages about the way forward.

 

  1. Why has better progress not been made? 4 key issues:

 

  • Delivery Mechanisms
  • Lifestyle Drift
  • Government handling of policy
  • Power, Knowledge and Influence.

 

1a. Delivery Mechanisms

 

  1. Delivery of public services and aspects of change has been based on a certain approach. This is the ‘rational linear change model’ which is both reductionist and mechanistic.
  2. This approach is also been driven from the centre.

 

The rational linear change model, is a process for making logically sound decisions. This multi-step approach aims to be logical and follow the orderly linear path from problem identification through to solution:  Problem: obesity. Cause: overeating. Solution: eat less, move more.

Reductionism means that the whole problem is broken down into reducible parts. Obesity can be broken down into its various elements and we can reduce it to a problem of over eating based on the simplistic notion of ‘calories in must equal energy expenditure’.

Mechanistic refers to the idea that one part of a mechanical system is easily affected in a ‘cause-affect’ way by another. This tinkering with a part of the system will produce observable and predictable results. So tinkering with the ‘calories in’ part of the mechanical system should produce weight loss outcomes:  ‘Eat less = lose weight’.

The centre includes central government departments such as the Department of Health. The tendency is to impose policy onto the NHS and front line staff. So an example of central policy is ‘Change 4 life’ or ‘Make every contact count’

1b. Failure of this approach to reduce health inequalities:

The Foresight Report (2007) on obesity identified the ‘obesogenic environment’. Therefore simple solutions (reductionist and mechanistic) such as targeting obese individuals with messages about eating less and moving more is only a small part of the solution. Foresight suggests there is no simple or single solution that works in a cause-effect way. ‘Change 4 life’ which focuses on individual lifestyle changes and behaviour changes will not be enough. This fails to engage with Foresight’s ‘whole systems approach’. Obesity has to be seen as a result of an interrelationship of factors (e.g. power relationships, poverty, employment). If responses are too narrow, focusing on individual lifestyle, the outcome will be failure.

The Economist Intelligence Unit published ‘Confronting Obesity in Europe. Taking action to change the default setting.’ (2015). It outlines the failures of such approaches. It accepts lifestyle and behaviour change programmes ‘are crucial’ but also frames obesity as a medical condition, note, not a socio-political one.  It also suggests that no European country has a comprehensive strategy for dealing with obesity. It quotes Zoe Griffith (of Weight Watchers):

“Education in schools , availability of healthy eating and restriction on marketing to children will go a long way towards resetting our society, but what they are completely ignoring is the majority of the population who are overweight and obese need treatment. It’s a very complex political and policy making environment”.

For current UK and Ireland trends see Public Health England data here.

Are Nurses who focus only on lifestyle and behaviour change with their patients, and who do not critique this approach, and who are also unable to be critically reflexive about their own weight gain, part of the problem and not the solution? This brings us to ‘Lifestyle Drift’ approaches:


 

2 Lifestyle Drift

This is the tendency for policy initiatives, for example Foresight, to recognise the need to take action on the social determinants of health (upstream approaches) but which as they get implemented drift downstream to focus on individual lifestyle factors. The Economist Intelligence Unit report illustrates the complexity of inter related factors. It also then asserts that lifestyle and behaviour change are ‘crucial’ and then frames obesity also as medical condition, thereby medicalising a social and political issue in an overly reductionist manner. It acknowledges the complexity but drifts towards medical treatment, as well as lifestyle change. However it does acknowledge the need for creating an environment that ‘deters obesity’ within a comprehensive strategy that involves transport, food, agriculture and education.

Lifestyle drift tends to move policy implementation away from measures that address the social gradient concept to measures that target the most disadvantaged groups in an attempt to deal with issues such as smoking habits, food choices and exercise levels. As nurses work with individuals and families it is easy to see how lifestyle and behaviour change tools are attractive in their attempts to ‘make every contact count’. Taking action on the social determinants of health is more of a challenge for many clinically based nurses who work in secondary and primary care. This is because nurses often don’t have either conceptual tools of analysis or control over social and economic factors such as housing. That being said, their understanding of their own weight issues would also be far too narrow if based intellectually on a lifestyle and behaviour change approach.

