Category: Public Health

The Violence of Austerity 2

Rudolph Virchow (1848) argued that ‘medicine is a social science and politics is nothing more than medicine on a grand scale’.

Structural and Institutional violence arises from the implementation of Austerity. Cameron, Osborne, May and Hammond have blood on their hands. Johnson, Gove, Rudd, Grayling…….

In 2013 David Stuckler and Sanjay Basu published ‘The Body Economic – Why Austerity Kills’ and stated that since 2007 the total number of suicides had risen by 10000 across the US and Europe while millions lost access to basic healthcare. Chopra (2014) reviews the book and points out that ‘Mental health outcomes feature prominently in these analyses. For instance, the authors report 1000 excess suicides in the UK due to the effects of this recession and a second wave of ‘austerity suicides’ in 2012‘.


Following the Great Financial Crash (GFC) of 2008, the neoliberal project in the UK was given an opportunity to push further on its (class) agenda which had been based on reducing State support for the public sector and social security claimants, encouraging privatisations, establishing financial deregulation, reduction of corporate tax and removing ‘red tape’ (worker’s rights and enviromental protection). The theory was based on ‘trickle down economics’ and Hayekian ‘free markets’. Jobs, growth and investment would follow. Austerity in this context was seen as a necessary corrective to the failing economy. It was not mentioned of course that one reason for the GFC was neoliberalism itself. In effect we have a neoliberal policy being implemented to correct the failures of neoliberalism.

For the sake of argument, lets accept the claim that indeed the UK enjoyed pre crash levels of growth above OECD averages (it has not), produced a high number of well paid secure, high skilled jobs with wage growth (it did not), and that investment significantly rose (it has not) and that productivity has soared (it has not). What is Austerity and what are its founding myths?

If a major tenet of neoliberalism is a reduction in state withdrawal from services and from support for workers and claimants, Austerity turbo charges it in the name of deficit reduction to address the national debt.

Austerity is first and foremost a move to permanently dissemble the protection state (Cooper and Whyte 2017) through reductions in targetted public spending. The view is taken that skivers and shirkers have grown fat on the largesse of the British Welfare State, a State that breeds dependency and since the GFC it is argued is now unaffordable. It is not about reducing state spending per se, as subsidies to the nuclear industry and help to buy schemes attest. Indeed State spending as a % share of GDP has not really moved since 2010. It is this that makes the ‘reduction of state spending’ neoliberalism rhetoric (as ideologically based class war) but not reality for the rich.


Austerity is based on the idea of ‘expansionary fiscal consolidation‘ (Alesina and Perotti 1995). Government cuts to public spending will (the theory says) encourage more private consumption and business investment. Not cutting public spending jeopardises investment and competitiveness. The reality is that public consumption in the UK is debt fuelled rather than from higher wages, and investment remains very poor.

Three myths underpin this approach from 2010:

  1. We all played a part in the financial crisis (New Labour caused the crash).
  2. Austerity is necessary.
  3. We are all in this together.

However, this masks real reasons for the policy:

  1. To further ease Capital Accumulation for the rich.
  2. To further extend wealth by growing inequality and through dispossession.
  3. To permanently dissemble the protectionist State.

In short: the violence of class war. Capital v Labour, the irreducible foundational contradiction of capitalism.

The institutional violence meted out by for example by G4S and ATOS is ‘ordinary’ mundane process violence, it is not exceptional but routine as experienced in people’s lives, involving fear humiliation, hunger, shame and early deaths. Using ‘maladaptive coping’ such as eating high fat sugary food, smoking, excessive drinking, taking drugs and having unprotected promiscuous sex, are as much reactions to as causes of poverty and violence. This ‘Moral Underclass Discourse’, which points to poor individual lifestyle choices, ignores the wider determinants of health, the mass of data on the ‘social gradient’ in health and of health inequalities. It also does not understand the complexity of personal agency and social structure in which reflexive deliberations (our inner voices) mediate between objective social structures, cultures and our personal concerns and projects.

We make our own history, but not in the circumstances of our own choosing“.

Institutional violence is pervasive and normalised so that we don’t always see it or feel it for what it is. Food banks, deportations, homelessness, debt, trafficking, evictions, precarity in low wage jobs are becoming part of the social fabric that is getting thinner by the day. This violence is slow violence whose effects may take time to come through. It also provides a pervasive threat of violence for those lacking the financial, social, cultural capital to either protect themselves or to escape.

Richard Horton (2017) in the Lancet (note not ‘Marxism Today’) outlined the arguments well:

Economists are the gods of global health. Their dazzling cloak of quantitative authority and their monstrously broad range of inquiry silence the smaller voices of medicine, trapped as we are in the modest discipline of biology. Economists stepped beyond the boundaries of the body long ago. They now bestride the predicaments of our planet with confident insouciance. It is economists we must thank for the modern epidemic of austerity that has engulfed our world. Austerity is the calling card of neoliberalism. Its effects follow an inverse harm law—the impact of increasing amounts of austerity varies inversely with the ability of communities to protect themselves. Austerity is an instrument of malice. Search under austerity and you will find few countries unaffected. Greece, of course, but also Mozambique, France, Scotland, Brazil, Portugal, Spain, Cameroon, Belgium, the Netherlands, South Africa, and England. Economists advocating, and governments implementing, austerity naturally reject the word. Instead, they call austerity, “living within our means”. But be clear. What is promoted as fiscal discipline is a political choice. A political choice that deepens the already open and bloody wounds of the poor and precarious. The Financial Times, a newspaper usually in thrall to the spectacle of economics, called these policies “inhumane” last weekend.

But austerity is also a social contract. People accept severe restraints in public spending, actively in democracies or passively in autocracies, because they accept the unpalatable prescription of abstinence. Yet the public too has a choice. And they are exercising that choice in countries across the globe. Take the UK. Back in 1991, two-thirds of the British population wanted more taxation and spending. But by 2006, only a third of people backed redistribution of wealth. If not welcomed, austerity was accepted. Not now. In the latest British Social Attitudes Survey, published last week, public opinion had turned against the idea of brutal scarcity. 48% of people wanted taxation increased to enable greater investments in society. 42% supported redistribution of income. And health was their priority—83% of people wanted more spending on our collective wellbeing. After a decade of cutting back the reach of government, the public is now demanding a stronger and more generous state. The contract authorising austerity has been torn up“.

