Category: Social determinants of health

Health based on Poverty and its measurement.

Photo by Adam Jang on Unsplash

Health based on Poverty and its measurement.

 

One of the explanatory frameworks, or ‘discourses’, for ill health and health inequalities around access to health services and health outcomes, is that of the ‘material deprivation’ thesis, which underpins much of the Marmot Review Fair Society Healthy Lives. It sits within a ‘Redistribution discourse’, which suggests the answer is redistribution of material resources. Alongside this is the ‘Psychosocial Comparison Thesis’, which underpins such work as Wilkinson and Pickett’s The Spirit Level. This forms part of the ‘Social Integrationist discourse’ in which reduction of social inequalities and better integration of marginalised groups is important.

 

Material deprivation focuses on a lack of resources to support healthy living while psychosocial comparison suggests one’s position in the social hierarchy, and the level of inequality in society, create psychosocial stress harmful to health. They are not mutually exclusive and of course might work together for some individuals resulting in poorer health outcomes for them. Being poor in a very unequal society is thus very harmful to health and results in gross inequalities in health.

 

A third explanatory framework is the ‘cultural thesis’ which suggests it is the culture of certain behaviours, attitudes, values and norms that are the root cause of ill health. Another term for this way of thinking is the ‘moral underclass discourse’. The answer is to make better choices and improve lifestyle activities such as stopping smoking, reducing alcohol consumption, exercising more and eating better. Poor people are disproportionately ill because of their poor life decisions. The ‘underclass’ make poor moral decisions and therefore bring ill health upon themselves. The material deprivation they experience is a result of their own poor life choices, their parents’ life choices, or it results from being ill, preventing them from working or making better life choices (the deserving poor).

 

The Consensual Method of measuring poverty.

 

A link between all three is material deprivation resulting from poverty, but what do we mean by poverty and how is it measured? In the UK we do not use the concept of absolute poverty, instead some reports are using the term ‘relative poverty’, one measure of which is the consensual method. The research project Poverty and Social Exclusion (PSE) outlines what this is. In short this focuses on deprivation as:

 

“enforced lack of necessities determined by public opinion”.

 

In the consensual approach we first need to establish what those items are that make up our ‘standard of living’ and then identify which of those items most people view as ‘necessities’. Consider a mobile phone as an item, if most people think this is a necessity, then not having one begins to identify oneself as poor. The necessities are what most people think everyone should be able to afford and which no one should be without. Poverty is where these deprivations impact on a person’s whole way of life; to measure poverty we need to know how many people there are whose ‘enforced lack of necessities’ affects their way of living. Note that those who choose not to have these necessities would not count.

 

Items that are necessary include the social as well as the material. The PSE have published data on what the public thinks those items are: for example, 96% of us think ‘heating to warm living areas of the home’, 94% think a ‘damp free home’ and 91% think ‘two meals a day for adults’ are some of the necessities. However some items go beyond ‘basic’ needs such as ‘visiting friends/family in hospital’ (90%), and ‘attending a wedding/funeral’ (79%).

 

What do you think everyone should be able to afford?

What do you think no one should be without?

 

Once we have these benchmarks, then we can start to measure the base line below which society considers people to be deprived. This is what is being attempted since 1983 and the ‘Breadline Britain’report.

 

The 2013 PSE first report ‘The impoverishment of the UK’ PSE first results: Living Standards’ indicates the scale and extent of poverty in the UK (the 6th richest country as measured by GDP per capita). One section of the report ‘Going backwards 1983-2012’ suggests that the proportion of households falling below minimum standards has doubled since 1983:

 

1. More children lead impoverished and restricted lives today than in 1999.

2. 5 million more people live in inadequate housing than in the 1990s.

3. 9% of households can’t heat their homes adequately today up from 5% in 1983 and 3% in 1999.

4. 33% of households experience below par living standards.

 

This is despite the fact that the UK is a far richer country now than it was in the 1980’s. The size of the economy has doubled over the last 30 years. This supports the claim that economic and wealth creation has benefitted the better off while families lower down continue to struggle to meet their basic needs.

