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.

Inequality, the Gini coefficient, does it matter?

Inequality (Income) and the Gini Coefficient.

(picture of global GC by Kurzon (Own work) [CC0], via Wikimedia Commons)

On 16th April 2016 The RSA held a discussion called the ‘Inequality debate’ which posed the question ‘is growing Inequality a price worth paying for London’s continued economic success?’ The panel largely answered in the negative but Mark Littlewood, Director of the Institute of Economic Affairs, questioned the accepted fact of inequality arguing that income inequality as measured by the gini coefficient (GC) has not increased in the UK.

This was an interesting point because it challenges much of the debate around social inequalities and health inequalities. Littlewood’s point is correct, but irrelevant, due to issues with the sensitivity of the GC, other measures of inequality and other dimensions of inequality for example  of health (Marmot 2010).

 

Gini Coefficient and the Palma ratio

The coefficient is between 0, where everyone earns the same, and 1, where one person earns all the money.

 

In 2012-13, the UK’s Gini score for income inequality was 0.332, as measured by the Office for National Statistics (Figure 1). Individual cities vary in their equality – London is the most unequal, as measured by the Joseph Rowntree Foundation, while Sunderland is the most equal.

 

However, it has been critiqued for not being sensitive enough at the extreme ends of the scale. It does not capture changes in the top 10% or the bottom 40% where most of the poverty lies. Sumner and Cobham have put forward the Palma ratio. If the top 10% has 5 times the income of the bottom 40% the ratio is 5.

 

 

In 2013 David Cameron also suggested that inequality was at its lowest level since the 1980’s again supported by the ONS measure of the GC.

 

So we both the prime minister and a director of a think-tank (the IEA) downplaying inequality in public.

 

The IEA published a blog Almost everything the left tells you about inequality is wrong by Ryan Bourne (12th April 2016). Bourne uses the ONS “Effects of taxes and incomes on household income” to argue that the gini coefficient has not exceeded its 1990 level. Income inequality went down largely due to the stagnation of incomes while the rich got relatively poorer than the poor. This indeed indicates an issue with using income inequality as measured by the GC to say much about inequality itself. Income inequality would fall if the top become poorer relative to the bottom but of course in absolute terms would remain far richer. Bourne then points out that it was the top 1% who experienced an income rise, especially the top 0.01%, a point noted by Danny Dorling who argues that it is the 0.01% we should be examining. This is the weakness of the gini coefficient in that it is not sensitive enough to address the 0.01%. Although the income of the top 10% remained unchanged, it is those in the 10% but outside the 1% who saw income fall.

 

As for incomes, Gabriel Palma argues that 50% of gross national income is captured by deciles 5-9, the other 50% is shared between the top 1 decile and the bottom 1-4. He used a data set from the World Development Indicators (135 countries) to argue that there are two forces at work: centrifugal meaning increasing diversity between the top 10% and the bottom 40% and centripetal meaning a growing uniformity of income share within the middle 50%.

The Institute for Fiscal Studies produced a more nuanced discussion than that presented by Littlewood of the IEA and pointed out that the GC was only one measure. Others include the 50/10, 90/50 and 99/90 ratios (figure 3). These are decile ratios so for example 90/50 is the ratio of income at the 90th percentile divided by the level of income at the 50th percentile, the higher the number the greater the inequality. The IFS confirms that within the 1% the incomes of the richest has grown fastest with income growth at 99.9th percentile even higher than at the 99th.

Reasons, say the IFS include:

  • Increases in the financial returns of education ( a wage premium of higher education).
  • Trade liberalisation.
  • Tax and Welfare policy
  • Employment patterns.

 

Top incomes are racing away, which might reflect globalisation and international labour mobility for ‘global stars’ coupled with the erosion of social norms regarding the acceptability of pay differentials. The IFS argue that evidence for these assertions is not yet forthcoming. Nonetheless the top 0.01% are racing away for whatever reason.

Fedirico Cingano (OECD 2014) reports in Trends in income Inequality and its Impact on economic growth that the gap between rich and poor in most OECD countries is at its highest level for 30 years. The top 10% earn 9.5 times the income of the bottom 10%. In the 1980s this ratio was 7:1. He writes;

“econometric analysis suggests that income inequality has a negative and statistically significant impact on subsequent growth” in the OECD. Also:

“In particular, what matters most is the gap between low income households and the rest of the population. In contrast, no evidence is found that those with high incomes pulling away from the rest of the population harms growth”.