Richard seems to be suggesting we may be at a turning point. I hope he is right, but with a Brexit fixated government backed by 30% of those eligible to vote (the 52%) and the cheerleaders in the right wing press driving politics onwards, I don’t yet see much hope.

The Sociological Imagination

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

Photo by Lance Anderson on Unsplash

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

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

C Wright Mills wrote:

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

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



Personal troubles:


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



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

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

We do not

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

In addition we:

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

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

What is a ‘structural transformation?’

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

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

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

To help answer that question Wright Mills argued that


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


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


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

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

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

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

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

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

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


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

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

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


Wright Mills outlines:

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


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

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



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


Public Issues:   

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

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

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

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

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

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

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


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

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

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

To summarise: 

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


Benny Goodman      September 2017


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

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


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

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

The Social Gradient


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.




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)


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.







Global health statistics reports and CRVS – Civil Registration and Vital Statistics

If you want to know how well the world is doing to meet the millennium development goals around infant mortality, child nutrition, maternal mortality and increased access to sanitation, the WHO produces annual reports:


  1. WHO annual world health reports


  1. WHO Global Burden of Disease Study.


In addition there is a separate study produced by the Institute for Health Metrics and Evaluation (IHME):


  1. IHME Global Burden of Disease


The IHME and the WHO use different methods to produce the data and the way it is calculated suffers from lack of transparency. Nonetheless both organisations are working to improve upon this situation.


“WHO’s health statistics or GBD’s estimates would undoubtedly be improved (and rely less on statistical modelling) if civil registration and vital statistics (CRVS) systems were strengthened worldwide. Presently, around 60% of deaths and causes of deaths and 35% of births are not registered, according to a new four-paper Lancet Series on Counting Births and Deaths, published online on May 11.” 2015.


The Lancet argues that CRVS systems drive improvements in health outcomes and thus investment in them is required.


No doubt Hans Rosling, and his gapminder data, would approve.

The health promotion role of the nurse in response to climate change and Ecological Public Health

“NOTICE: this is the author’s version of a work that was accepted for publication in Nursing Standard. Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication. A definitive version will be published in Nursing Standard Accepted 6th November 2014




Nurses have a history of engaging in health promotion and public health and both roles are reflected in the Nursing and Midwifery standards for education. However, future trends such as population growth, new technologies and climate change, suggest that their current understanding of these trends need to develop to adapt to a very different future. This paper argues that nurses need to quickly move beyond adopting individualistic and behaviour changing perspectives (Kemppainen, Tossavainen and Turunen (2012), to that of also adopting an ethico-socio-political role (Falk-Raphael 2006) in health promotion based on a wider understanding of what health promotion may mean. This paper reflects on climate change, an outline of the concept of ecological public health, and Kemppainen, Tossavainen and Turunen’s (2012) integrative review on the nurses’ role in health promotion to support this argument.


Climate Change

Despite the requirement to curb greenhouse gas emissions to prevent catastrophic climate change (Costello et al 2009, Roberts and Stott 2011, McCoy 2014) the world is experiencing a continuing rise in anthropogenic greenhouse gases (IPCC 2014). This emissions growth is expected to persist, driven by population growth and economic activity. This will result in global mean surface temperatures of 3.7o C to 4.8o C by 2100 if there is no further mitigation (IPCC 2014).  This is way beyond the 2o C ‘safety’ threshold (Peters et al 2013, McCoy et al 2014, Marshall 2014), a threshold beyond which there may not be a ‘safe operating space for humanity’ (Rockström et al 2009).

McKie (2014) suggests that global evidence supports the assertion that climate change is already happening, resulting in severe floods, permafrost melts, rising sea levels and lack of snow in the Alps. He states:  “In its latest report, the Intergovernmental Panel on Climate Change estimates that up to 139 million people could face food shortages at least once a decade by 2070”. According to Marshall (2014) we will routinely experience heat waves and extinctions; the feeding of 10 billion people becomes more difficult; the loss of glaciers and ice sheets will result in two-thirds of our major cities under water; and ocean acidification will be adversely affecting the ecosystem over two-thirds of its surface.

According to Climate Central (2014), the risk of record flooding in Washington DC this century is virtually guaranteed. This is a backdrop to thoughts about where it will be better, and safer, to move to in the United States. Alaska, the Mid West and the Pacific North West will fare much better than California and the South East when, according to Mora et al (2014) unprecedented high temperatures could become the norm by 2047. Mora et al go on to argue that Washington DC will reach its tipping point in 2047; Los Angeles, 2048; San Francisco, 2049 and Chicago, 2052. Detroit has until 2051, and Anchorage, 2071.

In other words, some scientists have accepted that temperature and sea level rises will severely impact on cities in the next few decades, requiring major adaptation responses around population migration, land and flood defences and major structural changes in economics and society. This is in accord with the National Climate Assessment (2014) third report which outlines the rises in temperatures and makes it clear we are talking in decades not centuries for the changes to impact.

The health impacts of climate change have been documented elsewhere (WHO 2014a) and is partly based on the social and environmental determinants of health (Barton and Grant 2006, WHO 2008). Barna et al (2012) have also set out what nurses need to know about climate change but the urgency of addressing this issue is increasing, as the National Health Service Sustainability Unit outlines in its ‘Fit for the Future Scenarios 2030 (NHS SDU 2014). All of this this leads us to consider what the health promotion role of the nurse might be in relation to this context.


Ecological and Planetary Public Health.

Horton et al (2014) call for a new social movement in their ‘manifesto from public to planetary health’ to support collective action on Public Health. They introduce the concept of ‘planetary’, rather than just public health.  As with Lang and Rayner’s (2012) discussion of Ecological public health, there is a strong focus on the unsustainability of current consumption and linking this with poorer health outcomes. It implicitly draws upon Barton and Grant’s (2006) health map which has climate stability in its outer ring. Interestingly, an overt political statement is introduced in the ‘manifesto’:

“We have created an unjust global economic system that favours a small wealthy elite over the many who have so little”.

The call is for an urgent transformation in values and practices based on recognizing our interdependence and interconnectedness on a finite planet, and 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.

In the same vein, Ottersen et al (2014) are explicitly political on the links between health inequity, globalisation and the current system of global governance, including the actions of ‘powerful global actors’. The tone of the report makes it quite clear that there is a need to address global governance and an analysis of power. This would put the fossil fuel industry clearly in sight as a major contributor to carbon emissions and therefore as a direct threat to Public Health.

