Tag: Discourse

Health based on Poverty and its measurement.

Photo by Adam Jang on Unsplash

Health based on Poverty and its measurement.

 

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

 

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

 

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

 

The Consensual Method of measuring poverty.

 

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

 

“enforced lack of necessities determined by public opinion”.

 

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

 

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

 

What do you think everyone should be able to afford?

What do you think no one should be without?

 

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

 

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

 

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

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

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

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

 

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

 

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

 

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

 

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

 

 

 

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

 

 

watch this video for a first hand account.

 

 

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

 

 

Neoliberalism: Rhetoric and Reality.

This paper was prepared as background to the 4th edition of ‘Communication and Interpersonal skills in nursing (Grant, A. and Goodman, B. forthcoming). In that book discourses of neoliberalism and their effects on health and health service delivery as well as the interpersonal communications nurses have with people will be explored and critiqued. An example is the discourse on ‘individual responsibility for health’ and ‘lifestyle drift’ responses to public health which draw upon the concept of ‘sovereign individual’ of neoliberal philosophy. This paper explores what neoliberalism might be to argue that it is more a discursive practice than a political action.

 

Neoliberalism is at once everywhere and nowhere. There is ‘appearance’ and ‘reality’, there is reification and fetishisation. Its name is spoken in certain circles and vilified (Springer 2016), it is an ‘imprecise exhortation’ (Thorsen and Lie 2007, Thorsen 2009), in others there is denial that it even exists (Talbot 2016). It might be best to understand neoliberalism as a ‘discourse’ (Foucault 1969) rather than an actuality of political practice, as a “rather radical set of ideas which nevertheless have had a certain influence on society and politics in recent times” (Thorsen 2009 p20).  It is a word used by the progressive and critical left, e.g. Saad-Filho and Johnson (2005), to counter what the right call the ‘free market’ in the context of the breakdown of the post war consensus around the social welfare democratic state.

 

I suggest that the discourse of the ‘Free Market’ was, and is, used to reshape the State, and civil relationships, away from ownership and control of the means of production, away from Keynesian state intervention in the economy and away from providing all social security (including housing, health, education, and transport). Free market rhetoric is used to mask the reshaping of State apparatus towards State intervention for wealthy landowners and corporates (financial and industrial). This is a bid by a capitalist class to (re)capture the State’s support for capital and property accumulation in their favour. This ‘support’ is referred to as a ‘framework’ in which ‘free’ markets are to operate. I also argue that there is nothing ‘neo’ or ‘new’ about the practical reality of this form of liberalism, tied as it is to the capitalist State.

 

The term ‘Free market’ is often preferred to ‘neoliberal’ by its supporters according to Talbot (2016) and Thorsen (2009) who argues that the term neoliberal is now most often used in a pejorative way by the left. We say ‘Neoliberal’ you say ‘Free Market’. ‘Free market’ or ‘neoliberal discourse’ is used as part of the Ideological State apparatus backed up by the Repressive State apparatus of the judicial system, police and ultimately, if needs be, the military.

 

An important idea of ‘Free Market/Neoliberalism’ is the espoused theory of a minimalist State. The theory in action is a State becoming minimal for social security but otherwise continuing the facilitation of capital accumulation and the ownership of wealth especially by the 0.01%. The ‘Nightwatchman’ minimal state of the 19th century is a goal of free market (or liberal) ideology, but this has not been achieved for all of the talk of the Reagan/Thatcher years of the 1980’s. This is possibly because the reduction of State spending down to 10% of GDP from the current 40% of GDP (per year, see figure 1 in the appendix) would be as disruptive for the capitalist class and the political power elites as it would for everyone else. This is also because key sectors of the economy such as agriculture, the military-industrial complex, and the nuclear power and fossil fuel industries, rely on government funds and subsidies without which their business models would have to be radically altered. Capitalism’s ‘creative destruction’ is a lauded dynamic feature, as long as its not your industry or business model that goes bust or, in the jargon; is ‘disrupted’.  It is also because in theory, liberalism is not a monolithic philosophy, ‘classic’ and ‘modern’ Liberalism (Ryan 1993) have different views of the State’s role.

 

The minimalist state (‘Nightwatchman’) ‘classic liberal’ solution to questions of political economy might still be the goal of some current thinking. This may include the Tea Party in the US, kicked into life by Rick Santelli’s comments on President Obama’s mortgage bail out plan (Pallasch 2010),  and perhaps in the UK by the Adam Smith Institute. Yet in current practice many of the Conservative capitalist class, and their political voices in the Tory party, seem as wedded to state intervention as they claim socialists to be.

 

Neoliberalism as a discursive practice, embedded and supported by an ideologically driven, highly funded ‘intellectual’ infrastructure, can also be linked to around 1,000 self conscious neoliberal intellectuals organised in the Mont Pelerin Society (Plewhe et al 2007). Its proponents fight for hegemony in research and development, and engage in political and communication efforts with well funded, well coordinated and highly effective new types of knowledge organisations: partisan think tanks such as the Cato Institute and the Heritage Foundation in the US, the Institute for Economic Affairs (IEA) and the Centre for Policy Studies (CPS) in the UK and the Institute of Public Affairs in Australia (IPA) (Beder 2001).

 

A Discursive Project.

 

This is an ongoing rhetorical project in the UK because as Desai (2007) argues, the values and principles of Thatcherism, which did not call itself neoliberal but did emphasis similar ‘free market, small state’ principles mixed with ‘Victorian values’,  were not wholly accepted by the British public. This is evidenced in surveys of public opinion in the 1980’s and 90’s and arguably even today if support for the socialist inspired NHS is an indicator.

 

Support in elections since 1979 have not won over majorities of the electorate, and it is only thanks to first past the post that Tories and clause 4 ditching ‘Tory lite’ New Labour, were able to win. See figure 1 (appendix) which shows what % of the electorate actually voted for the government of the day.

 

These figures show that at its peak only 33% of voters could be bothered to put an x next to free market rhetoric. This was down to 24% by 2015. Neoliberals/Thatcherites/ Conservatives have not won the hearts and minds of the British Electorate and neither has the goal of a small state in terms of GDP spend been achieved. Their success in the US and the UK, is to be measured not by the popular vote, but by their assaults on Trade Unions, by Privatisations, Tax breaks and Labour market and Financial deregulations.  And by the increasing share of wealth and high pay going to the 1% and 0.01% (Saez and Zucman 2014, Dorling 2014, Moshinsky 2016).

 

I argue here in accordance with Desai (2007) that:

 

“Market dogma may well be entrenched in capitals around the world, but its intellectual vacuity and practical failures have been documented in a vast literature. It would be truer to say that neoliberalism’s intellectual pretensions are designed to provide a fig leaf of intellectual respectability to the most naked pursuit of the interests of capital and property (my emphasis) than that neoliberalism has motivated this pursuit by intellectual force and political influence” (Desai 2007 p220).

 

In other words, powerful and rich individuals have used talk of free markets (and neoliberalism) to justify their ongoing grab of global wealth through using the levers of State power, rather than it being the case that the intellectual case motivates their actions.

 

Graham Scambler (2012) also points in this direction in his exposition of the ‘Greedy Bastards Hypothesis’ which is underpinned by the strategic actions of ‘focused autonomous reflexives’ in the capitalist class executive and the political power elite.