 

Source: http://www.poverty.ac.uk/pse-research/going-backwards-1983-2012

 

If you emphasise that ill health and deprivation results from poor life choices, then you might not be interested that more and more families are experiencing deprivation of this kind. It is a case of them not taking up opportunities, not working hard at their education or not moving to where employment is higher, i.e. London and the South East. However, you might want to wonder why more and more families are making these poor life choices since the 1980’s, especially if during that time knowledge about what is the basis for a healthy life, is more easily accessible with the internet.

 

Or you might think that regardless of the fact that more people falling into this category, this does not mean that they are also more likely to experience health inequalities such as reductions in life expectancy. The data from such sources as the Community Health Profiles and that contained in ‘Fair Society, Healthy Lives’ and ‘The Spirit Level’ would suggest otherwise.

 

 

 

Source: http://www.poverty.ac.uk/pse-research/going-backwards-1983-2012

 

 

watch this video for a first hand account.

 

 

What are the implications of this knowledge for nurses? Is this a ‘social issue’ irrelevant to nursing practice?

 

 

The Violence of Austerity

Photo by Samuel Zeller on Unsplash

This is based on the recent 2017 book by Vickie Cooper and David Whyte.

When society places hundreds of proletarians in such a position that they inevitably meet a too early and an unnatural death, one which is quite as much a death by violence as that by the sword or bullet, its deed is murder just as surely as the deed of the single individual.” Engels (1845) ‘The Condition of the Working Class in England’.

Let us be clear from the outset. This is not about interpersonal violence carried out by one person directly on another using physical or emotional force. This is about Institutional violence, carried out by smartly dressed ordinary men and women in offices up and down the country, who often are merely following orders or who were architects of the policies that kill or cause physical and psychological harm. The malefactors of great wealth stand behind the lines cheering them on, using their propaganda news media to convince the victims that the victims are to blame. The malefactors of great wealth also grow fat on the proceeds of the sales of products designed to dull the senses and anaesthetise the pain caused by institutional or structural violence – high fat, sugar loaded fast foods, cigarettes, alcohol, cheap TV and mass culture in a dystopian miasma of false dreams.

Some may doubt the existence of institutional violence, perhaps arguing that only human beings can directly inflict pain. Johan Galtung (1969) in ‘Violence, Peace and Peace Research’ wrote of structural violence; a violence in which some social structure or social institution causes harm by preventing people from meeting basic needs. This is a model of violence that goes beyond notions that focus only on individual agency. Gregg Barak (2003) in ‘Violence and Nonviolence: pathways to understanding’ argues:

Like interpersonal forms of violence, institutional forms include physically or emotionally abusive acts. However, institutional forms of violence are usually, but not always, impersonal: that is to say, almost any person from the designated group of victims will do.

Yes. “any person” from the sea of faceless ‘skivers, shirkers, unemployed, disabled, sick, mentally ill, low paid and feckless’ who have been systematically stripped of their personhood by bureaucratic processes designed to make their lives hell in order to ‘incentivise’ them to find work.

Barak goes on: “Moreover, abuses or assaults that are practiced by corporate bodies—groups, organizations, or even a single individual on behalf of others—include those forms of violence that over time have become “institutionalized,” such as war, racism, sexism, terrorism, and so on. These forms of violence may be expressed directly against particular victims by individuals and groups or indirectly against entire groups of people by capricious policies and procedures carried out by people “doing their jobs,” differentiated only by a myriad of rationales

People “doing their jobs” using thoughtlessness, banality and cliché to justify their actions or perhaps in fear of joining the ranks of the precariat themselves. The current most important banality and cliché currently in force is ‘Austerity’ and its attendant lies used as justification.

Galtung: “violence is present when human beings are being influenced so that their actual somatic and mental realizations are below their potential realizations”

  1. Violence is a phenomenon which reduces a person’s potential for performance. A distinction must be made between violence and force, since the former breeds negative results, while this is not necessarily so in the case of the latter. This is an important option, because many people consider that violence may have both positive and negative results.
  2. Violence should be objectively measured according to its results, not in a subjective manner. Suicide, mental illness, mortality and morbidity rates, hunger, and poverty.

Felipe, MacGregor and Marcial Rubio refer back to Galtung and provide their own definition of violence:

A physical, biological or spiritual pressure, directly or indirectly exercised by a person on someone else, which, when exceeding a certain threshold, reduces or annuls that person’s potential for performance, both at an individual and group level, in the society in which this takes place”.