Ecological Public Health (Lang and Rayner 2012) might be, they suggest,  the 21st century’s ‘big idea’. Lang and Rayner point out that public health proponents, and by implication public health nurses, have allowed themselves to be positioned within the language of individualism and choice. This leads of course to behaviour change models and theories of rational action. However, their view is that public health is about the bigger social (and political) picture that might threaten vested interests, e.g. of the fossil fuel lobby. They review public health developments over the decades and suggest a rethink is in order. They outline 4 current models of public health but suggest that they are anthropocentric, meaning that the health of the living, natural and physical world – ecosystems health – is marginalised. Climate change challenges those models as it is fundamentally about ecosystem damage and the concomitant threats to health on a global scale. Ecological Public Health (EPH) focuses on interactions, one strand on the biological world, e.g. biodiversity, and one on the material issues such as industrial pollution, including carbon emissions as pollution, energy use and toxicity. This is based on systems thinking and complexity in understanding health. EPH has four dimensions – the material, biological, cultural and social. This takes us way beyond simplistic behaviour change models which cannot deal with socio-political contexts.

“Telling families who live in poverty that they should make healthy choices ignores the conditions that prevent them doing so and is insulting and even futile” (Lang and Rayner 2012 p4).

Telling families to eat less red meat, fly less and to stop consuming without addressing the actions of global corporations is, arguably, similarly insulting and possibly futile in trying to curb carbon emissions.

The domains of Public Health, Medicine and Nursing may be insufficiently politically aware of the scale of these issues that impact on human health. This might be due to the possibly,  up to now, necessary ‘ahistoric’ and ‘apolitical’ education of health care professionals, resulting in a lack of a sociological or political imagination underpinned by a critical analysis of the link between current unsustainable lifestyles, political economies and public health. However, adopting the perspective of Ecological Public Health or seeing the world through a ‘sustainability lens’ (Goodman and East 2012) might move more health practitioners and policy makers into critique and action on current economic and political structures that result in health inequities, and indeed, if some are to be believed, threaten civilisation (Costello et al 2009, Hamilton 2010, Oreskes and Conway 2014, Klein 2014, Marshall 2014). There are countervailing voices who do not see the same level of threat or who even deny climate change is really occurring (Goklany 2007, 2009a,b,c,  ben-Ami 2010, Stakaitye 2014, Delingpole 2014, Lehman 2014), but this view is not shared by many health groups such as the WHO (2008, 2014b,c) the Faculty of Public Health (2014) and the International Council of Nurses (2008).

Nurse’s role in health promotion practice

Kemppainen, Tossavainen and Turunen’s (2012) integrative review on the nurses’ role in health promotion is based on an analysis of research papers from 1998-2011 and therefore misses important research that might have been published since. That being said, some of their conclusions resonate today, and if they still hold, then there is a requirement to change our understanding of health promotion to one that fits more readily with more recent arguments over climate change and the determinants of health. They argue that studies suggest that nurses have adopted an individualistic and behaviour changing perspective to health promotion (p490). This perspective is underpinned by nurses working from either a holistic/patient centred theoretical basis or a chronic disease/medical orientated approach (p492). Neither of these theoretical groundings equip nurses with the knowledge or attitudes to address the emerging public health concept of planetary health as outlined above. Although a common defining concept of health promotion found in the studies,  along with the ‘individual perspective’ and ‘empowerment’, was ‘social and health policy’. However ‘nurses were not familiar with social and health policy documents…did not apply them to their nursing practice’ (p494). Again, if still true then the policy initiatives such as the WHO’s ‘social determinants of health’ and Horton et al’s ‘Manifesto for planetary and public health’ will not be found in nurses’ concepts of health promotion.

As for the health promotion expertise nurses have, this is about being ‘general health’ promoters, ‘patient focused’ health promoters and ‘project management’ health promoters. Commonly this involved health education. The competencies outlined were based on multi-disciplinary knowledge, skill related competence and competence related to attitudes and personal characteristics. Nurses were expected to be aware of economic, social and cultural issues and their influence on lifestyle and health behaviour. Whether this included knowledge of climate change or other ecological issues is not clear and is not mentioned.

This review highlighted the need to clarify the concept of health promotion, and clearly stated that ‘health policies have little impact on nursing practice’ (p499). Therefore health policies directed at future trends, such as the ecological changes indicated above, will gain little traction in practice unless changes are made. Indeed, ‘knowing about future trends affecting population health were not identified as nurses’ health promotion competencies’ (p499). The review concludes ‘it appears that nurses have not yet demonstrated a clear and obvious political role in implementing health promotion activities….instead…their health promotion activities (are) based on knowledge and giving information to patients. (p499). Lang and Rayner (2012) argue that public health must…address complexity and dare to confront power. This understanding ought then to be part of the conceptual language of health promotion used by nurses.



Student nurses will be introduced to the Social Determinants of Health (SDoH) approach as outlined by the World Health Organisation (2008) and in the Rio declaration on the social determinants of health in 2011. The reason for this is that the UK’s Nursing and Midwifery Council state in their 2010 standards for education:


“All nurses must understand public health principles, priorities and practice in order to recognise and respond to the major causes and social determinants of health, illness and health inequalities. They must use a range of information and data to assess the needs of people, groups, communities and populations, and work to improve health, wellbeing and experiences of healthcare; secure equal access to health screening, health promotion and healthcare; and promote social inclusion”.


I think this introduces an ethical imperative and a socio-political role for nursing (Falk-Raphael 2006) as the NMC explicitly state that nurses are to “work to improve health….”.  If health has social determinants based on the ‘distribution of money, power and resources’ then nurses are required to understand what this means. Indeed public health principles are now embracing concepts such as the SDoH and going further in the Ecological Public Health approach (Lang and Rayner 2012).


Climate change and threats to ecosystems are very real health concerns for individuals, communities and populations both currently and in the medium to long term.  The long term, in this instance, being defined as ‘this century’. The world’s scientific community is agreed on the direction of travel towards a warmer world. The wider health community and some nursing organisations are aware of the issues and are advocating for changes to practice and education. There are many who disagree either about the phenomenon of climate change itself or on what to do about it. There is distrust of politicians based on fears of the introduction of global governance and state interference (Klein 2014, Marshall 2014) and many even distrust the scientists themselves. So who is left to trust with health issues? Nurses already have a health promotion role but it has been defined in particular ways that result in an inability to grapple with the new challenges that climate change and ecosystem damage are bringing. There is thus an urgent need to address the emerging paradigm of ecological or planetary public health into nurses’ health promotion definitions and competencies, to confront ‘entrenched interests’ through individual and community empowerment. As Falk-Raphael (2006 p2) argued:

“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”.