 

 

 

 

Discourse

 

 

In common understanding a ‘discourse’ is an exchange, perhaps of ideas, between two people involving language as the medium of transmission. This can be seen as a neutral exercise between two people of equal power and status using certain phrases, words, jargon and syntax to share understanding or to question the other’s statements. Consider the situation when two Tory MPs are talking to each other about a ‘flexible labour market’  or the need for people to be ‘taking responsibility for one’s health’. The first is an example of the neoliberal/free market discourse that favours weak labour regulations to make it easy to hire and fire staff making them ‘flexible’. The second brings in and joins the ‘Moral Underclass discourse’ (Carlisle 2001) to the free market’s central idea of ‘free sovereign individuals’ in charge of their own destiny in order to shift responsibility fully onto the shoulders of individuals. This discourse can then blame individuals for being obese, for smoking or for any other ‘moral failing’ such as catching an STI or binge drinking.

 

Discourse as a critical concept is associated with Michel Foucault. For Foucault (1969) discourses are institutionalised patterns of speech and knowledge seen and felt in ‘disciplinary’ structures, e.g. in the medical clinic or in the prison (Foucault 1963, 1975). Discourses connect knowledge to power. Knowledge is power. To oversimplify, the concept refers to the idea that a discourse shapes, or constructs what we know, what we can say and also reflects differences in power between people. Becoming a Tory MP introduces one to the institutionalised patterns of speech which might be very familiar to that experienced in public schools (e.g. Eton) and certain Oxbridge clubs (e.g. Bullingdon).

 

 

 

 

Discourses are more than mere words.  A discourse, Foucault (1969) suggested, actually brings into being that of which they speak.

 

“…discourses…are nota mere intersection of things and words….

 

The task of analysing discourses is to show that they are not just:

 

groups of signsbut as practices that systematically form the objects of which they speak.discourses are composed of signs; but what they do is more than use signs to designate things. It is this more that renders them irreducible to language and to speech. It is this morethat we must reveal and describe (1969 p 54)” (my emphasis).

 

By continually repeating the discourse, and getting it accepted by enough people, that “There is no money” or “There is no Alternative” or “Labour caused the public debt” or “Banks are too big to fail” or “Top cornflakes rise to the top” or “high pay rewards hard work and intelligence” or “Inequality is good for competition” or “Skivers v Strivers” or “In this together” or “we must balance the books and bring down the deficit” these things are brought into being. They are part of a larger, taken for granted, understanding of the ‘proper’ role of the state, the individual and the corporation.

 

 

What then is ‘Neoliberalism’ and what is formed by that of which it speaks?

 

 

Traditional Enlightenment ‘classical liberalism’ (Ryan 1993) emphasises:

 

  1. Individual Freedom (liberty) through limiting government and maximising capitalist market forces.
  2. Civil liberties under the rule of law and laissez faire economics.
  3. Free markets, utilitarianism, natural law (inherent rights which are universal, uncovered by reason) and progress.

 

Key thinkers: Adam Smith, John Locke, Thomas Hobbes, David Ricardo. Alexis de Tocqueville

 

Modern liberalism accepts a greater role for the State in the economy, manifested in regulation and the State supplying of goods and services (Ryan 1993). Laissez faire economics cannot in this interpretation meet the goals and purposes of liberalism. Thorsen (2009) argues that liberalism has many facets and has become in effect a contested concept particularly over the role of the State.

 

 

Neoliberalism is associated with ‘Austrian’ economists Ludwig Von Mises (1881-1973), Friedrich Hayek (1899-1992) and the American economist Milton Friedman (1912-2006). Around 1950, the classic liberal state had grown into, for some, a social democratic monster driven by Keynesian economic theory and the growth of Welfare States. In both the US and the UK, governments were beginning to spend more and more of GDP and intervening in many areas of the economy including social security programmes. Von Mises, Hayek and Friedman would have noted that the share of GDP spent by the State on welfare and public services had grown from about 10% in the middle of the 19th Century (figure 2 in the appendix) to around 40% by the 1970’s.  Today the share of GDP spent by the government in the UK is about 41% (figure 3 in the appendix).

 

In the context of the centrally planned Soviet Union and Hitler’s Germany, Hayek (1944) argued that any government control of economic decision making through central planning leads to tyranny and that civilisation requires liberty as a prerequisite for wealth and growth (1960). Hayek and Freidman (in the 1950’s) referred back to classical liberalism rather than ‘neoliberalism’ in their reaction to the amount of state intervention in the economy.  Yet, they accepted some aspects of welfare provision by the State although this provision in their view should be greatly reduced. Their status as fringe economists  in the 50’s was altered when their economic theory and political philosophy was then taken up by Reagan in the US and Thatcher in the UK around the late 1970’s. At this point there had been a sort of post WW2 consensus between Conservatives and Labour regarding the level of state intervention in the economy.

 

 

 

Margaret Thatcher was to change that cosy relationship.

 

At a Conservative Party policy meeting in the late 1970’s, Thatcher made it clear upon what her approach to the economy was based:

 

Another colleague had also prepared a paper arguing that the middle way was the pragmatic path for the Conservative party to take…the new Party Leader [Margaret Thatcher] reached into her briefcase and took out a book.  It was Friedrich von Hayek’s The Constitution of Liberty…..she held the book up for all of us to see.  ‘This’, she said sternly, ‘is what we believe’, and banged Hayek down on the table.” (Ranelagh 1991).

 

Neo simply means ‘new’ and refers us back to the earlier liberal small state. The ‘Nightwatchman’ state in the 19th century provided for property rights, contracts, markets and personal/national security. That was about it. No provision for schools, health, transport or subsidies for industries. Hence the relatively small % of GDP being spent by the government. Talbot (2016) argues that the 1950’s Neoliberalism was new in that it also embraced social as well as economic and political rights. Social protection, workers rights and public health would actually help the capitalist society, however following the Chilean coup of 1972 a theoretical inversion took place in which it now meant a reversion to 19th century free market liberalism.

 

Four Definitions

 

Stuart Hall (2011) argued that:

 

The term ‘neo-liberalism’ is not a satisfactory one. Intellectual critics say the term lumps together too many things to merit a single identity; it is reductive, sacrificing attention to internal complexities and geo-historical specificity. However, I think there are enough common features to warrant giving it a provisional conceptual identity, provided this is understood as a first approximation…..What, then, are the leading ideas of the neo-liberal model? ….neo-liberalism is grounded in the idea of the free, possessive individual. It sees the state as tyrannical and oppressive. The state must never govern society, dictate to free individuals how to dispose of their property, regulate a free-market economy or interfere with the God-given right to make profits and amass personal wealth”.

 

A ‘tyrannical and oppressive’ State was of course Hayek’s view.

 

George Monbiot (2016) outlined its main principles in this way:

 

“Neoliberalism sees competition as the defining characteristic of human relations. It redefines citizens as consumers, whose democratic choices are best exercised by buying and selling, a process that rewards merit and punishes inefficiency. It maintains that the marketdelivers benefits that could never be achieved by planning. Attempts to limit competition are treated as inimical to liberty. Tax and regulation should be minimised, public services should be privatised. The organisation of labour and collective bargaining by trade unions are portrayed as market distortions, that impede the formation of a natural hierarchy of winners and losers. Inequality is recast as virtuous: a reward for utility and a generator of wealth, which trickles down to enrich everyone. Efforts to create a more equal society are both counter-productive and morally corrosive. The market ensures that everyone gets what they deserve”.