Criticism of structural or institutional violence, and the denial thereof, may focus on the need for an actor; an actor who can then be held liable for such action. Personal or direct violence is a violence in which an aggressor can be identified, face to face, whereby the victim can recognise a guilty person through direct confrontation. This is far too narrow a definition with perhaps the paradigm case for institutional violence being Adolf Eichmann who never actually got his hands dirty.

If these definitions hold, current government ministers, civil servants, local authority bureaucrats are complicit in the violence inflicted upon claimants for universal credit, those who died undergoing work capability assessments and those who died in Grenfell Tower.

It is the contention of Cooper and Whyte, along with Stuckler and Basu, that ‘Austerity kills’.

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)

 

Poverty Privilege and Health

In two of the richest nations ever to have existed on planet earth we have a separation which allows affluent whites to exist in a bubble of privilege; a bubble of privilege which survives the shooting of police, deindustrialisation, poverty, precarity and the social gradient in health. Privilege understands and sees how radical losers exploit poverty and exclusion, but does not want to address social and economic structures; privilege understands that pain and anger can be turned both inward and outward but looks for solutions in the individual and ‘security’; privilege sees the transmission of poverty and exclusion only in the personal agency of the poor themselves.

Washington Heights is a suburb of the most segregated city in America. Charles lives in a part of Milwaukee where the residents are 99% white, yet a few blocks up are black neighbourhoods where shops are boarded up, many houses have repossession notices on their front doors, and the air is one of decay and poverty. The separation of black and white in Milwaukee is replicated in big cities right across the US, and separation breeds a lack of empathy.”

“Local authorities which report the highest rates of people facing severe and multiple disadvantage are mainly in the North of England, seaside towns and certain central London boroughs”

“Women who live in the least deprived parts of Kensington & Chelsea can expect almost a quarter of a century more of good health than their female counterparts in the most deprived part of the borough. For females at birth, the number of years an individual could expect to live in good health based on current rates – known as healthy life expectancy – differed by an average of 24.6 years between the most and least deprived parts of the borough” (ONS, 2015)

…and yet politicians like to focus on a ‘moral underclass’, blaming them for their behaviour that causes poverty. Drink and drugs are key factors in this regard:

“Ian Duncan Smith, Secretary of State for Work and Pensions, shocked readers of the Daily Mail with: ‘Addicts and alcoholics cost us £10billion a year, says Duncan Smith: Blitz launched to help people with drink drug problems find work’ “. (Glen Bramley LSE Blog)

There is a very old debate about whether poor people owe their circumstances to structural economic factors or to moral/behavioural failings. Sandra Carlisle in 2001 argued that there are ‘contested explanations, shifting discourses and ambiguous policies’  for health inequalities: there is the ‘Moral Underclass’ discourse, the ‘Social Integrationist’ Discourse and the ‘Redistrubutive’ discourse. Each has its own explanation as to why there are inequalities and then what to do about them.

Since Sandra Carlisle wrote her paper, there has been a a good deal of evidence to suggest that structural/economic forces are a major factor in people’s health and illness. There is some evidence also of ‘transmitted poverty‘ due to adverse childhood experiences. The misuse of Alcohol and Illegal substances (they are all drugs) are of course correlated:

“There is a huge overlap between the offender, substance misusing and homeless populations. For example, two thirds of people using homeless services are also either in the criminal justice system or in drug treatment in the same year”.

Many people faced with adverse social situations learn to cope, or they become fatalistic,  or they cling together in supportive communities or they become activists fighting for social justice.  Some self harm, some drink to excess, some go to University and become doctors or lawyers or politicians.  They exercise their personal agency and succeed or fail within structurally determined circumstances. They succeed, despite not because of, the activities and ideology of the privileged. A few of the successful however, then refuse to provide more ladders while shouting “I did it so can you”.

