Category: Sociology of health and illness

Why do we do what we do?

Photo by Alvin Mahmudov on Unsplash

Why do we do what we do?

 

“The powers of ordinary man are circumscribed by the everyday worlds in which they live, yet even in these rounds of job, family, and neighbourhood they often seem driven by forces they can neither understand nor govern. ‘Great changes’ are beyond their control, but effect their conduct and outlook none the less. The very framework of modern society confines them to projects not their own, but from every side, such changes now press upon the men and women of mass society, who accordingly feel that they are without purpose in an epoch in which they are without power” (Wright Mills 1956).

 

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

The same goes for individual success. The advice is “work hard, take your opportunities, be focused, dedicated and determined”. If you fail, it is only down to you.

Most people probably know that eating well and taking more exercise is better for health. Most people probably accept that hard work and dedication is a necessary condition for achievement.

So why do we see continuing patterns of chronic ill health, early deaths, and deprivation? These patterns show social class differences, i.e. the  ‘social gradient’, and unequal health outcomes. Those in the lower socio economic groups die younger, experience more chronic illness and have fewer disability free years.  Is it really all down to individual moral failure?

The question is posed in common discourse:  ‘why don’t millions of us get up off our fat arses, do something positive and take responsibility for health and success’? Why don’t we as a population or as individuals always exercise our agency to act for better health? After all, we are all ‘free autonomous sovereign individuals ’ able to choose courses of action unconstrained by social conditions. If the individual is poor or unhealthy then it is probably a result of the decision making of that individual or so the extreme version of the narrative goes.

I would argue that we are free to be critically reflexive about our socially structured conditions and thus to a degree free to change circumstances, but that we are also products of our biology, psychology and social circumstances. Our actions are highly structured (e.g. by class structures) but not structurally determined.

The complete freedom to think and act may be more complicated than adherents of the ‘autonomous sovereign individual’ may have us believe. The model of the ‘free sovereign individual’, so beloved by libertarians, neoliberals and most hues of conservatism in their political stances, is a flawed and incomplete model of human behaviour. It is a model of human behaviour that arose in Enlightenment modernity, and results in the creation of ‘homo economicus’, the free instrumentally rational being, who weighs up the pros and cons of action independently of social or cultural influences or internal psychological drivers, and is 100% responsible therefore for the consequences of their action. The adherents of this model of the human are often in adversarial and vehement denial of the ‘social’ and the cultural, they deny completely that there just might be a social reality or cultures in which our individual agency operates. Many have a visceral loathing of concepts such as gender, ethnicity and class affecting life chances.

 

To better understand this mode of thinking which underpins beliefs about human action, it is necessary to root it in its history of social relationships and cultures. Max Weber, along with Emile Durkheim, Karl Marx, Auguste Compte, and many others, for example, C Wright Mills (1956, 1959) attempted to do just that. Currently, Roy Bhaskar and Margaret Archer have further expounded on ‘Agency, Culture and Structure’. But to keep it simple, Weber’s contribution sheds some light on ways of thinking that lead to action.

 

Max Weber introduced the word ‘Verstehen’ (German for understanding, perceiving, knowing) to describe the sociologists’ attempt to grasp both the intent and context of human action. The 18th century’s Enlightenment ‘man of modernity’ was seen to be increasingly using instrumental rationality to guide action and becomes a model explanation for human behaviour.  During this period, Enlightenment philosophers thought that the main basis for authority and legitimacy in social affairs should arise from the exercise of reason in opposition to authoritarian monarchy or religion. Hence concepts such as liberty, progress, tolerance were emphasised along with science and reductionism (understanding something by reducing it to its parts). These ideas arose alongside the rise of mercantile and then industrial capitalism.

 

Weber, in trying to understand why capitalism succeeded in Europe even though its conditions elsewhere in the world could have given rise to it, wanted to consider ideas and ways of thinking (e.g. the Protestant Ethic) that underpinned action.

 

He described 4 ‘types’ of social action and the thinking behind it:

 

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

 

In short, the Enlightenment was emphasising ‘zweckrational’ alongside developing a model of humanity as an autonomous rational being. This idea is still core to much of current ‘common sense’ orthodoxy. Today, many ignore or forget the other 3 types while focusing on ‘zweckrational’, assuming that this is our only way of thinking.