Income of course is not the only inequality, we also need to consider:

  • Health
  • Educational attainment
  • Wealth
  • Land ownership
  • CEO pay and employee pay
  • Housing
  • Consumption

 

Inequality is a complex concept and care has to be taken when discussing it. There is a mass of data on the subject for example the equality trust publish data from several sources, but there is no doubt about the scale of inequality in the UK. Does it matter? For those of a neoliberal persuasion, no it does not. In fact, inequality is good because for them it provides incentives and rewards hard work. The rich should be lauded as tax heroes. For others, such as Wilkinson and Pickett, inequality not only harms those at the bottom, it harms everyone in society by eroding trust, increasing anxiety and illness and encouraging excessive consumption.

 

 

 

 

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/#

Should we laud the rich as tax heroes?

Boris Johnson, aka ‘top cornflake’, argued in 2013, that the top 1% contributes almost 30% of income tax and that top 0.01% contributes 14% of all taxation. However, as income tax is 26% of all government revenue (NI raises 18% and VAT raises 17%) this equates to 8% of all government revenues. Therefore his claim that top 0.01% contributes to 14% of all taxation is just wrong. The top 1% actually contribute 8% of all government revenues.

In making this claim he is arguing we should thank the rich for their contribution:

“I proposed that we should fete them and decorate them and inaugurate a new class of tax hero, with automatic knighthoods for the top ten per cent”. Of course this is jest and rhetoric; surely he cannot be serious and muses on this as bit of lefty baiting?

He creates a value system, which results in lauding the rich for taking more than they ever have done, by trying to claim they are contributors beyond calling enough to warrant knighthoods. I don’t think giving 8% of all revenue is anything to be proud of, especially when the gap between the 99% and the 1% is so large. This is much, much worse if we focus on the 0.1%. The disparity within the 1% is breath-taking.

I would invert that value system and call it a self-serving  justification for the biggest income and wealth grab we have seen since Edwardian times.

This is mere number crunching, the actuality is more relevant. People’s lives are affected not by overall tax rates quoted by Johnson but by their absolute incomes and thus the % paid as a proportion of that income. If we focus on this, then we find that the poorest 20% pay 36.6% of their income in taxes, just a tad more than the top 1% who pay, 35.5% (Dorling 2014 p162). Tax heroes? How heroic is it to pay about the same proportion of your income as the bottom 20% do, when what you have left is riches beyond the dreams of avarice?

You might want to consider that 36% of a low wage leaves much less than 35% of a very high wage.  Food, petrol, utilities, clothes still costs the same amount whether you are rich or poor. If I earn £10,000,000 pounds pa and am taxed at 80% that leaves a ‘mere’ £2,000,000 to live on. Poor me, some tax hero!

See: http://www.thersa.org/events/audio-and-past-events/2014/inequality-and-the-1

Dorling D (2014) Inequality and the 1%. Verso. London

Social mobility for the Rich

Fact of the Day:

“In the UK, the poor stay poor and the rich stay rich”.

It seems to be the case that the greater levels of inequality there is in a country correlates with lower levels of upward mobility.

So choose your parents very carefully.

If your mum has not got a pot to piss in, then choose another one. Choose a Mum that is, not a pot. Preferably one like Lady Mary on Downton Abbey. She is a good choice, especially if you like repressed emotions and pent up sexuality with your cash. Why you should be looking for pent up sexuality in a mother is another issue and one that Freud would have a field day with, you dirty little b*gger. You could of course go for Kate Middleton//Saxe-Coburg Gotha-don’t mention the war-Windsor. Trouble is I think she has done with sprog sprouting for the moment and would welcome your advances to be offspring as she would a dose of syphilis.

If this strategy does not work try getting yourself adopted by some other posh bird. Try hanging around in Kensington and Chelsea looking suitably adorable and cuddley (don’t puke down your babygro and make sure you cover up the piss stains). Try burbling the baby equivalent of ‘Yah daarling’ and drink fizz out of your bottle. Do not wear a football shirt. There is nothing guaranteed to invoke disdain more quickly in the upper classes than a baby oik in West Ham colours.

Avoid certain areas of the country to be born in. Access the Community health profiles (http://www.apho.org.uk/default.aspx?QN=P_HEALTH_PROFILES) and do a bit of research to find the area with the highest income decile and lowest social deprivation index. Then get born there. You’ve got be smart these days to join in with the Eton and Harrow crowd. Redruth is of course right out, You’d be better off being born in a manger than in Drump Road.