The lack of empathy, the total separation of lifeworlds, arises partly from moral intuitions that both blinds many politicians and commentators to alternative explanations pf poverty and binds them together in a bubble of privilege that prevents them from analysing the evidence. As we all do, they engage in post hoc rationalisations – in their case that that the poor are a moral underclass who are less intelligent, lazy, and hard working than the successful – to explain and justify their own positions.  This is almost a moral imperative, because not to blame the poor opens one up to the need to justify or critique the structural and economic privileges one has unequal access to. Placing the focus on the work, drinking and drug taking habits of a ‘moral underclass’ provides one with a sense of superiority and entitlement so much on show in both US and UK politics. No doubt the same occurs in Russia and China. To acknowledge that there are structural and economic conditions, for example the public school system or the service sector low wage economies,  or the inverse care law, opens up the middle class to accusations of champagne socialism.

This is a common tactic to deflect the argument away from an examination of causes to one of ‘ad hominem’.  Another tactic is to argue that the best way to address structural and economic factors is more of the same economic policies that have held sway especially in the US and UK. Indeed on a global scale the numbers of people living in absolute poverty is decreasing. Inequality is also decreasing with in the UK (gini coefficient). However these two factors are not the only issue.  Both the UK and the US are rich and other measures of inequality have increased, see for example the use of the Palma ratio. It matters greatly for very poor people to get incomes, and mortality rates, enjoyed by the poor in the UK and the US, but that is not enough as the social, health and political problems in both countries testify.

Privilege looks around and is satisfied knowing that the ‘have nots’ only have themselves to blame. They reach for the moral underclass theory and publish it relentlessly in their newspapers and commentary. They also have the wealth and political power to ensure this ideology is accepted by the poor themselves. However, many do not. In this context:

The losers get sick.

The losers get poor.

The losers get defeated.

The losers get mad.

The losers get even.

‘Many professions take losers as the object of their studies and as the basis for their existence. Social psychologists, social workers, nurses, doctors, social policy experts, criminologists, therapists and others who do not count themselves among the losers would be out of work without them. But with the best will in the world, their clients remains obscure to them: their empathy knows clearly-defined professional bounds’ (Enzensberger 2005). Enzensberger (2005) goes on to argue:

‘one thing is certain: the way humanity has organized itself – “capitalism”, “competition”, “empire”, “globalisation” – not only does the number of losers increase every day, but as in any large group, fragmentation soon sets in. In a chaotic, unfathomable process, the cohorts of the inferior, the defeated, the victims separate out. The loser may accept his fate and resign himself; the victim may demand satisfaction; the defeated may begin preparing for the next round. But the radical loser isolates himself, becomes invisible, guards his delusion, saves his energy, and waits for his hour to come’.

Shoots a Policeman, drives a truck through a crowd, blows himself up in an airport…..all the while privilege looks on in dumb uncomprehending horror calling for more security and economic crackdowns on the moral underclass upon whom the often middle class radical loser preys.

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/

 

 

 

 

 

 

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/#

Planetary and Public Health – its in our hands ?

From public to planetary health: a manifesto.

The Lancet (Horton et al, 2014) has just published  a manifesto for transforming public health.

You can read the full one page easy to read manifesto here.

This is a call for a social movement at all levels, from individual to the global, to support collective action for public health. Public Health has been widely defined in this manifesto and draws upon the ideas of Barton and Grant’s health map which has climate change, biodiversity and global ecosystems as the outer ring of the determinants of health.

The current definitions of public health, for example from the Faculty of Public Health,  draw upon Acheson’s 1998 definition “The science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society”.  However this definition may now be outdated as there is no mention of environmental or ecological determinants of health and no express action on planetary health at all.

Therefore this manifesto is an implicit call to redefine what public health means. Currently you can read the FPH’s approach to public health and fail to consider issues around climate change, biodiversity loss or the crossing of planetary boundaries which delineate a ‘safe operating space for humanity‘. This needs changing.

The main points within this manifesto  include a definition of ‘planetary’ , rather than ‘public’ health which they argue is an “attitude towards life and a philosophy for living… emphasising people not diseases, and equity not the creation of unjust societies”.  There is a strong focus in the manifesto on the unsustainability of current consumption patterns of living, based on the harms this has on planetary systems. They argue “overconsumption…will cause the collapse of civilisation”. Jared Diamond is worth a read on the collapse of civilisations,  and this argument is in line with his analysis.