In ‘Lethal but Legal’ Freudenberg (2014) argues that the most important and modifiable cause of health inequalities is the “triumph of a political and economic system that promotes consumption at the expense of health” (p viii). To address health inequalities requires “taking on the world’s most powerful corporations and their allies”. Similarly, Stuckler and Basu (2013) point to Government policy, specifically austerity, as a danger to public health. A question for nurses is to what extent do we recognise that it is the actions of powerful actors that shape the social and economic conditions that result in the social gradient? Lifestyle approaches do nothing at all to address this aspect.

Hunter et al then discuss government handling of policy to explore more reasons for poor progress. Nurses will have a marginal interest in this aspect at best, beyond noting that failures of outcome include the internal processes in and between government departments. Therefore we will move on to their fourth issue.

 

  1. Power, knowledge and influence.

 

There is a causal relationship between inequalities in health and the social, material, political and cultural inequalities of the social determinants of health. Scambler’s health assets approach argues that material health assets are paramount in determining health outcomes. His ‘Greedy Bastards Hypothesis’ asserts that health inequalities in Britain are first and foremost an unintended consequence of the ‘strategic’ behaviours at the core of the country’s capitalist-executive and power elite. This is where health gets political. The strategic behaviours include getting governments to reduce state regulation, tax, control, ownership and provision for public services in order to facilitate the transition to corporate ownership, provision and control of public goods such as health and education. These corporations include Mitie, Serco, GE, Virgin and Capita. They are currently negotiating the Transatlantic Trade and Investment partnership (TTIP) between the US and the EU in order to make it easier to engage in business across the Atlantic. The TTIP will also allow corporations to sue national governments if they try to block renationalisation of health services, or if they engage in environmental or social regulations that is perceived to hurt business.

Scambler argues that the ‘capitalist class executive’ (CCE) are a core ‘cabal’ of financiers, CEOs and Directors of large and largely transnational companies, and rentiers. This ‘cabal’ has come to exercise a dominating influence over the state’s political elite including those in government. Quoting David Landes, Scambler suggests:

“men of wealth buy men of power” who then enact state policy which supports their activities and interests.

 

An example is Sir Philip Green’s handling of the BHS sale and the resulting shortfall in worker’s pension funds. It is argued that both Green and the new owner ran BHS for their own ends with little attention paid to the affect on 22,000 people working on relatively low incomes who now face a drop in pension income.

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 to avoid externality costs resulting in the externality of, for example, increased air pollution.

Hunter et al argue that genuine redistribution of power and resources are required to address health inequalities. This reflects the WHO’s definition of the social determinants of health. They argue that policies aimed at wealth creation result in inequalities in social status and health, the latter is the price to be paid for wealth creation. This is commonly seen in justifications that argue that health, education and social security can only be paid for if the UK economy grows. Health inequalities that result from wider inequalities, and in keeping with lifestyle drift responses, are seen as the result of individual failure and behaviours, what Sandra Carlisle refers to as the ‘moral underclass thesis’ for health inequalities. This is allowed to occur because:

  1. The UK is a class divided society
  2. Behavioural Explanations support the idea of class division
  3. Public spaces for debate have declined, this contributes to the lack of a shared narrative and collective action. It allows the demonization of the working class via ‘Chav’ tropes.
  4. Political action has not allowed public engagement in decision making sufficiently to address the balance of power.

 

Conclusions:

 

To address health inequalities there is a need to consider:

 

  • Health Inequalities are a ‘wicked problem’.
  • Alternatives to the market model.
  • Social movements for change.
  • Current economic and political circumstances.

 

Wicked problems are such that there are no easy quick solutions, we need to understand that such issues as obesity result from a complex interplay of systems that is not always amenable to simple analyses and interventions. Telling people to eat better and move more clearly does not work.