Word count 2289



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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.

Food poverty in the UK

George Osborne will give his Autumn statement to the House of Commons this Thursday. He will be upbeat about ‘recovery’ and GDP growth. What he will ignore is the fact that the recovery is very patchy, based on rising house prices, a mini consumer spending spree in certain areas (e.g. London) and increasing consumer public debt within the context of a low wage, precarious job market. These are part of the UK’s social determinants of health. The ’causes of the causes’ of ill health.

Admissions for malnutrition, BMJ graph

Watch out for entreaties to those will little resources to learn to cook and spend their money more wisely – in other words, “if your child goes hungry, it is your fault”.  This is what I call the default ‘Daily Mail’ individualist analysis which only gets you so far.  Use your sociological imaginations to analyse what is going on – how do you link the personal trouble of going hungry and being admitted for malnutrition with the public issue of food poverty in the UK today? The graph published by the BMJ shows that in 2008 when the UK experienced the start of the financial collapse, bank bail outs and the beginning of austerity policies aimed at reducing welfare spending, there were a little over 3000 admissions for malnutrition. In 2012 that had risen to about 5,500 admissions.

If only one person was admitted due to malnutrition we should look to the character and situation of that person for a proper understanding and analysis of why. When admissions have increased to 5,500 we need to look to wider explanations that go beyond the individual. What structural transformations are occurring which provide a fuller understanding of people’s experiences?

Both the correct statement of the problem and the range of possible solutions require us to consider the economic and political institutions of society and not merely the personal situation and character of a scatter of individuals” (C Wright Mills 1959).

Global Citizens for Health


Global Citizens for Health.






1.              To discuss the concept of the ‘global citizen’

2.              To discuss the implications for the curricula and student experience.

3.              To develop plans for further work.





Health is founded upon on social and environmental factors that often transcend national boundaries. This is not to ignore biological influences (such as genetic diseases) but rather to focus activities on those factors that health workers may influence in individuals and populations. Therefore, as the determinants for health are social and often global, one way of addressing the issue is through developing a sense of global citizenship. Global citizenship, as we define it and argue below, has to have sustainability at its core because sustainability and global health are inextricably linked (Goodman and Richardson 2010).


In addition to the health focus, other drivers for global citizenship are clear and many of the most pressing issues facing us must be addressed internationally. The policy context includes the WHO Millennium Development Goals, the G8 Gleneagles Communiqué on Africa (2005) and the COP 15 Accord (2009). In addition to these policy statements which sets out the context, there are global threats to well being from a wide range of economic, environmental and political issues:


   climate change and its concomitants e.g. ocean acidification, climate migration.

   unsustainable practice such as deforestation, soil erosion, overfishing.

   water, food and energy shortages (peak oil).

   mineral and other resource depletion.

   population growth.

   toxic chemical and nuclear waste disposal.

   international terrorism.

   shifts in the power base of the global economy (Rosling 2009).

   unsustainable GDP growth as a policy objective (Jackson 2010).

   post (?) ‘Washington Consensus’ economics (Rodrik 2006)

   inequalities in health and wealth.

   alcohol and substance abuse.


……and of course ‘globalisation‘ in its various guises.


Climate change has been identified as the biggest threat to global health of the 21st century (Costello et al 2009) and health workers have been urged to take action (BMA 2008). International nursing organisations have highlighted this as an imperative (ICN 2009, CNA 2009, 2010, AAN 2008).


Global citizenship can be seen as an emergent concept in this context. 



Graduates from UK universities will not be insulated from these global trends. However there are opportunities as well as threats. Adopting global perspectives also offers opportunities for large-scale beneficial change. For example, the transition to a low carbon economy provides new opportunities for innovation and creativity in energy use, production and distribution. For health, the message is that a low carbon lifestyle is also good for health.


Graduates from UoP must be encouraged to think as widely as possible about the future world they are going to inherit and eventually help shape. Sustainable development (or contraction) and the limits to growth as currently defined (Meadows and Meadows 1972, Jackson 2009) may be the defining context for the coming graduate generation. If so, an insular inward looking mindset will not serve us well.


Having an idea of what it is to be a global citizen, living in world where prosperity is  meaningless when 80% of humanity live on less than $10 a day (Chen and Ravallion 2008), may be a necessary first step to foster a global consciousness and willingness to engage with these challenges.


Higher Education Institutions have a responsibility to encourage graduates to think about their roles and responsibilities as global citizens in the world they will help to shape. 





In this presentation, we will address the following issues in relation to students in the Faculty of Health:


1.  What is global citizenship?

2.  How can we encourage students to develop their identities as global citizens?

3.  Existing good practice in the curricula and student experience 

4.  Future opportunities.



A note on the challenge in HEI funding:


According to Paul Marshall, chief executive of the small research intensive universities group, there has been an announcement of a £135 million cut and a drive £180 million in efficiency savings. Lord Mandelson’s announcement (Dec 2009) of further budget restraint mean HEFC’s annual budget would fall from £7.291 billion in 2010-11 to £6.376 billion in 2012-13. This would be a 12.5% cut in its annual funding over three years. The December (2009) pre budget report had already announced £600 million in cuts. Therefore any initiative will need to come within existing and reducing funding.


Therefore to address the third aim we will need to be very creative.









What is global citizenship?


Global citizenship (GC) applies the concept of citizenship to a global level. Citizenship entails rights and responsibilities in civil society, is active as well as passive. GC can be defined as a moral and ethical orientation which can guide the understanding of individuals or groups of local and global contexts. As an ethical endeavour it reminds us of our responsibilities within and to various communities.


Activism, as the translation of this theoretical understanding of the world into actual practice, and appears to be a core idea.

Thomas Paine (1727- 1809) in the ‘Rights of Man’  could be thought to be an early exponent of global citizenship:


            “My country is the world, all mankind are my brethren, to do good is my religion”


So GC could mean:

   Respect for all human beings regardless of race, religion or creed (that does not mean respect for their ideas).

   Reaching beyond national barriers to act on inequalities, ecological degradation and the promotion of well being.



Therefore GC has both and an ethical and an action dimension. One follows from the other. It involves both rights and responsibilities.
























Falk (1994) identifies five potential categories of global citizens. He describes these as:


            “a series of overlapping images of what it might mean to be a global citizen at      this stage in history.”(p132).