Interestingly, an overt political statement is introduced: “We have created an unjust global economic system that favours a small wealthy elite over the many who have so little”. They attack the idea of progress, and of neoliberalism  including ‘transnational forces”, for deepening this ecological crisis and for being socially unjust. There is also a hint of the ‘democratic deficit‘ in which trust between the public and political leaders is breaking down.

The call is for an urgent transformation in values and practices based on recognizing our interdependence and interconnectedness, a new vision of democratic action and cooperation.  A principle of ‘planetism’ is invoked which requires us to conserve and sustain ecosystems upon which we rely.

Finally they suggest that public health and medicine can be independent voices of conscience who along with ’empowered communities’ can confront entrenched interests.

So far so good, and in a one page document the detail is necessarily missing.  The principles outlined in this manifesto and the analysis focusing on neoliberalism and ‘entrenched interests’ point us in a direction. However, there is now a need for a map.

I am not convinced that public health, medicine and certainly not nursing, is sufficiently politically aware of the scale of the issue and the sheer force and dynamic of capitalism to even begin constructing the map. That may be an unfair criticism because the education of health care professionals is ‘ahistoric’ and ‘apolitical’ by nature,  they simply lack a sociological or political imagination underpinned by a critical theory of capitalism. And for good reasons.

However, if doctors and nurses are to engage with this manifesto and to debate and argue for an alternative world view, then there is an urgent need to understand the forces railed against them. This manifesto rightly points out the political nature of the issue and the authors no doubt have a clear idea what they mean, however I doubt very much if the majority of healthcare professionals really understand, or even perhaps care about,  the concept of neoliberalism.

In the UK we will be having an election in 2015, in which we will be offered similar versions of the system that is causing the mess. There will be little in the way of mainstream reporting or argument on radical alternatives to consumption or finance capitalism. Indeed parties will be arguing over who can best manage the system.  The only exception will be the Green party who are a fringe party, in terms of votes.

As an example of the scale of the problem, consider Bill McKibbens’  ‘three numbers‘ argument: 2 for two degrees, the threshold beyond which we should fear to tread; 565 gigatons of CO2 we might be able to put into the atmosphere and have some hope of staying below or around 2 degrees; 2795 gigatons which is the amount of carbon in current reserves, but is the the amount of carbon we are planning to burn!  Further, the wealth of investors is tied up in this number and would evaporate like petrol in a hot day should we globally decide that this reserve should stay in the ground. This is an example of an entrenched interest backed by neoliberal politics which is antithetical to global and governmental regulations. The current TTIP negotiations which is trying to establish a free trade area between the US and the EU,  possibly exemplifies the powerlessness of states in the face of lawsuits by corporations if George Monbiot is correct. TTIP is a public health issue and forms part of the backdrop to this manifesto.

I welcome this manifesto, and would urge public health bodies to become overtly political in their statements about public health, perhaps revisiting Acheson and redefining public health to include planetary health.

Following that observation, a new publication published in February 2014, appears to address the politics in an overt way. The Lancet – University of Oslo Commission on Global Governance for Health argues in a document called ‘The political origins of health inequity: prospects for change’ : “Although the health sector has a crucial role in addressing health inequalities, its efforts often come into conflict with powerful global actors in pursuit of other interests such as protection of national security, safeguarding of sovereignty, or economic goals.”

This then sets up political determinants of health which sit alongside the social determinants of health. Whether it goes as far as critiquing the underlying dynamic of various forms of capitalism remains to be seen.

Your health depends in where you live

Your health depends in where you live

Child Mortality, poverty, globalisation

Global Perspectives on Child Health.

 

It might be a little trite and clichéd to state that our future is bound up with the current health and welfare of our children. Nonetheless, it is a matter of ethical practice how the next generation is faring. This is not about creating a healthy workforce for the economy, that is a secondary (and possibly questionable) ethical aim. It is a good in itself, to care for children. As a society in our concerns for children, we should not rely on utilitarian ethics (i.e. the consideration of ‘what good comes of doing it’), this is about a ‘universal good’, one that applies in whatever time in whatever culture.