 

David Harvey (2005) defines it thus:

 

Neoliberalism is in the first instance a theory of political economic practices that proposes that human well-being can best be advanced by liberating individual entrepreneurial freedoms and skills within an institutional framework characterized by strong private property rights, free markets, and free trade. The role of the state is to create and preserve an institutional framework appropriate to such practices. The state has to guarantee, for example, the quality and integrity of money. It must also set up those military, defence, police, and legal structures and function required to secure private property rights and to guarantee, by force if need be, the proper functioning of markets. Furthermore, if markets do not exist (in areas such as land, water, education, health care, social security, or environmental pollution) then they must be created, by state action if necessary. But beyond these tasks the state should not venture. State interventions in markets (once created) must be kept to a bare minimum because, according to the theory, the state cannot possibly possess enough information to second-guess market signals (prices) and because powerful interest groups will inevitably distort and bias state interventions (particularly in democracies) for their own benefit.

 

 

Thorsen (2009) after an examination of literature on liberalism including the critical literature argues:

 

“Neoliberalism is…a loosely demarcated set of political beliefs which most prominently and prototypically include the conviction that the only legitimate purpose of the state is to safeguard individual liberty, understood as a sort of mercantile liberty for individuals and corporations. This conviction usually issues, in turn, in a belief that the state ought to be minimal or at least drastically reduced in strength and size, and that any transgression by the state beyond its sole legitimate raison d’etre is unacceptable (cf, especially Mises 1962; Nozick 1974; Hayek 1979).

 

This latter two descriptions  are that of the ‘Nightwatchman State’. Remember at this time in the 19th century less than 10% of GDP was spent by the government on public activities. Is this the goal of current Conservatives? Or is neoliberal/free market discourse an ideological mask for something else?

 

A minimal state safeguarding individual mercantile liberty and that is it?

 

We have to question whether in action Tory ministers believe this and wish to cut public spending from around 40% to 10%. To see what that would mean, we would need to look at the current 2017 budget (approximately £800 billion which is 40% of GDP) and note that to get down to 10% of GDP the budget would have to be £200 billion. See the appendix figure 4 for the 2017 budget. This is not 10% of GDP. Social Protection (pensions in the main) is over 10% on its own.

 

This is not a ‘Nightwatchman’. Is it a socialist utopia? The State is spending a lot of money still. However, what is actually happening is that in each sector, privatisation means that more and more government money (taxpayer’s money) is subsiding private provision. This is an explicit aim of the Adam Smith Institute who explicitly call for private provision but public funding for health. In Rail the government is subsiding private train operating companies and in housing the government is subsidising landlords through housing benefit.  In employment the government is subsidising employers through tax credits.  Figure 5 in the appendix shows where the revenue comes from.

 

The UK government spending accounts for about 40% of GDP, leaving 60% going elsewhere. Spending on health, social care and social protection (pensions) accounts for £426 billion, that is over 50% of the total spend. Add £102 billion for education (total now is £528 Billion).

 

Who pays for that? Well, whoever pays Income Tax, National Insurance, VAT, Council Tax and excise duties. All of this accounts for £628 billion.

 

What we have is redistribution from the 99.9% to the 99%.

 

‘Neoliberalism’ as rhetoric actually works for 0.01% – the plutocrats, the global capitalist executive. Henry (2012) argues that anything between $21 to £31 trillion as of 2010, has been invested tax free in about 80 ‘offshore’ secrecy jurisdictions. That is trillion not billion.

 

What we don’t have is a minimal state focused solely on safeguarding liberties for markets.

 

This idea of a small state free market economy is of course patent nonsense as it has just not happened. The reduction of public spending and deficit reduction are two current policy goals (i.e. Austerity) but this is hardly neoliberalism.  Neoliberal purists have failed to get the Tory party to reduce spending to these ‘classic liberal state’ levels. So what was all that Thatcherite talk for?

 

The reduction of state spending down to 10%, I suggest is either a complete failure of the neoliberal project or it is deliberate policy failure in that this is not the neoliberal goal at all.

 

It could be the case that the free market discursive practice is a cover for capital and property accumulation through curbing what is seen as labour power but more importantly by capturing the levers of the State. Cutting state spending to 10% would be seen by the capitalist executive and the political power elite to be socially and politically dangerous to capital accumulation.

 

Marx once remarked in the Communist Manifesto:

 

the executive of the modern state is but a committee for managing the common affairs of the whole bourgeoisie”.

 

One does not have to be a communist to begin to see how executive power is being used to the advantage of Capital (deregulations, subsidies and offshore tax breaks) while at the same time weakening labour through strict union laws, wage freezes and labour market ‘flexibility’.

 

Prior to 1900, no state spent more than 3% of GDP on ‘social programmes’. Around 1870 the average public spending level of ‘advanced economies’ was 10% (Talbot 2016). The 1914-1918 war saw an increase to 20%, followed by a steady growth to the 40% of today. This leads Talbot to argue that the neoliberal state of the 1970’s with 40% spending is actually little different from liberal market/social democratic states. Therefore it is all talk and no action since that level of spending has not been reigned back to 19th century levels.

 

Does this mean that Thatcherism was not neoliberal in action? Yes, if by that we define a neoliberal state as that in which only 10% of GDP is spent. Was Thatcherism even ‘free market’ in action given the continuing level of state intervention in many sectors of society and economy? Both Thatcher and Reagan promised to ‘roll back the frontiers of the state’ or that ‘government was not the answer, it was the problem’. This was ‘New Right’ talk to distinguish it from post WW2 Conservatives who accepted the post war social democratic consensus based on around 40% GDP spending and intervention.

 

Talbot (2016) argues that neoliberalism exists only as a ‘bogeyman’ created on the left to oppose various conservative attempts to ‘rebalance’ government-market relations. Bruff (2017) however argues that ‘neoliberalism’ is not about a return to free markets and 10% spending levels but is an ideology to mask a coercive, non-democratic and unequal reorganisation of society. There is seeming agreement that this is not about cutting government spending per se down to 10% but about reshaping democratic social and political relationships in favour of Capital. To repeat Desai (2007):

 

neoliberalism’s intellectual pretensions are designed to provide a fig leaf of intellectual respectability to the most naked pursuit of the interests of capital and property”.

 

Bruff (2017) points out that many current governments are not neoliberal in that they actually oppose free markets in practice and instead are engaged in protectionist rhetoric and practice. A 40% GDP spend does not indicate much in the way of ‘cutting back the state’ except for the working classes as a result of austerity politics and social security spending decisions.

 

This results in socialism for the rich (state spending) and neoliberalism for the poor (welfare cuts).

 

If neoliberalism is narrowly defined as a political programme valorising free markets then indeed leaders such as Trump, Modi, Erdogan and Abi are not neoliberal. Instead ‘free market’ rhetoric is just that: rhetoric. Bruff goes on to suggest that actually Hayek et al constantly invoke ‘free markets’ as an abstract principle but then they have a preference for certain types of markets to prevail in actuality. Neoliberalism in this definition is the use of the State in a central role to maintain a certain kind of market:

 

“neoliberalism has nothing to do with markets as commonly conceived, and everything to do with the orchestration of social relations in the name of markets…it is about the coercive, non democratic and unequal reorganisation of society along particular lines…intensification and extensification of the differences, inequalities, hierarchies and divisions that pervade capitalist society as delivered by authoritarian states and global corporations…neoliberalism is a way of seeing the world that is carved from the empty words ‘free’ and ‘markets’ ”. Bruff calls this ‘Authoritarian Neoliberalism’

 


 

Some Free Market advocates get this too.