 

We know from experience and research however, that we choose courses of action not because they always meet a certain goal, but because of a mixture of all 4 types of reasoned action. Many also think about these types (if at all) as existing independently of society. They do not want to consider, or fail to consider, that the human actor is actually not an autonomous individual existing separate from society and culture from which they spring, but are social and relational. They do not want to consider that personal agency operates within society and culture which has a reality “behind our backs”.

 

Weber’s insight was to link these types to changing social conditions. He argued that modern societies differed from those of the past because of the shift to zweckrational thinking rooted in the growth of bureaucracy and industrialism. This might explain why today, in bureaucratised, industrialised societies, that instrumental, technical, means ends thinking came to dominate. The error for many is that the ‘is’ of the dominance of zweckrational becomes the ‘ought’, the only way to think and it becomes the assumed method of human thinking. I suggest that those trained in scientific, technical and logical (means-ends) occupations are apt to think using ‘zweckrational’ but assume that is how everybody else does and ought to think. They then become one dimensional in their own thoughts, unable to grasp the complexity of human decision making.

 

The social theorist Margaret Archer describes this ‘man of modernity’ as “a being whose fundamental constitution owes nothing to society” (2000 p51) and who is increasingly driven by instrumental rationality or ‘means-ends’ thinking. This is the ‘ready-made man’ who turns up out of nowhere to impose his own order on the world and applies rational thought to social concerns. It is a view of humanity that believes that our ‘self’, our individuality,  exists totally separate from society, that it is not constituted at all by society or culture. The free acting self is an independent of society and culture free thinking and rational being. We will hear echoes of this man’s voice when we hear such statements as “only the individual should and can take responsibility for health”, “there is no such thing as society, just individuals and families”. Any idea of social structure, culture or social forces is completely denied. In this view there are no social mechanisms operating ‘behind our backs’ that might be guiding free choices.

 

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

 

Those who adhere to this model might think that obese and overweight people merely freely choose to eat more than they need, that their inability to lose weight is down only to their weak moral character and lack of will power. The obese should “just say no” to a second pork pie. Against this I suggest that they eat and move within the structures and cultures of the ‘obesogenic environment’ (Foresight 2007) and within cultural practices around food that becomes aspects of who they are, that they build into their self-concept. Veganism for example has been seen as the preserve of a slightly effete (?) minority and for many men especially, just cannot be built into their own notions of self as ‘red meat eating males’. Their self-concept as a man excludes this food choice as viable. They are of course free to act as a vegan but the structural and cultural context militates against men many doing so. Some men will be able to draw upon their material, psychological, biological, social, cultural, spatial and symbolic assets to exercise their agency to become vegan. Many others will not be able to exercise the same degree of freedom to do so. Some men will be critically reflexive of their meat eating and will easily see it as a cultural construct not a biological imperative. Many others will not do so because meat eating is too intertwined with their own unreflexively criticised ideas of masculinity and their social group feels exactly the same way. They of course will offer up superficial reasons such as taste and protein to justify eating meat but will downplay its symbolic value (its ‘sign value’), its ubiquitous availability and price and finally they ignore or forget as irrelevant that there are huge vested interests in keeping the link between meat and masculinity alive.

 

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

 

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

 

The Sociological Imagination.

Part of the answer to understanding why we do what we do,  will be found by exercising our sociological imaginations (Wright Mills 1959) to gain a fuller understanding of human behaviour. We need to think beyond the action of an individual, to consider the wider actions of society and culture that provides the context for individual choices at this point in history.

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

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

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

 

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

 

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

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

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

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

 

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

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

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

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

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

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

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

Weber’s ‘Affective Action’ comes into play at this point as we realise the part feelings play in decision making.

The smug middle classes may easily shun chavs for their  smoking and drinking habits but they are unable to grasp what poverty does to one’s feelings.

Orwell again clearly describes this process.

“…it is altogether curious, your first contact with poverty….you thought it would be terrible, it is merely squalid and boring. It is the peculiar lowness of poverty that you discover first…the shifts it puts you to, the complicated meanness, the crust wiping.