According to Oxford University, there is social mobility except it is downward. So all you middle class types had better watch out, you and your sprogs could slip down the ladder quicker than a fireman with sh*t on his boots.

“the chances of a child with a higher professional or managerial father ending up in a similar position, rather than in a wage-earning working-class position, are up to 20 times greater than these same chances for a child with a working-class father”.

So choose your dad as well, or get your mum to sh*g a doctor.

http://www.ox.ac.uk/…/2014-11-06-study-shows-more-us-are-he…
http://us4.campaign-archive1.com/…

Royalty and the 1%

Fact of the day.

 

The money taken by the top 1% of earners in the UK each year could be spent instead on 1,100 royal families.

(from Danny Dorling’s Inequality and the 1%).

 

Just think, we could have over 1000 Charles, Lizzies, Phils and the other ones with the funny haircuts and strange habits. Hundreds of lazy, imperialist and sexist commentators flooding our media with un asked for opinions on the ‘fuzzy wuzzies’, fashion and cake. The Daily Express would have a fit for not knowing which princess to pine for next. As a bonus we could piss off the Australians by sending a royal visitor every day to remind them the Mother Country still has cultural superiority. The Scots tourist industry would get a boost – all those Balmorals for US tourists to drool over. We could charge them to meet a royal in person! We would have to raze Glasgow to the ground in order to provide more grouse moor for the royal shoots. Christ, it would sound like the bloody Somme up there come June.

 

This is based on the cost of the current incumbents – the saxe-cobourgs, don’t mention the war, aka ‘Windsor’ – being £100,000,000 per year. This figure is hallway between what royalists and republicans think they actually cost. The top 1% of earners in the UK trouser £100 billion, or if you prefer £100,000,000,000. Per annum. I say ‘trouser’ because the majority of the top 1% are men, white, over 55. Those trousers will be worn most often by financiers and bankers and if not Savile Row pin striped will be as expensive as a two week all inclusive holiday in the Maldives or a weekend overlooking the doom bar in Rock.

 

Alternatively, we could stick with just the one royal family, and let the 1% keep that £100,000,000,000 per year. Oh, sorry, we already do because paying tax is for the ‘little people‘ (that’s you and me).

 

The next time you wait for a GP appointment, face a rent rise, wonder at the huge class sizes and stressed teachers your kids endure, top up your adult teenager at university, watch your pay shrink and pension disappear (if you have one), and pay some of the highest rail fares in Europe, just bask in the glow that the 1% simply don’t give a f*ck.

Funding cuts to nurse education – austerity hits students

“Universities say nursing education has reached a “tipping point”, with proposed funding cuts putting the quality of courses and ultimately the quality of nursing care at risk”

The funding cuts and increase in student numbers may well have a detrimental affect on the learning experience. To address it we have to adopt new methods – some of which we need to do anyway – such as increasing use of web 2.0 technology for example ‘webinar’ presentations and discussions. Simulations are expensive and time consuming and allied to pressures on mentors, we have an overall picture of stress on the system. This will increase the call to take education back into the NHS, to see students as part of the workforce and not supernumerary, and the adoption of training rather than education. The wider context is the increasing control of nursing for managerial reasons within the contested economic policy of austerity. The country largely believes there is no money for education, health or welfare. In addition the policy is one of creating a market for those public goods based on the idea of a ‘consumer’ exercising rational choices. That is why the student pays fees so that through a market mechanism they will drive up quality by only buying education from quality providers. That is the theory. There is money – its just that it is in the hands of the few that gov’t dare not touch.

In a report, a Tale of Two Britains, Oxfam said the poorest 20% in the UK had wealth totalling £28.1bn – an average of £2,230 each. The latest rich list from Forbes magazine showed that the five top UK entries – the family of the Duke of Westminster, David and Simon Reuben, the Hinduja brothers, the Cadogan family, and Sports Direct retail boss Mike Ashley – between them had property, savings and other assets worth £28.2bn.

The UK study follows an Oxfam report earlier this year which found that the wealth of 85 global billionaires is equivalent to that of half the world’s population – or 3.5 billion people. The pope and Barack Obama have made tackling inequality a top priority for 2014, while the International Monetary Fund has warned that the growing divide between the haves and have-nots is leading to slower global growth.

This is the real issue – inequality politics resulting in an impoverished public sector. JK Galbraith way back in 1958 argued that a feature of advanced capitalism was that public (sector) squalor went alongside private affluence. Quite.

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.