 

 To consider the issue of child health I would like us to think about:

 

1.  Issues – ethical practice what is our responsibility? To whom are we ethically responsible?

2.  What is the role of the nurse as a global citizen for health ?

3.  What are our actions that flow from this?

 

Issues:

 

“Considerable evidence suggests that neocolonialism, in the form of economic globalization as it has evolved since the 1980s, contributes significantly to the poverty and immense global burden of disease experienced by peoples of the developing world, as well as to escalating environmental degradation of alarming proportions. Nursing’s fundamental responsibilities to promote health, prevent disease, and alleviate suffering call for the expression of caring for humanity and environment through political activism at local, national, and international levels to bring about reforms of the current global economic order” (Falk-Rafael 2006).

Falk-Raphael implicitly draws upon a social determinants of health approach which argues:

 “The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries”.

Globalisation results in large capital flows, labour movement and displacement and the increasing dominance of TransNational Corporations (TNCs) on economic, social and political life. The demise of state power – its withdrawal from public services, the rise of TNCs and the primacy of the market are three voices guiding politics.

 

I would argue that there is a need for a fourth voice to defend global public goods such as health. This voice is civil society, which includes nurses. Collier (2008) suggests that we have a bottom billion stuck in poverty. Even for the Rich, threats to survival are not domestic but global. Perspectives are changing from local to global, the ethics of healthcare thus need to be discussed in this context. The WHO’s Millennium Development Goals also set a global policy framework.

 

The fact of children dying under the age of 5, and the concentration of that statistic in certain countries, is largely preventable. The developed rich nations of the West have achieved huge gains in child mortality, despite a socioeconomic gradient still evident. By that I mean the children of the poor are over represented in mortality statistics. This will be true in countries with high mortality rates (Nigeria, India and China). It is the children of the poor who die young.

 

Globalization cannot be the cause of poor child mortality rates, rather it is the poverty that existed before global capitalism that is the main cause. Therefore efforts at eradicating poverty will bring down the rates (along side simple things like fresh water, malaria nets and vaccinations). Global capitalism is producing the goods we need and improving the living conditions of many so that many countries will eventually join the developed west with their low mortality rates. However, we must not lose sight of the socioeconomic inequalities in health in the rich West. However, there is an ideology attached to globalization that would rather spend trillions of $s and £s on bank bail outs, military spending (estimated cost of the UK’s trident replacement  – anything between £20 and £100 billion) and the mismatch between research funding and the research need of low and middle income countries remains. This has been referred to, by the Global Forum for Health Research, as the 10:90 gap (10% of global funding going towards 90% of global needs –research favours the rich in the rich world).

 

Ethical practice. Paul Ricoeur suggested that ethics are about “aiming at the good life”, and so if this is the case we ought to consider the good for all. If everyone has a right to the opportunity for a good life, what should the Nursing response be? 

 

Consider the codes of Ethics that govern nursing practice. Where are they, and what do they say? Consider the international nursing codes of ethics rather than just the Nursing and Midwifery Council’s.

 

As stated above, child health should be a matter of universal concern to us all. To focus only on the children of the rich in the rich world, who already have a surfeit of resources and health access, may be an abrogation of our moral obligations as global citizens for health. There is therefore a need to think differently about our role in the world as a nursing community.

 

Acting Ethically as a nurse in a global community requires a need for Transformative thinking.

 

 

 

Part of that thinking involves seeing our selves as interconnected in systems on a finite planet. We have been told that climate change is the biggest threat to public health this century. Children already at risk in the developing world could face, some say are already facing, health threats from changing climates. Food shortages, droughts and crop failures have affected many parts of the world in 2012. Current economic practices are implicated in carbon emissions. Thus mitigating and adapting to climate change will be on the agenda in the developed world if we are to keep our gains. In the United Kingdom carbon reduction already is an NHS aim.

 

 

Child Mortality: the facts:

 

Use the websites below to gather a fuller picture of current trends in child mortality and the factors that reduce child deaths. Consider what role nurses can play in this. Think about the relationship between maternal health, family size, female education and child mortality.

 

Websites:

 

http://www.globalissues.org/about – facts about global health issues. Click on issues and then health issues for an overview.

 

http://www.un.org/millenniumgoals/childhealth.shtml – the WHO’s Millennium Development Goals.