 

Jamie Whyte is a free market advocate and in the BBC radio programme Analysis ‘Keeping the Free Market faith’ (8th October 2012) thinks Conservatives are now losing that faith in the free market, implying neoliberalism has lost its grip. Of course, as figure 1 to 5 show, it never had one.

 

Three Conservatives said this about the state of politics in 2012:

 

An Unholy alliance between a free market ideology which took over a government and a process of social change in which fair dealing and trust were ditched in favour of get rich quick economic libertarianism”

 

“We have to challenge the assumptions of laissez faire economics…”

 

“…the left wing account (of a conspiracy of the rich against poor people) is much more believable (since the credit crunch) than in 1990, although I don’t believe it”.

 

(Jessie Norman, Matthew Hancock (Tory MPs) and journalist Charles Moore).

 

In the ‘Free Enterprise Group’ in the Tory party, Andrea Leadsom argued deregulation in the banking sector had caused major problems. Ferdinand Mount also queried deregulation and the big bang which ‘had its downside’. Matthew Hancock (Tory Minister for Skills) also of the Free Enterprise Group, argued free markets need strong frameworks. He argued we should not muddle up laissez faire economics with free markets, and that the banking sector is special, it is an exception where free market principles should not hold! The State also should have a view of what are sustainable business models for many industries.

 

Jamie Whyte interviewed Ferdinand Mount, who helped write Thatcher’s manifesto in 1983, argued in the radio programme that ‘bankers are the worse kind of oligarchs, immune to old standards of corporate governance, paying themselves whatever they like. Shareholders are sleeping and are not taking them to account’. Qualms about high pay, argued Mount, is about social justice and economic efficiency (rewards gained despite performance). He argues against total deregulation and against withdrawal of state support for the ‘too big to fail’ banks.

 

Whyte interviewed Lord Griffiths (advisor to Thatcher in 1986) who dents Thatcher’s image as a neoliberal or free market ideologue. He argues that Thatcher believed in a ‘moral market’ and the value of enterprise but was never a total free marketeer. Free markets yes, but within a boundary of social justice, including consumer protection. Thatcher he suggests was not a purist Hayekian. Despite the earlier Hayekian gesture in the 197o’s, Griffiths argued that Thatcher believed that the market economy had a moral basis in a Judeo-Christian ethic; a ‘moral market’ and this was the underpinning of the economy. Thatcher was free market enough to let the UK coal mines close and railed against support for ‘lame duck’ industries. She also began the wave of privatisation of nationalised industries.

 

What then now of Theresa May’s reintroduction of industrial policy, of explicit talk of government involvement in various sectors of the economy? Since 2010, there has been the  setting up of a British Business bank and the rebalancing of the economy as policy goals. Government should now have a view over the structure of the economy (Matthew Hancock MP), and support for successful business is a legitimate role. ‘Active and thoughtful’ government should support successful companies, and not be neutral between sectors. Hancock argued that there needs to be a strong framework around a market supporting successful industries, i.e. those that work well. An industry strategy must allow new challengers, but there must not be a planned economy. This must be done through looking at regulation and providing industry with the skills it needs.

 

Pro-Business rather than Free markets?

 

However, businesses are good at lobbying government (Zingales 2012), they ask for and get support rather than just asking for arm’s length regulation.  Zingales (2012) also argues that the US risks deteriorating into a pro-business rather than pro-market system. Jamie Whyte calls the relationship between business and government  ‘cosy and corrupt’.

 

Trump’s election and his appointees and advisors might indicate or vindicate Zingales’ point. His first big meeting in January 2017 (Feloni 2017) was with 12 CEO’s of the United States’ largest companies and he told them that he would ‘prioritize corporate tax cuts and decrease regulation’ (free market talk) and impose a ‘border tax’ on companies that move production outside the US (state interventionist).

 

Key appointments include:

 

Rex Tillerson (ex CEO of ExxonMobil), Steven Mnuchin (Goldman Sachs, Hedge Funder), Robert Lighthizer (Corporate and Trade Lawyer), Andrew Puzder (CEO of restaurant chains) and Wilbur Ross (Billionaire Investor). Well, who else would you want to run the capitalist executive but capitalist executives?  Smith (2016) suggests that ‘Trump’s billionaire cabinet could be the wealthiest administration ever’:

 

Todd Ricketts ($5.3 bn), Betsy DeVos ($5.1 bn), Wilbur Ross ($2.9 bn), and Steve Mnuchin ($46 m).

 

In the UK, May’s cabinet are pretty rich but look like paupers compared to Trump’s (Saner 2017).

 

As for business connections, in the UK, there are 50 official ministerial ‘business buddies’ for large firms in the Business Council. Glaxo Smith Kline had David Willetts while Vince Cable worked with Oil and Gas. Hancock in the Whyte radio programme argued they ‘listen’ to their companies and the government then does what they would like. This is not only a UK phenomenon. Angresano (2016) argues there is a ‘Corporate Welfare Economy’ in which the US government has increasingly been influenced by corporate lobbyists with regulation skewed in order to suit the interests of the privileged.

 

Other examples include the United States Department of Agriculture’s plan to buy 11 million pounds of cheese worth $20 million (USDA 2016) to support US dairy farmers. The Overseas Development Institute (ODI) and Oil Change International found that as a whole, G20 nations are responsible for $452bn (£297bn) a year in subsidies for fossil fuel production. Bergin (2016) reported that compensating carmakers in Britain for any post-Brexit tariffs on exports to Europe could see the government hand the companies more money than they need to pay the salaries of all their British workers. For decades British farmers have received subsidies under the EU’s Common Agricultural Policy (CAP). Full Fact (2016) report that the average farmer made £28,300 in subsidies in 2015 and £2,100 from agriculture. Wealthy land owners, such as the Daily Mail’s Paul Dacre, the Queen, a Saudi Prince, the Dukes of Westminster and Northumberland, the Earl of Moray also received subsidies from the CAP (Press Association 2016). Hinkley nuclear power station will have a subsidy worth £30 billion (Ward 2016). George Monbiot (2011) wrote:

 

the Guardian revealed that the government’s subsidy system for gas-burning power stations is being designed by an executive from the Dublin-based company ESB International, who has been seconded into the Department of Energy. What does ESB do? Oh, it builds gas-burning power stations. On the same day we learned that a government minister, Nick Boles, has privately assured the gambling company Ladbrokes that it needn’t worry about attempts by local authorities to stop the spread of betting shops. His new law will prevent councils from taking action”.

 

The Economist (2012), a free market paper, also reports on the US Chamber of Commerce and its lobbying and influence in US politics:

 

“Small firms can get a lot out of the Chamber—its annual small-business summit is well-regarded, for instance. But some feel under-represented: most of the firms represented on the board are large. Others worry that they are being used as pawns. In a letter to a Philip Morris executive just after he took over, Mr Donohue said that small firms provide the foot soldiers, and often the political cover, for issues big companies want pursued, because Congress listens more to them than to big business”.