According to Lagos (2002), except for the example of elite global business people, the majority of Falk’s categories


            “have grassroots activism at their core”(p6).     


Falk’s five categories are:


1.   Global reformers


“[A]n individual that intellectually perceives a better way of life of the planet and favours a utopian scheme that is presented as a practical mechanism.”(p 132).

This may entail some form of centralised world government or organisation in order to avoid global turmoil and maintain some form of unity.There may be a tendency for reformers to filter their visions through the cultural and political outlook of their own “political community” (p 133), and thereby impose their framework on the rest of the world.

This ‘centralised world government’ of course could be interpreted as dictatorship. Stalin and Hitler may have had  their own ideas for global reform that went beyond their own borders. In their own terms they may have thought of themselves a ‘reformers’ ushering in a ‘new world order’ (be it a Thousand Year Reich or a Communist utopia). The ‘Washington consensus’ could be seen in this manner – a new world order based on neoliberal capitalism and the dominance of US foreign policy.

Falk summarises the global reformers’ “spirit of global citizenship”(p132) with the statement:


            “It is not a matter of being a loyal participant who belongs to a particular political community, whether city or state, but feeling, thinking and acting for the sake of the     human species, and above all for those most vulnerable and      disadvantaged.”(p132).


It may be the focus on the ‘disadvantaged and vulnerable’ (with a nod to the universal declaration of human rights to help identify who that group is) that makes GC objectively different from national socialist dictatorship. This is still problematic. The definition of who is disadvantaged and vulnerable may seem self evident but a moments thought suggests subjective definitions alter membership of that group. In Palestine today who thinks of themselves as disadvantaged – jew or arab, who is oppressed and who oppressor? Islamists and Jihadists may also have a wish to create a global muslim brotherhood based on sharia law. The muslim brotherhood transcends national boundaries and could be seen as a way of establishing a new global order. Global citizenship for Islam may have its own meaning.




2.   A man or woman of transnational affairs.


This category of global citizens could also be described as elite global business people.Falk also points out that the vast majority of these people are men. He writes:


            “This second understanding of global citizenship focuses upon the impact on     identity of globalization of economic forces. Its guiding image is that the world is        becoming unified around a common business elite, an elite that shares interests and experiences, comes to have more in common with each other than it does with the more rooted, ethnically distinct members of its own particular civil society: the    result seems to be a denationalized global elite that at the same time lacks any   global civic sense of responsibility”(p 134).


This description is similar to those that inhabit ‘Richistan’ a term coined by Frank (2007) in a book of the same name who argued:


            “The wealthy weren’t just getting wealthier — they were forming their own            virtual             country. They were wealthier than most nations, with the top 1% controlling $17 trillion in wealth. And they were increasingly building a self-contained world, with its            own health-care system (concierge doctors), travel system (private jets, destination     clubs) and language. (”Who’s your household manager?”) They had created their             own breakaway republic — one I called Richistan.”



The difference is that Richistan’s elite may see themselves as apart from other citizens and not members of global citizenry, although their actions are self justified on the basis that their actions are good for the world.



3.   Managers of environmental and economic global order.


This perspective focuses more on environmental needs but also looks at economic concerns. This view is exemplified by the Bruntland Commission’s report, which:

            “stress[es] the shared destiny on the earth as a whole of the human species …    [and] argues that unprecedented forms of cooperation among states and a      heightened sense of urgency by states will be required to ensure the sustainability of industrial civilization”(p135).


This perspective is often concerned with:


            “making the planet sustainable at current middle-class lifestyles.”(p136)


Key thinkers in this perspective would be Rachel Carson (1962), Aldo Leopold (1949), Eric Schumacher (1979), David Orr (1994) and those involved in the ‘green movement’, sustainability and environmentalism. Environmentalism and green politics however, is not about establishing a global political order rather that the current dominant economic models need revolution to be replaced with a world based on economic localism (Wood and Lucas 2004). Frank’s ‘middle class lifestyles’ in this analysis may not survive the greening of the new world order especially if it is based on current economic models.

There are of course divisions, Bruntland has been criticised as merely greening the status quo (Sinclair 2009) while others argue for more thoroughgoing reform of Sustainability (Sinclair 2009, Selby 2007). This perspective suggests that ‘industrial civilisation’ is not  worth saving.


4.  Regional political consciousness.


Within Europe, the birthplace of the modern state, “The Euro-federal process is creating a sufficient structure beyond the state so that it becomes necessary, not merely aspirational, to depict a new kind of political community as emergent, although with features that are still far from distinct, and complete.”(p137)

Falk asks,

            “Can Europe … forge an ideological and normative identity that becomes more    than a strategy to gain a bigger piece of the world economic pie? Can Europe             become the bearer of values that are directly related to creating a more peaceful        and just world?”(p137)


To state that  this sort of regional project is not without its critics is self evident to most people in the UK. Eurosceptics in all major parties plus UKIP argue that this movement is undemocratic and dissolves national sovereignty.


5. Trans-national activists.


Amnesty International and Greenpeace are examples of transnational activism, in part because they transcend national boundaries.Falk writes of the emergence of transnational activism:


            “the real arena of politics was no longer understood as acting in opposition          within a particular state, nor the relation of society and the state, but it            consisted more and more of acting to promote a certain kind of political             consciousness transnationally that could radiate influence in a variety of        directions, including bouncing back to the point of origin.”(p138)


This kind of activism became important to social movements during the 1980’s. Falk also emphasises that:


            “this transnational, grassroots surge, is not, by any means, just a Northern            phenomenon.”(p138)

Linked with this is the idea of the ‘multitude’. Hart and Negri’s idea is that ‘the multitude’ is a new model for resistance to global capitalism. However this does not imply any organised connectedness between members (except perhaps in the digital world) or a transnational organisation. The idea of the multitude can be traced back to Machiavelli, Hobbes and Spinoza who argued in Tractatus Theologico-Politicus;

‘Every ruler has more to fear from his own citizens […] than from any foreign enemy, and it is this “fear of the masses” […that is] the principal brake on the power of the sovereign or state.’

Global citizenship may take the form of activism at grass roots level using digital technology with individuals forming (online) groups ad hoc around emergent issues. Facebook is a platform may may be used by these ‘global citizens’ to get their message over. Note the response on twitter to comments made by a Daily Mail journalist’s comments on Stephen Gatley’s death. See  Twitter and Facebook outrage over Jan Moir’s Stephen Gately …   Though national in nature it demonstrates the potential for activism using digital technologies.