 You discover, for instance, the secrecy attaching to poverty…you dare not admit it, you have to pretend that you are living quite as usual.

 You discover what it is like to be hungry…everywhere there is food insulting you in huge wasteful piles…a snivelling self pity comes over you at the sight of so much food.

 You discover the boredom…you discover that a man who has gone even a week on bread and margarine is not a man any longer, only a belly with a few accessory organs…

 …but you discover the great redeeming feature of poverty: the fact that it annihilates the future…

 And there is another feeling that is a great consolation in poverty. It is a feeling of relief, almost of pleasure, at knowing yourself at last genuinely down and out. You have talked so often of going to the dogs – and well, here are the dogs, and you have reached them, and you can stand it. It takes off a lot of anxiety”.

(Chapter 3, Down and Out in Paris and London 1933)

In this context. Smoking is not quite so bad.

 

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

You and I are confronted in our daily lives by social circumstances, and we have a choice of action. We bring to that choice of action our own priorities, our ‘projects and concerns’. What we then do is mediated by the type of internal conversation, or reflexive deliberation. Archer’s thesis is that in the past social structures were such that little self reflexivity occurred. We ‘knew our place’, we knew what our role was and what status we had.  This was Weber’s ‘Traditional Action’.

However, as societies modernised, cultures and structures confronting us are far more open to change and critique, and are so by the actions of the people involved. The use of ‘Zweckrational ‘replaced’ ‘Traditional Action’. Women for example, no longer took for granted that their place was to rear children and to engage in unpaid domestic labour. They thought about the franchise and employment and some decided to act differently to ‘break the mould’. Why do some act to challenge social structure and why do others conform and thus replicate social structures?
 

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

In other words, your inner voice is confronted by the facts of the obesogenic environment or of social class or of gender relationships in the workplace, but you can be reflexive upon that fact and so it can be acted upon. Action can be, for example, fatalistic towards that circumstance or instead might confront it in an attempt to overcome any perceived or actual disadvantage. You might engage your zweckrational, your affective rationality, your values based rationality and/or act based in tradition, custom and practice. In short, you exercise critical reflexivity, or not!

Agency and Context

Yet Agency is necessarily contextualized, it occurs in a context of social structure and culture characterised by power differentials. That is the objective fact the people confront every day. For example, an objective social fact that predates your existence is the social structure of education in the UK. Exercising personal agency towards financial and material success is a lot easier if you are born into a wealthy family and are sent to one of the prestigious English public schools and Universities.

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

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

 

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

 

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

 

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

 

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

Non variant FTO gene

No chronic illnesses

Endomorph

Variant FTO gene

Type 2 Diabetic

Psychological High self-efficacy

High self esteem

High body image (body reality matches body ideal

Internal locus of control

Emotional and sexual support

Depression free

Positive outlook

Low self-efficacy

Low self esteem

Poor body image (body reality far from body ideal)

External locus of control

Emotional and sexual abuse

Bouts of depression

Suicidal ideation

Social Similar looking thin peer group

‘Network effect’ is positive

Social support for domestic needs

Child care easily affordable

Food prepared by nutritionist

Supportive parents and spouse

Socially popular

Wealthy successful peers

The 0.01% Global elite

Private School and Drama School paid by parents

Similar looking fat peer group

‘Network effect’ is negative

No social support for domestic needs

Child care expensive

Food prepared by Greggs

Parents both dead, absent partner

Social pariah

Poor just about managing peers

The local Precariat

Left at 16 with no qualifications.

Cultural Ambitious

Health high priority

Non Smoking

Gym Membership

Non Violent

Survivalist/Fatalist

Health discounted

Smoking

Daytime TV

Emotional, verbal and physical violence is common/expected

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

This asset is paramount as it feeds into the others

High Net worth

 

In debt.

 

 

Conclusion.

It is complicated.

The data clearly, for example in ‘Fair Society, Healthy Lives’, shows social patterns for a whole range of indicators from educational achievement to premature death. These patterns are characterised by the ‘social gradient’, i.e. the lower down on the socio-economic scale you are, the worse your outcomes are likely to be across the board. These patterns are further complicated by intersections of ethnicity and gender, but the most salient is social class. Your individual success or failure at anything is down to luck: primarily who your parents are (determines your class, ethnicity, geographical location and you’re your access to education, networks, supportive cultures and material well-being).