 

Traynor et al (2014) similarly reported on corporate lobbying in the EU, claiming that there are over 30,000 lobbyists operating in Brussels while Drutman (2015) argues US lobbying is ‘America’s Business’ leading to ‘politics becoming more corporate’.

 

Jamie Whyte argues for a genuine free market, unregulated and free from government, even in the banking sector whereas Ferdinand Mount argued that it would be a ‘brave thing to do’, and it is  “rather terrifying”. Whyte argues however that the market is a mechanism for experiment and trial and thus there is no place for state regulation and subsidy. Banks should be allowed to fail. However, not bailing out the banks in 2008 would have been a brave thing to do, argued Mount, but he thinks ‘free market’ ideology will return.  Luigi Zingales (2012) supports Whyte in arguing that too much intervention creates perverse incentives. The State’s involvement in protecting money lent by the banks, means we have socialised the losses and privatised the gains. Free markets should apply to banks, they should not be bailed out, and government protection of their lending, subsidises the bank’s risks.

 

Neoliberalism, if defined as ‘small state’ and free markets, does not exist. If however ‘neoliberalism’ is understood as a discourse including ideas around individual liberty within free markets with minimal state intervention including cutting welfare programmes  aimed at the ordinary people, then it does. Its function is to reshape society by using the rhetoric of free markets while at the same time controlling certain markets though state intervention. Neoliberalism for the poor, socialism for the rich.

 

We have the data on wealth and income distribution, land ownership, offshore tax wealth, derivative values, corporate subsidies and the connections between the capitalist class executive and the political power elites which includes the military-industrial complex.  We know what money is, that it is not a physical commodity or has material existence in any form whatsoever (Harvey 2008, Pettifor 2017) and is therefore not in short supply. We know that it is now nothing more than a set of social relationships, ‘promises’, and thus is in infinite supply, but it is backed by judicial and ultimately military power. One reason we perhaps do not join the dots is too many of us have swallowed neoliberal ideology that argues ‘free markets and individual effort brings success’ while ignorant of its real effect to cover the actions of Capital which operate in rigged markets.

 

 

What should current neoliberalism look like?

 

The Adam Smith Institute (ASI) (https://www.adamsmith.org) is a free market think tank. It calls itself, “independent, non-profit and non-partisan…(to) promote neoliberal and free market ideas through research, publishing, media commentary and educational programmes”. Their priorities:

 

…are driven by a desire to rid the system of rent-seeking and inefficiencies that destroy wealth, and to create public services that are both innovative and in the hands of the people who use them, not the people who run them”.

 

The use of the word ‘neoliberal’ is interesting because it is not easily clear at first from the website that the ASI wants actually to be as neoliberal as Talbot’s ‘Nightwatchman’ state. It is not immediately obvious at first glance that they would wish to reduce public spending from 40% to 10% of GDP. However, the ASI published a blog on the level of public spending (as a % of GDP) that states that we are stuck with current levels “much as we ourselves would prefer the Hong Kong option”. Hong Kong’s spending ranges from 5.7% in 1960 to 10.9% and in 2015 was 9.15%. Therefore, buried in a blog an aim would be levels of spending equal to the ‘Nightwatchman’. The ASI believes in ‘market efficiency’:

 

  1. Low, simple, flat taxes that encourage investment and innovation, and hence economic growth (OK, need to read upon on that).

 

  1. A voucher-based education system that gives parents and schools complete freedom over how and where children are educated. (Hang on, vouchers, who is paying for that?)

 

  1. A privately-provided, publicly-funded healthcare system where patient outcomes, not NHS wages, are the focus. (what, publicly funded?)

 

  1. Freedom of trade with the world, and a liberal immigration system that is designed to work for migrants and natives alike.(open borders and requires ‘flexible’ labour markets?)

 

  1. A liberalised planning system that lets many more houses be built, so everyone can afford to own their own home. (so, environmental protection to go?)

 

  1. A simple welfare system based around a Negative Income Tax or Basic Income that tops up the wages of the poor and guarantees that work always pays. (basic Income…that’s more like it…something Marx would approve of)

 

  1. Free market money and an end to bailouts of private banks, in all their forms (Yes, nothing for a Marxist to disagree with).

 

 

 

 

The need to ‘rid the system of rent seeking’ echoes Thomas Picketty’s (2014) analysis of current capitalism and Marxist critiques of rentier forms of capitalism. The importance of wealth in attracting rent, is once again asserting itself as wealth grows faster than economic output. The ASI is sounding a bit marxist here.

 

Conclusion

 

If it is serious about a minimalist state and protection only for market transactions then free market/neoliberal ideology ought to be seeking to get private corporate and wealthy landowning snouts out of the State trough. In that, Marxists would agree. A free market should be just that. No bank bail outs, no subsidies for private schools in the form of charitable status; Oil, Gas and Nuclear power to stand on their own two feet; Farmers to earn from agriculture not government handouts; Aristocratic grouse moor owners likewise; Employers should pay what the market bears and not rely on working tax credits; Private health care companies should rely on what private individuals are willing to pay; Train operating companies should pay the full price of running the network and keep all of the profits from passengers while receiving no state funding; social care to be provided by charity, families or private individuals buying from care companies; private citizens should insure themselves for ill health and old age; Schools and Universities should compete in a market for students paid for by their parents or themselves with no state funding or through loans at market rates of interest; the road network sold off and motorists to pay to access; no housing benefit, no unemployment benefit, no sickness benefit, no pension unless paid for by private schemes, no business rates, no corporation tax; Free trade across borders with no tariffs, free movement of people, capital and services.  With the state off your back: “no income tax, no VAT, no money back, no guarantee…Good Bless Hooky Street” in a ‘Del Boy’ economy.  Libertarianism for all. Freedom from the State! Let the market decide!

 

A bit much?

 

The problem with neoliberalism and free market ideology is indeed a Hobbesian one: life could be ‘nasty, brutish and short’ as we compete one with another in a dog eat dog ‘ubermensch take the hindmost’ world.  And there’s the rub. Do they really mean it, or have they not only accepted a role for the state but embraced it for their own ends under the guise of ‘market efficiency’?

Appendix

 

  winning % Turn Out Total who did not vote

at all

Total Electorate

Who voted for

Thatcher 1979 44% 76% 24% 33%
1983 42% 72% 28% 30%
1987 42% 75% 25% 31%
Major 1992 42% 77% 23% 32%
Blair 1997 43% 71% 29% 30%
2001 41% 60% 40% 25%
2005 35% 61% 39% 21%
Cameron 2010 36% 65% 35% 23%
2015 37% 66% 34% 24%

 

 
Figure 1. Voter support for free market discourse. Increasingly it is the case that nearly a third (range 23% to 40%) or more of voters were either apathetic, disillusioned, disengaged or too distracted to bother to give their support for any political party.

 

 

Figure 2.     1900-2010 spending  as % of GDP

http://www.ukpublicspending.co.uk/past_spending

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 3. 1996-2017 spending as % of GDP.

 

 

The following two figures illustrates the degree of State involvement in the economy. The spending accounts for about 40% of GDP, leaving 60% going elsewhere. Spending on health, social care and social protection (pensions) accounts for £426 billion, that is over 50% of the total spend. Add £102 billion for education (total now is £528 Billion).

 

Who pays for that? Well, whoever pays Income tax, National Insurance, VAT, Council Tax and excise duties, accounts for £628 billion. What we have is redistribution from the 99.9% to the 99%.