Using ‘the market’ to address health is inadequate. People do not respond to price signals in the rational way that market theory expects, markets also rely on a balance of information between parties for equity to prevail and markets often ignore power imbalances and the rigging of such markets. The market in food and exercise regimes for example is skewed towards vested interests and the profit margin. Companies claim that in a market it is up to the consumer to make choices thus providing market information. The theory is that if we all shun sugar based foodstuffs the market would reflect those choices and companies would change business practices to suit.

There may be a need for social movements ‘from below’ to change powerful vested interests who profit from current economic structures and who also focus on the extremes of health (the obese rather than the overweight) for interventions. People are ‘free’ to make their own societies but not in the circumstances of their own choosing. Individualised responses cannot address those wider determinants of health.

The politics of ‘personal responsibility for health’ in the context of economic structures in which it is said “there is no money” for health and social services because the public debt has to be reduced requires challenging. For three decades a ‘hands off neoliberal approach’ to all social and political issues has been argued as the only approach. Public services have been privatised and marketised as if this is the only way to provide services.

 

Hunter et al conclude by arguing:

  • We need to debate redistribution and the type of society we wish to live in.
  • We need sustained resistance to lifestyle drift.
  • We need to resist silo based working.
  • We need to resist policy aimed only at ‘low lying fruit’ – the easy wins.

“the only way to achieve lasting reductions in inequality is to address society’s imbalances with regard to power, income, social support and knowledge…implement upstream policy interventions….supported by downstream interventions. ” (Priority Public Health Conditions Task group 8)

 

Our social environment encourages obesity

our social environment encourages obesity

Feminist poststructuralism as a lens towards understanding obesity.

More than meets the eye.

Feminist poststructuralism as a lens towards understanding obesity.

Firstly this paper by Aston et al (2011) opens by accepting the framing of obesity as a health emergency or ‘concern’ and it does so by referencing the World Health Organisation’s (2011) ‘global epidemic’ phrase. Thus it contributes to a value position that obesity is indeed a medical issue with negative health consequences. The position is then taken that obesity is a ‘disease’ arising out of social and environmental conditions. That is to say it accepts that obesity is a disease but that its causes are not rooted only within individuals and their behaviour but as arising from their social position and the environment they live in (the ‘obesogenic’ environment).  They argue “Obesity now represents a major public health issue” (p1188) and according to the WHO (1998) is the second most modifiable cause of ill health after smoking. Aston et al use the word alarming to describe Canada’s population where 60% are overweight or obese. The issue as to whether obesity is simply a disease that needs curing regardless whether its aetiology is individual or social, is open to question. However for the purposes of this paper I wish to explore what feminist post structuralism (FPS) can bring to understanding obesity.

Feminist Post Structuralism.

Aston et al argue that FPS seeks to understand the meaning and experience of obesity as arising from our social relationships. It also seeks to understand how power relationships work between individuals as they are constructed through social, institutional and political structures. In other words, what are the power relationships involved in for example daughter-mother family relationships “mum’s on a diet again…and my bum does look big in this!” (social); worker-employer relationships “oi!  lard arse, get off yer bum back in the office or we’ll put you on a fitness course!” (institutional);  and patient-health policy relationships “I note Mrs Jones, that you BMI is well into the overweight category…we need to reduce that to reduce your risk of diabetes and heart disease…what weight loss programme shall we use, have you seen Change for life?” (policy-political),  and how do they affect the individual’s life experiences and chances? In this context, we would seek to examine the talk between the ‘fat’ and the nurse, we would want to understand both their beliefs and values and stereotypes and how this talk and interaction (including body language) constructs the experience of being fat in this encounter. This also examines how the fat are observed and measured, what questions are asked of them and how those questions are put to them and what solutions are put forward (e.g. eat less, exercise more!).

FPS seeks to examine the personal experiences, the relationships people have, and how they understand how power operates in each social setting, be it the family, the workplace or the health clinic. This point of view (perspective) accepts that life is social and therefore our personal experiences (personal troubles) can be understood through examining how social, cultural and institutional beliefs, stereotypes and norms (public issues) affect us.

This perspective is an alternative to a medical discourse (a medical way of thinking and talking about) which accepts as axiomatic, as self-evident, that a person’s health is predominantly under the control of the individual. Therefore a good deal of research within this sort of thinking seeks to understand obesity as arising from psychological and genetic factors and examines personal behaviours  involved in weight gain.