The period of history you were born in is also crucial. The post war baby boomers in the UK benefitted from an explosion in middle class and managerial white collar jobs, the expansion of educational opportunities,  the breaking down of class barriers and status, well paid industrial employment and cheap credit, mortgages and house price affordability. To be born white, male, middle class in the UK in 1955 was a huge privilege. To be born black, male, poor in Alabama in the 1920’s could see you lynched on the Courthouse lawn.

Biology plays its part but is by no means determines your destiny. Hard work, focus and determination are also key but they operate in this wider context.

That is why your life is highly structured but not structurally determined. You are not a free autonomous rational individual even if it feels that way. ‘Poor boy done good’ does not validate the system it merely shows it is complex. This narrative can also be used to justify the status quo as meritocratic, a concept in practice which is largely mythical.

The political issue that arises then is one of whether you see the status quo and just accept it as inevitable, or whether you think something can be done. I suggest that many of the ‘Greedy Bastards’ (with notable exceptions) take the former, it is not in their interests to change anything at all.

 

 

 

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

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

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

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

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

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

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

 

See also C Wright Mills (1959) The Sociological Imagination. Oxford University Press. Oxford. Chapter 1 ‘The promise’.

C Wright Mills (1956) The Power Elite. Oxford University Press. New York.

 

 

 

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

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

 

Photo by Sofiya Levchenko on Unsplash

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

 

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

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

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

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

 

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

 

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

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

 

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

 

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

 

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

 

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

 

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

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

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

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

 

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

 

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

 

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

 

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

 

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

Non variant FTO gene

No chronic illnesses

Endomorph

Variant FTO gene

Diabetic

Psychological High self-efficacy

High self esteem

High body image (body reality matches body ideal

Internal locus of control

Emotional and sexual support

Depression free

Positive outlook

Low self-efficacy

Low self esteem

Poor body image (body reality far from body ideal)

External locus of control

Emotional and sexual abuse

Bouts of depression

Suicidal ideation

Social Similar looking thin peer group

Network effect positive

Social support for domestic needs

Child care easily affordable

Food prepared by nutritionist

Supportive parents and spouse

Socially popular

Wealthy successful peers

The 0.01% Global elite

Private School and Drama school paid by parents

Similar looking fat peer group

Network effect negative

No social support for domestic needs

Child care expensive

Food prepared by Greggs

Parents both dead, absent partner

Social pariah

Poor just about managing peers

The local Precariat

Left at 16 with no qualifications.

Cultural Ambitious

Health high priority

Non smoker

Gym membership

Non violent

Survivalist

Health discounted

Smoker

Daytime TV

Emotional, verbal and physical violence common/expected

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

This asset is paramount as it feeds into the others

High Net worth

 

In debt.

 

 

 

 

 

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

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

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

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

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

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

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

 

 

 

The 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 Violence of Austerity

Photo by Samuel Zeller on Unsplash

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Sociological Imagination

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

Photo by Lance Anderson on Unsplash

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

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

C Wright Mills wrote:

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

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

 

 

Personal troubles:

 

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

 

 

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

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

We do not

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

In addition we:

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

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

What is a ‘structural transformation?’

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

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

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

To help answer that question Wright Mills argued that

 

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

 

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

 

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

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

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

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

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

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

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

 

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

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

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

 

Wright Mills outlines:

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

Troubles:

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

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

 

 

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

 

Public Issues:   

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

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

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

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

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

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

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

Implications:

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

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

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

To summarise: 

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

 

Benny Goodman      September 2017

 

Poverty Privilege and Health

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

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

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

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

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

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

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

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

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

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

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

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

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

The losers get sick.

The losers get poor.

The losers get defeated.

The losers get mad.

The losers get even.

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

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

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

Our social environment encourages obesity

our social environment encourages obesity

Your health depends in where you live

Your health depends in where you live

What doctors don’t know about the drugs they prescribe

What doctors don’t know about the drugs they prescribe

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