Falk’s 5 categories of GC

1.   Global reformers

2.   A man or woman of transnational affairs.

3.   Managers of the environmental and economic global order.

4.  Regional political consciousness.

5.  Trans-national activists.








Lagos (2002) relates the concept of activism to citizenship:

            “Global protest activity is on the rise. Demonstrations in Seattle in 1999, Genoa in           2001 and at dozens of other sites, brought activists together from around the world   and localized global issues in unprecedented ways. These and other activities          suggest the possibility of an emerging global citizenry. Individuals from a wide             variety of nations, both in the North and South, move across boundaries for different      activities and reasons. This transnational activity is facilitated by the growing ease   of travel and by communication fostered by the Internet and telephony”.  (p3)

then again:

            “A visible expression of global citizenship is the many global activists who debuted             spectacularly at The Battle in Seattle (1999). These protests continue at other       venues, such as at meetings for the World Bank and the IMF, and most recently at    the Summit of America in Quebec City. Other activists fight for environmental        protection, human rights to the impoverished and the unrepresented, and for       restrictions on the use of nuclear power and nuclear weapons . Freedom from    bureaucratic intervention seems to be a hallmark of global citizenship; the lack of           a world body to sanction and protect these citizens also means to a certain             degree freedom from bureaucratic control”.(p4)


Lagos then elaborates:

            “Scholars have already noted the emerging power struggle between corporations           and global activists who increasingly see the nexus of de facto governance taking     place more and more within the corporate world (and as mediated by            communication technologies like the Internet) and not in the halls of representative government. Hence, the tendency on the part of activists to promote rallies and     events like the protests at WTO, as more effective means of citizen participation and democratic accountability(p 13).


So clearly from this perspective global citizens not only think about the connectedness of their world transcending national boundaries, but are also spurred to action. There is an echo of Marx (1845, 1888) who argued “the philosophers have hitherto only interpreted the world in various ways; the point is to change it” (11th thesis:  Theses on Feuerbach).


Globally Orientated Citizenship


Parekh (2003) advocates what he calls globally oriented citizenship, and states:

            “If global citizenship means being a citizen of the world, it is neither practicable nor             desirable”(Parekh 2003 p12).

He argues that global citizenship, defined as an actual membership of a type of worldwide government system, is impractical and dislocated from one’s immediate community. He also notes that such a world state would inevitably be:

            “remote, bureaucratic, oppressive, and culturally bland.”(Parekh 2003 p12).

Parekh (2003) argues:

            “Since the conditions of life of our fellow human beings in distant parts of the world       should be a matter of deep moral and political concern to us, our citizenship has an inescapable global dimension, and we should aim to become what I might call a           globally oriented citizen.” (p12).

Parekh’s concept of globally oriented citizenship consists of identifying with and strengthening ties towards one’s political regional community (whether in its current state or an improved, revised form), while recognising and acting upon obligations towards others in the rest of the world.








A Multi dimensional concept


Falk’s 5 categories above may illustrate the multi-dimensional nature of GC and the various ways it could be defined. This is supported by Byers (2005 and 2008) who questions the assumption that there is one definition of global citizenship, and suggest that we could unpack aspects of all the various potential definitions. He argued:

            “Global citizenship’ remains undefined. What, if anything, does it really mean? Is           global citizenship just the latest buzzword?”

Byers notes the existence of stateless persons, whom he remarks ought to be the primary candidates for global citizenship, yet continue to live without access to basic freedoms and citizenship rights.  He does not oppose the concept of global citizenship, however he criticizes potential implications of the term depending on one’s definition of it, such as ones that provide support for the:

            “ruthlessly capitalist economic system that now dominates the planet.”




global citizenship

An ethical imperative.

An action imperative.


But whose ethics and whose action?


But it may be conservative upholding the current order or radical challenging the current order. Change could be advocated within the system to (make it fairer) or to change the system itself as this is the root of inequity.


Health care workers will  need to construct their own ideas for GC based on their understanding of ethics of caring, professional philosophies and the foundations for health.













Implications for Education.


The challenge for HEIs then is to decide if they should take a stance or be neutral and let the students decide. Each discipline may (will) have their own ideological or philosophical underpinnings that guide their educational practice. These may have to articulated more clearly in addressing ideas around GC. For example, an economics course that teaches within the frame of reference of capitalism (e.g. growth as a given) ignoring other political economies would proffer particular solutions to global finance within its own definitions of what it is to be a GC.

Thus GC is a contested space, but one view within nursing is that nursing is an ethical practice orientated towards health and well being. However this view says nothing about the political and social dimension of nursing. nothing about what is ‘ethical’. One may (‘must’ according to the NMC) act ethically towards our patients and clients but this does not automatically mean an international orientation challenging power structures as acting ethically is open to interpretation. So to what degree should students of nursing be orientated towards socio-political and international activism? Does being a GC mean challenging and overturning  or (merely?) mitigating the effects of the current global order? Working for an NGO in a health clinic in Africa could be seen to fulfill one’s responsibilities as a GC and for some this will be enough. For others being a GC will mean more radical action.


Raising awareness

A starting point could be to outline global disparities in health and well being such as that found on – For a fact based world view., and poverty such as Poverty Facts and Stats — Global Issues   and then to encourage discussion about the remedies (which according to one’s ethical standpoint) may be many and varied. A focus on action needs to stressed if one wants to be a GC, however the nature if that action is debatable. The question arises should and to what degree should lecturers and the HE sector provide leadership in a particular direction?

A response is to argue that given the global crises facing humanity, academia cannot be neutral and objective researching and charting current trends and processes. However each discipline will articulate its own standpoint(s) in response. For health the challenge is to encourage a global outlook within the context of training an NHS workforce. The NHS itself will not look beyond its own borders and the training needs of its own staff.


Biomedicalism and Individualism v GC

Whatever GC may mean in terms of actual action, it is clear that the idea takes one out of narrow contexts bounded by local, regional or national UK boundaries and forces one to think about the health and well being of people living outside of the UK. In this task, we would need to move beyond individualistic bio-medical models of health and illness and draw upon more ecocentric paradigms (Kleffel 1996 and 2004, Goodman and Richardson 2010). We would have to examine current curricula to identify where we are focused on disease and illness in the individual and to where we adopt more a SOCIAL DETERMINANTS OF HEALTH model.  A public health (WHO | The public health approach) and a social determinants approach supports and is supported by the concept of GC as both address the environment and human activity as foundations for health.