 

http://www.gapminder.org/videos/reducing-child-mortality-a-moral-and-environmental-imperative/ -Hans Rosling on child mortality

 

 

Levels and Trends in Child Mortality 2012 http://www.unicef.org/videoaudio/PDFs/UNICEF_2012_child_mortality_for_web_0904.pdf   UNICEF.

 

Every Woman Every child is a United Nations campaign which acknowledges that the health of women and children are priorities, as reflected in the Millennium Development Goals (MDG 4 and 5). See box 1.

 

 

MDG 4 Reduce Child Mortality

MDG 5 Improve Maternal Health

 

By focusing on the maternal and child health it is hoped that we will help to maximise global health gains.

Box 1

 

What is Every Woman Every Child?

 

 

Launched by UN Secretary-General Ban Ki-moon during the United Nations Millennium Development Goals Summit in September 2010, Every Woman Every Child aims to save the lives of 16 million women and children by 2015. It is an unprecedented global movement that mobilizes and intensifies international and national action by governments, multilaterals, the private sector and civil society to address the major health challenges facing women and children around the world. The effort puts into action the Global Strategy for Women’s and Children’s Health, which presents a roadmap on how to enhance financing, strengthen policy and improve service on the ground for the most vulnerable women and children.

 

‘Every Woman Every Child’ http://www.everywomaneverychild.org/about

 

http://www.everywomaneverychild.org/images/content/files/global_strategy/full/20100914_gswch_en.pdf

 

Conclusion.

 

We know there is a huge disparity in the under 5 mortality rate (U5MR) and that this is linked to socioeconomic status. This may well be exacerbated by climate change. There are variances within countries as well as between them. We know that rates are falling on a global basis and many countries are making good progress. We also know that nurses are charged with having a health promotion and public health role to play. This could go beyond a medical approach (e.g. vaccinations) and adapt the social model of health. As global citizens nurses could address social determinants through individual actions as well as through their socio-political roles, the least of which means developing political awareness of such things as the UN’s ‘Every women every child’ campaign.

 

Benny Goodman 2012

Class divide in health widens

Class Divide in Health Widens

http://gu.com/p/3av95

 

What is the mechanism at play which prevents poor people from changing their lifestyles? Why do many not ‘take responsibility’ for unhealthy choices? The structural issues (e.g. unemployment which leads to sickness which leads to unemployment; another is long term low pay and part time work) are some mechanisms. Try living on <£12,000 pa on a monthly rent of £450 to see just how hard it is…so why smoke and drink and eat junk food then, all activities which eat into the funds that are available?? The evidence suggests that relative social status is a key mechanism (Wilkinson and Pickett 2010), i.e. living in a social group means also comparing oneself to those around us, a negative appraisal results in stress and physiologically this means corticosteriod release as well as adrenaline.  It sets up anxiety (physical stress as well – it makes the body unwell), now it just so happens that smoking, drinking and high sugary junk foods are great at hitting the pleasure centre in the brain, and giving us a shot of the pleasure hormone dopamine (the same hormone that ecstacy floods your system with). The advertising industry and corporate activity manufactures demand in the population, it needs you to buy stuff and one mechanism it subliminally uses is social comparison, you are invited to consider how your present self is and how your future self could be if you had this product. This also involves comparison with other social groups. So a lack of resources to engage in that activity advertised as a ‘good thing’ paradoxically leads to precious resources going into activities that relieve the stress and provide instant gratification. Smoking, drinking a junk food are excellent at instant gratification. Add to that mix a sense of fatalism, long term sickness, poor education, a lack of ‘self efficacy’, poor social capital and a perceived and often actual lack of a means to address these issues and hey presto you have an underclass mired in poor health and the cycle begins again. These are just some of the mechanisms at play. We are living in an insane society (see Erich Fromm ), which also creates this underclass and ensures this class has the mechanisms to self defeat. Social mobility in the UK has all but halted, so my advice is: choose your parents very carefully.

 

http://www.guardian.co.uk/news/datablog/2012/may/22/social-mobility-data-charts

http://www.dailymail.co.uk/news/article-2137585/Britain-worst-social-mobility-Western-world.html

http://www.guardian.co.uk/politics/blog/2012/may/30/milburn-social-mobility-politics-live-blog#block-10

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