 

‘Neoliberalism’ as rhetoric actually works for 0.01% – the plutocrats, the global capitalist executive, as Henry (2012) argues that anything between $21 to £31 trillion as of 2010 has been invested tax free in about 80 ‘offshore’ secrecy jurisdictions.

 

 

 

 

Figure 4. 2017 UK budget. Spending £802 billion

 

 

 

Figure 5 Revenues. £744 billion.

 

UK Budget:  https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/597467/spring_budget_2017_web.pdf accessed 22 march 2017

 

 

References

 

 

Angresano, J. (2016) A Corporate Welfare Economy. Routledge. London.

 

Beder, S. (2001) Neoliberal Think Tanks and Free Market Environmentalism.

Environmental Politics, 10(2), Summer 2001, 128-133.

 

Bergin, T. (2016) Britain’s Brexit subsidies for carmakers could top wage bills. Reuters Business news. November 2nd

http://uk.reuters.com/article/uk-britain-eu-nissan-subsidies-analysis-idUKKBN12X0K7 accessed 20 march 2017

 

Bruff, I, (2017) Authoritarian Neoliberalism and the Myth of Free Markets.

http://ppesydney.net/authoritarian-neoliberalism-myth-free-markets/ accessed 20 march 2017

 

Carlisle, S. (2001) ‘Inequalities in health: Contested explanations, shifting discourses and ambiguous policies’, Critical Public Health, 11: 3, 267 — 281

 

 

Desai, R. Neoliberalism and cultural nationalism Chapter 12 in Plehwe, D., Walpen, B., and Neunhoffer G. (2007) Neoliberal Hegemony: A Global Critique. London. Routledge.

 

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

 

Drutman, L .(2015) The Business of America is Lobbying: How Corporations became Politicised and Politics became more corporate. Oxford University Press. Oxford.

 

Feloni, B. (2017) Trump: We’re going to ‘cut regulations by 75%’ and impose a ‘very major border tax’. Business Insider UK. Available http://uk.businessinsider.com/trump-cut-regulation-border-tax-imports-2017-1?r=US&IR=T accessed 22 March 2017

 

Full Fact (2016) Do Farmers make more from subsidies than agriculture? August 11th.

https://fullfact.org/economy/farming-subsidies-uk/ accessed 20 march 2017

 

Hall, S. (2011) The Neoliberal Revolution. Cultural Studies. 25:6, 705-728

http://dx.doi.org/10.1080/09502386.2011.619886

 

Harvey, D. (2005) A brief history of Neoliberalism. Oxford. Blackwell

 

Harvey, D. (2008) Reading Marx’s Capital vol 1. Class 3 Chapter 3. Money, or the circulation of commodities

http://davidharvey.org/2008/06/marxs-capital-class-03/ accessed 20 march 2017

 

Hayek, F. (1944) The Road to Serfdom. London. Routledge.

 

Hayek, F. (1960) The Constitution of Liberty. University of Chicago Press. Chicago.

 

Henry, J. (2012) The Price of Offshore Revisited. Tax Justice Network. Available at http://www.taxjustice.net/wp-content/uploads/2014/04/Price_of_Offshore_Revisited_120722.pdf accessed 22March 2017

 

Monbiot, G. (2011) Its business that really rules us now. The Guardian 11 November.

https://www.theguardian.com/commentisfree/2013/nov/11/business-rules-lobbying-corporate-interests accessed 20 march 2017

 

Moshinsky, B. (2016) The global wealth pyramid is still topped by the 1% who own almost half of the world’s wealth. World Economic Forum. Online available at https://www.weforum.org/agenda/2016/11/the-distribution-of-global-wealth-has-stayed-just-as-skewed-as-last-year accessed 22 march 2017

 

Office for National Statistics (2015) The Effects of taxes and benefits on household income : financial year ending 2015. https://www.ons.gov.uk/peoplepopulationandcommunity/personalandhouseholdfinances/incomeandwealth/bulletins/theeffectsoftaxesandbenefitsonhouseholdincome/financialyearending2015 accessed 20 march 2017

 

Pallasch, A. (2010) ‘Best 5 Minutes of my life; His ’09 CNBC rant against mortgage bail outs for ‘losers’ ignited the Tea Party movement’ Chicago Sun-Times.

 

Pettifor, A. (2017) The Production of Money; how to break the power of the banks. Verso. London

 

Picketty, T. (2014) Capital in the Twenty-First century. Harvard. United States

 

Press Association (2016) The Queen, aristocrats, and Saudi prince among recipients of EU farm subsidies.

https://www.theguardian.com/environment/2016/sep/29/the-queen-aristocrats-and-saudi-prince-among-recipients-of-eu-farm-subsidies accessed 20 march 2017

 

Ranelagh, R. (1991) Thatcher’s People:  An Insider’s Account of the Politics, the Power, and the Personalities.  London:  HarperCollins.

 

Ryan, A. (1993) ‘Liberalism’ pp 291-311 in Goodin, R and Pettit, P. (eds) A companion to Contemporary Political Philosophy. Oxford. Blackwell.

 

Saad-Filho, A. and Johnson, D. (2005). Neoliberalism – a critical reader. London. Pluto Press

 

 

Saez, E. and Zucman, G. (2014) Wealth inequality in the United States since 1913: Evidence from capitalized income tax data National Bureau of Economics Research Working Paper, October 2014. Available at http://www.nber.org/papers/w20625 accessed 22 march 2017

 

 

Saner, E. (2017) ‘Theresa May’s cabinet: pretty rich, but nothing on Trump’s’. The Guardian online. Available at https://www.theguardian.com/business/shortcuts/2017/jan/17/theresa-mays-cabinet-pretty-rich-but-nothing-on-trumps accessed 22 march 2017

 

 

Scambler, G. (2012) GBH: Greedy Bastards and Health Inequalities. Available at:

https://grahamscambler.wordpress.com/2012/11/04/gbhgreedybastards-andhealthinequalities/  accessed 20 march 2017

 

Smith, D. (2016) ‘Trump’s billionaire cabinet could be the wealthiest administration ever’. The Guardian online 2 December available at https://www.theguardian.com/us-news/2016/dec/02/trumps-rich-pickings-president-elects-team-could-be-wealthiest-ever accessed 22 March 2017

 

Springer, S. (2016) Fuck Neoliberalism. ACME 15 (2)

https://ojs.unbc.ca/index.php/acme/article/view/1342/1172 accessed 20 march 2017

 

Talbot, C. (2016) The Myth of Neoliberalism.

https://colinrtalbot.wordpress.com/2016/08/31/the-myth-of-neoliberalism/ accessed 20 march 2017

 

The Economist (2012) Corporate lobbying. The Chamber of Secrets. The biggest business lobby in the United States is more influential than ever. April 21.

http://www.economist.com/node/21553020 accessed 20 march 2017

 

 

Thorsen, D. and Lie, A. (2017) Kva er nyliberalisme? Nyliberalisme – ideer og politisk virkelighet? What is neoliberalism? Neoliberalism ideas and political reality?  Online. Available at http://folk.uio.no/daget/neoliberalism.pdf  accessed 22 March 2017

 

 

Thorsen, D. (2009) The Neoliberal Challenge. What is neoliberalism? Working Paper October 10. University of Oslo. Available at http://folk.uio.no/daget/neoliberalism2.pdf accessed 22 March 2017.

