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