Current and developing educational practice.


We argue there is a ‘sustainability-climate change-health’ triad (Goodman and Richardson 2010) that GC may assist in addressing:


Sustainability-Climate Change-Health Triad



Positive feedback                                                  

·          Keeping healthy will assist sustainability and climate change.

·          Sustainable living mitigates climate change and improves health.

Negative feedback

·          Unsustainable living causes climate change and poorer health.

·          Climate change negatively affects health and sustainability.


This theoretical model needs testing and evidence, but may act as a framework for promoting the idea that good health results from unsustainable living and will be affected by climate change. Thus the payoff of adapting current lifestyles is twofold. Increased health, promoting sustainable living and mitigating climate change.

This task has begun in Faculty of Health modules where the embedding of sustainability has begun. Sustainability is unrelated to GC in terms of defining GC but is a very important policy and philosophical driver not just for developing global citizens but also for the HE sector as a whole (HEA 2009,  HEFCE 2009). The Centre for Sustainable Futures has produced guidance for curriculum planners and developers which may prove useful starting points. In addition, the principles underpinning Education for Sustainable Development (ESD) (Sterling 2001) and ecological (Orr 1994) and sustainable literacy (Stibbe 2009) would enhance discussion around global citizenship and its meanings.

For example , Stibbe (2009) emphasises ideas such as the interconnectedness between people and planet and ‘being in the world’ whereby people have the:


“ability to think about the self in interconnection and interdependence with the surrounding world”  (Danvers 2009 p185)


and the ‘systems thinking’ ability:


“to recognise and analyse interconnectedness between and within systems” (Strachan 2009 p84).


Both ‘being in the world’ and ‘systems thinking’ are concepts which are congruent with nursing theory which focuses on holistic care.


Comparing concepts embedded in Education for Sustainable development principles and those that may be found in some interpretations of GC indicates some common ground. 










global community



futures thinking


systems thinking

people centredness

student centredness








The link between ESD and Global Citizens (ESDGC) has been made explicit in Wales (leadership from both Welsh assembly and the HEFCW ) at both secondary school and in higher education. The argument is made:

“The role of Higher Education Institutions within ESDGC is pivotal in that they education a great number of the professionals and leaders of tomorrow’s society. They have a large role to play within the environmental management of their institutions and procurement policies, ensuring that globally aware, ethically sound and environmentally balanced processes are introduced. They also have potential for influencing others outside the university through professional development and training opportunities”.

(Welsh Assembly 2009  and ESDGC 2010)



The Global citizen within Nursing Education and Education for Sustainable Development/Contraction:

Because there is a pending planetary crisis, education (and nurse education) should attempt to challenge and prepare students for a not so brave new world. Selby (2007) suggests 10 Propositions for education:

1. Confront denial by challenging learners’ base assumptions, knowledge and responses. Get them to feel unease at the current situation: Nursing education attempts to develop the personal as well as professional competencies and thus challenges individuals’ world views. Therefore this approach would not be out of place.

2. Given the threat, education needs to address despair, grief, loss. Student nurses have to address loss in personal and individual patient cases: These concepts are already in many curricula (see the work of Kubler Ross for example) but the perspective may have to shift to embrace wider loss and grief issues that flow from climate change.

3. Shift to a holistic dynamic understanding of the relationship between humans and nature is an end in itself not a means to an end: Again this would not be necessarily a radical departure for nursing philosophy in any discussion regarding the value of humanity and the goal of nursing


4.Cultivate a poetic understanding alongside a rational understanding – we need to develop awe, celebration, enchantment, reverence as well as classification, prediction, evaluation and exploitation of nature: This mirrors the ongoing debate within nursing education concerning the art science dichotomy and would provide another useful lens to address the need for scientific competence and artistic appreciation and application in nursing praxis.

5. Marginalised ‘educations’ will be important (e.g. the field of non -violence): Rather more challenging for some fields of nursing such as acute hospital care but may well be core to therapeutic approaches within mental health.

6. Given the heating – sustainable and emergency education need to come together. Social dislocation, hunger, environmental disaster, tribalism etc necessitates an education that can respond (e.g. global citizenship, peace education, conflict resolution, anti discriminatory education etc): Nurses may well be key professionals in dealing with emergencies and disaster management with other healthcare professionals and thus education and training that explicitly addresses these skills may well be valued and developed.

7. Alternative ideas of what ‘the good life’ means need exploring: Again this could be core to nursing philosophy especially within the contexts  of mental health and palliative care and living with long term or life limiting conditions.

8. Rethinking notions of democracy, citizenship and sustainability could be  part of the professional responsibilities of the registered nurse.

9. Shift from atomistic/reductionist thinking to holistic ways of mediating reality. This is not an unknown concept for nursing, but may require further exploration and development.

10. “Everyone has to understand and come to terms with the fact that we are threatening our own existence. To confront this requires a Copernican revolution in aims, structures, processes of education and perhaps in the loci of learning ... as the heating happens, education and educational institutions ... will be deeply disrupted and if unresponsive to the need for transformation, will disintegrate as people find other more relevant loci for learning what they have to learn”.  (Selby 2007).

10 propositions for education

1. confront denial

2. address loss and grief

3. human-nature relationship

4. poetic understanding

5. marginalised education

6. sustainability and emergency education

7. alternative good life

8. democracy and citizenship

9. holistic thinking

10. accept we are threatening our own existence


Flowing from and building upon Selby’s suggestions, we could apply the following principles  for a  Nurse Education for Sustainable Wellbeing (NESW).

1. Wellbeing

Recognises that human well being depends on foundations of biological, emotional, cognitive, politico-social, and environmental existence which are transient, inter-dynamic and coexistent.  This involves understanding that a goal of nursing is to recognise which current state is achievable, acceptable, manageable and desirable by the individual, society and the environment and to support the movement of existence towards wellbeing. Sustainable Wellbeing rests on a relationship between the five but also recognises that the individual’s ultimate existence is non existence.


2. Interdependence

Involves an understanding about the connections and links between all aspects of people’s lives and places at a local and global level, and that decisions taken in one place will affect what happens elsewhere. Nurses should develop an understanding that living things depend on each other and should acquire a sense that all living things have value. This should lead to an understanding that what people do elsewhere affects them, the places they live, other people, and plants and animals. They should become increasingly aware of the global context within which health, trade, industry and consumption operate.