 

 

Traynor I (2014) 30,000 lobbyists and counting: is Brussels under corporate sway? The Guardian 8 May.

https://www.theguardian.com/world/2014/may/08/lobbyists-european-parliament-brussels-corporate accessed 20 march 2017

 

United States Department of Agriculture (2016) USDA to purchase cheese for Food banks and Families in need, Continue to assist dairy producers.

https://www.usda.gov/media/press-releases/2016/08/23/usda-purchase-surplus-cheese-food-banks-and-families-need-continue accessed 20 march 2017

 

Ward, A. (2016) Subsidy for Hinkley nuclear power station quintuples to £30 billion. Financial Times. July 13

https://www.ft.com/content/b8e24306-48e5-11e6-8d68-72e9211e86ab accessed 20 march 2017

 

Whyte, J. (2012) Keeping the Free Market Faith. BBC Analysis. October.

http://www.bbc.co.uk/programmes/b01n625z accessed 20 march 2017

 

Zingales, L. (2012) A Capitalism for the People: Recapturing the Lost Genius of American Prosperity. New York.NY: Basic Books

How responsible am I for my health 2

How responsible am I for my health?

 

The answer to that question from the dominant discourse is an overwhelming “very”.

This response sits alongside more scholarly understandings of the social determinants of health.  This ‘upstream’ understanding is open to ‘Lifestyle Drift’ , ‘downstream’, responses to health. Lifestyle Drift is:

“the tendency for policy to start off recognizing the need for action on upstream social determinants of health inequalities only to drift downstream to focus largely on individual lifestyle factors” (Popay et al 2010)

McKenzie et al (2016) argue:

“Although policy documents may state that the causes of poor health or inequalities in health are to do with poverty and deprivation, the interventions which actually operate on the ground focus much less (if at all) on changing people’s material circumstances and rather more on trying to change behaviours (which are in fact heavily shaped by material circumstances)”.

Nurses might understand the concept of the social gradient in health inequalities but drift into advocating lifestyle changes for the individual, centring around smoking, diet, and exercise messages.

So why is this happening? Why resort to lifestyle approaches to health when we know health is largely socially and politically determined?

 

One answer is that lifestyle answers fit within the neoliberal social imaginary which individualises health and social problems and seeks market solutions to those problems. Neoliberalism is a doctrine well known to many scholars and academics but is hardly mentioned in popular discourse.  To understand responses to health inequalities and poverty , we need to understand the tenets of neoliberalism underpinning much of current thinking:

 

  • Neoliberalism sees competition as the defining characteristic of human relations. Therefore competition between service providers should be introduced into the NHS.
  • It redefines citizens as consumers, whose democratic choices are best exercised by buying and selling, a process that rewards merit and punishes inefficiency. So patients can and should choose between hospitals and GP practices as consumers of health care using their purchasing power (not yet realised in the NHS). This way, poor service providers should go out of business.
  • It maintains that “the market” delivers benefits that could never be achieved by planning. Therefore NHS = bad, US private health insurance = good; BBC = bad,  SKY/Fox = good;  British Rail = bad, Great Western/Virgin = good; Royal Mail (state owned) = bad, Royal Mail (privately owned) = good.
  • Attempts to limit competition are treated as inimical to liberty. Thus socialised NHS service provision must be broken up to allow freedom in the market. The BBC must be sold off because it is unfair competition for Sky.
  • Tax and regulation should be minimised, thus the use of offshore tax havens, reduction in top rate of tax, mistrust of EU environmental standards and hatred of health and safety regulations.
  • Public services should be privatised. The Health and Social Care Act 2012 facilitates this, there may well be more to come for the NHS.
  • The organisation of labour and collective bargaining by trade unions are portrayed as market distortions, that impede the formation of a natural hierarchy of winners and losers. Unison, RCN, BMA etc, must have their power curtailed. The Junior doctors cannot be allowed to win or else it will be a victory for organised labour.
  • Inequality is recast as virtuous: a reward for utility and a generator of wealth, which trickles down to enrich everyone. Those at the bottom require incentives to better themselves, therefore benefits need cutting, those in the middle will benefit from wealth creation.
  • Efforts to create a more equal society are both counter-productive and morally corrosive. The market ensures that everyone gets what they deserve. The arguments from books such as ‘The Spirit Level’ are therefore irrelevant. If there is a social gradient in health then this is the natural outcome of people’s decisions and choices and any attempt to change this invokes  ‘moral hazard’ arguments; that is if people know they have a safety net (someone else takes the risk) they will not try to avoid poor choices.

(Monbiot 2016 The Zombie Doctrine)

 

 

 

Tory Rituals on poverty:

 

 

·         Blame the individual for their illness and poverty.

·         Benefits cause dependency , repeat this ad nauseam.

·         Deny any political responsibility for ill health, emphasise culture as causative.

·         Divide population into:  skivers v strivers, deserving v undeserving poor, low achievers v high achievers.

·         Deny the ‘social’ exists, there are only individuals

·         Privilege wealth through tax breaks and preferential treatment.

·         Deny one’s own privilege as a white affluent male.

 

 

These attitudes underpin the ideology of neoliberalism.

 

For a statement about what the Conservative Party should be about see:Direct Democracy – an agenda for a new model party’ (2005) especially the chapter on health:

 

 

“The problem with the NHS is not one of resources. Rather, it is that the system remains a centrally run, state monopoly, designed over half a century ago”.

 

 

 

All of this results in the politics of blame and shifting responsibility for health fully onto individuals.

If material health assets are paramount, poverty and our response to it is a foundation for understanding health in society. Poverty can be defined as 60% of the median income or using the ‘consensual method’  it is “enforced lack of necessities determined by public opinion”.

However, the UK government’s position is that poverty is not caused by lack of income. Based on Charles Murray’s idea of the ‘Culture of Poverty’, poverty is a result of individual deficits, as Kitty Jones writes:

“the poor have earned their position in society, the poor deserve to be poor because this is a reflection of their lack of qualities, poor character and level of abilities”.

Kitty Jones has written clearly on this issue in 3 blogs, which can be found here.

The alternative view, expressed in for example the ‘Greedy Bastards Hypothesis’ is that poverty, and health inequalities, is caused by the rich, often through unintended consequences of their actions but also through design. It results from structural socio economic conditions that neoliberal governments encourage: for example, low wages, withdrawal of benefit provision and the use of offshore tax regimes. Osborne’s ‘living wage’ is a cynical political manoeuvre designed to woo middling swing voters rather than to address structural economic issues such as under and unemployment , lack of investment in a green economy, deficits in the housing stock and affordability and a zero hours, self employed precarious job structure.

 

Nurses offering health advice, are not immune to this dominant discourse. It suffuses health advice on such sites as NHS choices and is supported by health campaigns which focus on changing individual habits. Action on social inequalities as root causes for ill health sits within specialised public health literature, for example ‘Fair Society,  Healthy Lives’, and unless nurses are exposed to an alternative perspective they will naturally draw upon dominant explanations for health inequalities. These are often either biologically/hereditarian explanations* or a ‘moral underclass discourse’ (Ruth Levitas) or a mix of the two. The politics of neoliberalism encourages the latter perspective.

 

 

Benny Goodman 2016

 

*See Chapter 4 in Psychology and Sociology in Nursing  Goodman 2015 for explanations.