Furthermore, health interventions and health professionals may tacitly accept this medical discourse and design interventions around changing personal and behavioural factors (e.g. ‘Change for Life’). This approach has not and will not work. It is largely ineffective in reversing population obesity. Roberts and Edwards (2010) in ‘The Energy Glut’ suggest that whole populations across the globe are ‘getting fatter’; waist circumference and BMI measurements are increasing in developing as well as developed nations. If obesity needs to be understood as part of social relationships and relationships of power at that, then we need to challenge the notion of obesity as only a personal problem (a personal trouble). Applying the sociological imagination (Wright Mills 1959) to obesity we would seek to understand the personal trouble of obesity as a public issue, relating the personal biography of the ‘fat’ individual to historical changes and social structures.

So how does FPS throw light upon this issue?

1.      By focusing on discourse.

2.      By focusing on power relationships.

3.      By focusing on subjectivity (one’s ‘subject position’) and agency.

Discourse.

One’s experience, beliefs and values are shaped by and shape the language we use about obesity. By examining how we talk about it to uncover our stereotypes and beliefs allows us to clarify our personal understanding and how we come to our understanding. When we listen to healthcare professionals talking about obesity as a disease and the need for personal responsibility for behavioural change we may believe that it is down to us to eat less and exercise more. After all that is the main message. We may even use this language to describe our battle with weight.

Power

Individuals and groups have the power to impose a discourse onto interactions. These are supported by contextual factors (where that interaction takes place, for example the GP surgery). Health policies such as Change for Life position the fat as needing to take personal responsibility.  Being overweight and its negative connotations is supported by medical research into the health risks and positions it as a ‘bad thing’. The fat can’t challenge this discourse as they don’t have a counter position. There are plenty of places where fat is seen as negative and as a disease (hospitals, clinics, surgeries, health centres, leisure and sports centres) and where it fat and fat people are excluded except as negative stereotypes (magazines, film and TV programmes, advertising, jokes, comedy).

Subjectivity and Agency.

We can come to see our subjective selves as being constructed through the above discourses and power relationships but through our agency (our ability to act) can come to challenge dominate negative or ‘disease’ discourses through dialogue, research, speaking out and open communication. So, on the one hand our subjective self can be beaten down with an acceptance that it is my personal responsibility to get thin and if I cannot then it is my fault. My subjective self may even accept the need for doing so in an attempt to align my body image with some thin ideal and as part of healthy living to prevent disease. I may accept that I am already ‘ill’ by being overweight. However by engaging my ‘agency’, my ability to act, I may challenge some of these assumptions and want evidence for the positions taken. For example, at what stage does extra weight really become unhealthy? How do I balance enjoying life with all that it offers with a rigid abstinence regime in the hope of achieving a thin ideal? Do I want to live longer as a thin person (if that is actually what may occur) if I have to count every calorie and give up beer?

“You call me fat, I feel fat, but actually I don’t think it is my fault entirely…this is not about blame or making me out to be a victim…you have to realise that the food choices I am faced with, the transport options I have are having an impact. It is not easy to change everything about my life when society continues to encourage weight gain. In any case the athletic thin ideal is unobtainable for me and I like a glass of wine and cheese, it what makes for a bon viveur”.

 

However, what is so F about FPS?

It seems clear from the paper that we need to challenge health, media, medicine and education organisations in their understanding about obesity. Society and the healthcare system has to recognise that the modernisation of our world (Wright Mills’ historical and structural changes) has set the global populations up for failure with respect to maintaining a healthy body weight through increases in opportunity for food intake and decreases in opportunity for energy expenditure, but I fail to see the feminism in this piece. What is the gendered nature of social relationships which would presumably affect women’s experiences? This paper does not make that clear. The obese in this paper are neither  male or female.

Aston M, Price S, Kirk S, and Penney T. (2011) More than meets the eye. Feminist poststructuralism as a lens towards understanding obesity. Journal of Advanced Nursing.

Benny Goodman. 2012

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