3. Citizenship and stewardship

Recognises that people have rights and responsibilities to participate in decision making and that everyone should have a say in what happens in the future. This involves a willingness to act as responsible global citizens while developing the ability to engage with and manage change at individual and social levels. Nurses are expected to know and understand the connection between personal values, beliefs and behaviour and how the hospital, health centres and community can be managed more sustainably. The choice agenda explicitly recognises this value but may focus too narrowly on choices regarding treatment options rather than choices regarding health inputs (for example – choices around sustainably developed food sources).


4. Needs and rights of future generations

This concept is about learning how we can lead lives that consider the rights and needs of others and recognising that what we do now has implications for what life will be like in the future. This involves nurses in discussing the way they live and the products and services they use, to distinguish between actions and products which are wasteful and those which are sustainable. This should enable nurses to begin to assess the sustainability of their own lifestyle.


5. Diversity

This concept is about understanding the importance and value of diversity in people’s lives – culturally, socially, economically and biologically – and realising that all our lives are impoverished without such diversity. Through learning, Nurses should appreciate cultural and biological diversity in the hospital and community and eventually be able to reflect critically on, and engage in, debates and decisions on political, technological and economic changes which impinge on diversity and sustainability. Diversity is recognised as a key concept with the NMC professional code of ethics


6. Quality of life, equity and justice

Recognises that for any development to be sustainable, it must benefit people in an equitable way. It is about improving everybody’s lives. At a basic level this involves understanding the essential difference between needs and wants and developing a sense of fairness. It involves understanding the difference between quality of life and standard of living and seeks a good quality of life for all people, at local, national and global levels and an appreciation of why equity and justice are necessary to a sustainable society. These concepts are addressed in quality healthcare provision frameworks and ought to be  part of the nurses’ understanding of the management of quality services. It should challenge the funding of some high tech-high cost (big pharma?)  treatment options for the (rich) few .

7. Sustainable change

Promotes an understanding that there are limits to the way in which the world, particularly the richer countries, can develop. The consequences of unmanaged and unsustainable growth in health provision for the rich might include increasing poverty and hardship and the degradation of the environment, to the disadvantage of everyone. This involves nurses in understanding how their hospital and community may be managed more sustainably and beginning to question decisions, practices and processes that affect sustainable development issues. Health care practices and delivery systems which result in inequities on a global scale should be challenged.

8. Uncertainty and precaution

Involves a realisation that because people are learning all the time and that their actions may have unforeseen consequences, they should adopt a cautious approach to the welfare of the planet. This implies understanding that different people want to do things in different ways and are able to listen to arguments and weigh evidence carefully. Nurses should thus be able to think critically, systematically and creatively about sustainable development issues, solutions and alternatives.

(these 8 key concepts are adapted from the Sustainable Development Education Panel 2000).Taking the first step forward towards an education for sustainable development (PDF)


Principles for a Nurse Education for Sustainable Well Being

1. well being

2. interdependence

3. citizenship and stewardship.

4. needs and rights of future generations

5. diversity

6. quality of life, equity and justice,

7. sustainable change

8. uncertainty and precaution




The challenges facing humanity in the 21st century require a radical rethink of ‘business as usual’. Education is important, but is not the only game in town. There are other agencies and ideologies shaping the future. However, education is the HEI’s sphere of immediate influence and although it may be morally questionable to ask the next generation to clear up after our own mess we may have little choice. The principles for educational programmes are enunciated above but they may be seen to be mediated through some notion of global citizenship that has to have a moral and political dimension if we are to move civilisation towards moral, economic and environmental sustainability.





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Communicating health messages in contemporary culture.

Jon Snow, the channel 4 journalist, chaired the morning’s panel discussions at the BMJ’s ‘Climate Change, health and security’ conference held at the BMA in London on Monday 17th October. In addition to his skills and experience based on years of writing and presenting, he brought interesting insights into how the media works, insights which healthcare professionals could learn from.

One message was that the media had lost interest in climate change, partly due to the hard lobbying by climate sceptics, partly due the East Anglia ‘climategate’ emails but also due to the financial crash of 2008. This illustrates Roger Pielke’s ‘iron law of climate policy’: “when policies to curb emissions come up against policies for economic growth, economic growth wins every time”. The lesson? Messages compete on an ideological stage for their performance time.

The medium of communication is important. The panel of 9 on the stage were asked whether they use twitter. One person affirmed this to be the case. Snow pointed out that those working in the media use twitter and other social networks as core tools in their armoury. Snow argued that he gets a great deal of useful information from twitter and suggested that the doctors ought to seriously consider it as a medium of communication.

This illustrates another issue. Healthcare professionals work in a particular communication bubble, as do academics. Those who we need to communicate with (the public, journalists) live in another communication bubble. There is some crossover between the two but the implication is that healthcare professionals (clinicians and academics) are out of the communication loop, that the overlap between the two worlds is not large enough.

At root is a misunderstanding of the link between knowledge and policy decisions/public understanding. Healthcare knowledge is often  science based and rooted in medical understanding. There were suggestions from the floor that the science needs to be simplified and clarified in order to transmit the correct messages. This will not work in the way we think it ought to.

Firstly, policy and understanding is not based on medicine and science, it is based on what the popular culture tells us, which in turn is shaped by various vested interests, ideology, misconceptions, advertising, public relations and dominant cultural paradigms (e.g. the ‘economic growth’ paradigm, the tenets of consumer capitalism, anthropocentrism and philosophical ‘dualism’ i.e. the ‘objective-subjective’ , ‘nature-man’ divide).

Secondly we are using the wrong tools. Those who need the messages do not attend conferences, read academic journals or are linked into professional networks. They use facebook, twitter, radio, television and popular magazines. These media are not often used enough by academics, doctors and nurses.

Therefore the worlds are apart, divided by the understanding how the world works and by different tools of communication. The growing interest in ehealth and web based methods is an attempt to bridge that divide, but to date is still in its infancy. This is not to say these attempts are entirely absent, see for example the facebook group ‘Nursing Sustainability and Climate Change’, or the ‘Climate and Health Council’ website, but that there is a long way to go to understand what our story is and how to best connect with a wider audience. Healthcare professionals need to learn from media studies, social marketing and cognitive psychology on how to reach those who matter if we are interested in promulgating our messages.


Pielke, R. (2010) The Climate Fix. Basic Books. New York.

Nursing Sustainability and Climate Change

Climate and Health Council

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