Watch Richard Wilkinson discuss inequalities at a TED talk.

https://www.facebook.com/groups/Sociologyhealthnursing/

 

 

 

 

 

 

Why do nurses behave as they do?

Subject Positions Theory.   Why do individual nurses behave as they do?

SPT tries to explain how ‘subjects’ will behave in certain situations. It can be used to explore what ‘positions’ we take up and what identities we either assume or refuse within a social context that is characterised by power relationships. It allows the question about how powerful ‘others’ (i.e. Health Secretaries, CEOs, Consultants, Managers) position the relatively powerless ‘subject’ (staff nurse, patient) into certain subject positions (e.g. handmaiden, passive recipient) simply through an unconscious, uncriticised and shared language, discourse and power. Objective formal power involving clear boundaries, sanctions and authority also operate in social relationships. Objective formal power needs to be called out, and its foundation clearly described as operating often on an unspoken ideology. In the current context of health care delivery, that ideology is founded upon the twin pillars of neoliberalism and managerialism. These are macro level positions, whereas SPT allows exploration of informal power at the micro level that might go otherwise unanalysed.

 

The ‘subject’ within this theory refers to the individual human being who engages in creating an identity and does so partly by being the ‘subject’ of language, discourses and power relationships. The subject position, or identity, one takes is created by language, discourse and power and in doing so also creates that identity. This operates within a set of social relationships that are characterised by differences such as ethnicity, sexuality, gender and class. These relationships are also relationships of power. They operate through and within language. Our subject positions are partly defined by others unless we recognise the process of positioning and resist it. However, a good deal of positioning by others can be successful because we take subject positions often unconsciously. We have already accepted the language, discourse and power of others. Within any social interaction, powerful ‘others’ may engage in ‘interpellation’ (Althusser 1989). They ‘call’ us into a subject position by our intersubjective acceptance of the language, discourse and power of the other.

 

When a doctor, or manager, calls upon a nurse to do something, they are often ‘interpellating’ the nurse into a subject position of obedience to a medical or hierarchical regime. This can only work if the nurse recognises and accepts the subject position of junior partner. This process of identification creates an identity. The doctor identifies the nurse and the ‘subject’ within the nurse becomes a nurse. The subjective ‘I’, which in other social situations is not identified as a nurse, now becomes one. This is not to be confused with the formal title that the qualification RN bestows upon someone. Merely having been registered with the Nursing and Midwifery council does not identify a subject as a ‘nurse’, it is merely a formal recognition of one’s status on a register. One becomes and assumes the identity of nurse through social interaction and the ‘interpellation’ of others. A nurse is a nurse only when others say so within a social context. Upon leaving the clinical setting, the subjective ‘I’ is now free to assume other identities such as mother, friend, runner or dancer.

 

When a nurse is called in this manner, it may well be the case that the nurse recognises this calling, and that the subjective ‘I’ is now the subject position of ‘me’ as nurse. This operates through the unconscious acceptance of that subject position. Through such mechanisms as ‘occupational socialisation’ the calling out of ‘me as nurse’ feels natural and in that acceptance further cements this identity. The nurse has been ‘recruited’ into that subject position and over time bonds with that identity and its underlying ideological sets of discourses and power relationships that go with it.

 

Within the occupation of nursing there may be a number of subject positions open to individual nurses. Some of those positions are overt and openly discussed, others operate within the covert, intersubjective, lifeworld of nursing. Thus, nurses assume certain subject positions, such as ‘nurse advocate’, and attempt to assume this identity to further patient care. In doing so, do other ‘powerful subjects’ may position the ‘nurse advocate’ identity into one of ‘whistleblower’ or ‘uppity nurse’, ‘non-medical care worker’ or ‘junior partner’.

 

Potential Subject Positions that might be open to nurses: they operate as binaries – one position is assumed other is an ‘abject’ position.

 

·       Advocate/Non advocate

·       Carer/patient

·       Empathiser/task completer

·       Doer/Organiser

·       Whistleblower/Compliant worker

·       Educator/Student

·       Trainer/Trainee

·       Supervisor/worker

·       Female/male

·       Good nurse/uppity nurse

·       Coper/Whinger

·       Emotional supporter/distant professional

·       Responder/avoider

 

 

‘Subjects’ have the ability to occupy and move between a variety of identities, or ‘subject positions’, within an interaction in the clinical setting but this depends on the power dynamics and context of that exchange. We can therefore try to analyse in any given interaction what those power dynamics are and what the context consists of. So, how do nurses either comply with or resist positioning for example as a ‘doer’ within a power struggle?

 

Lacan (1977) suggests we assume identities, or positions, in response to punishments or threats of punishment. In the clinical context that might include bullying, intimidation, snubbing, patronising language or lack of promotion. The fear of punishment arises out of ‘knowing’ the rules of interaction and being aware of power and the rules of hierarchy.

 

Once an identity has been assumed it is associated with a particular discourse, i.e. a stock of words, phrases, concepts, theories, that support and explain the position taken. The subject position of nurse, according, to society, should display feminine attributes based in an ethic of care. The discourse associated with this is about being a ‘good nurse’ emphasising nurturance, obedience, support, listening and helping. This recently has been given even more support through emphasising the 6 Cs. This sits in opposition to critical advocacy especially in relation to the medical profession and NHS management. The discourse available to critical advocacy emphasises challenge, assertiveness, rights, and standards. The subject position of whistleblower is similarly contradictory, at once being that of advocate and patient champion while the reality is also one of irritant, turncoat and rebel to the hierarchies of power. SPT requires a critical theory of power to move beyond analysis at the micro level to critique of power structures (be they gendered, class, managerial) at the macro.

 

Clinical decision making, such as advocating a certain course of action such as moving an older person within the hospital at night, or changing the operating list to avoid delays, or getting analgesia prescribed, operates within this matrix of subject positions involving negotiating the social order of hierarchy and power. Sundin-Huard (2001) argues the subject position of advocate is countered by the subject position of ‘good nurse’ in that in exercising advocacy the nurse threatens the identity of ‘good nurse’ and becomes the ‘uppity nurse’. A vignette illustrating this positioning is used as an exemplar. In the vignette, a neonatal nurse advocates, unsuccessfully, for analgesia as she is positioned and assumes the position of advocate and uppity nurse. In the training film ‘just a routine operation’, two nurses are similarly positioned as ‘junior without formal decision making power’ within a critical airway emergency in theatre. The resulting death of the patient in that scenario clearly demonstrates that this analysis is no mere sociological abstraction.

 

Conclusion

 

Nursing does not operate in a neutral power context. Nurses work in a gendered occupation underpinned by a range of discourses using certain languages that often position them into subordination. Those in formal power positions also understand these discourses and through language use can ‘call’ nurses into subordinate and contradictory subject positions. Hierarchies of gender, class and occupation provide the context for these positionings to take place. In order to minimise moral distress and the burden of emotional labour, nurses require an emancipatory understanding of these taken for granted power plays to enable practical resistance to develop. In this they can be aided by the discourse of humanism recognising the requirement for patient safety, comfort and cleanliness in the provision of quality care. The nurse who feels emotional and moral distress as a result of the actions and omissions of other power actors in the workplace, requires an analysis of the basis of this power relationship so that rather than turning in on oneself in defeat, a resistance can be mounted by creating alternative languages, discourses and power bases. Resilience in the face of threat in this context is not enough. Nurses need to find a language to speak truth to power and then forge political alliances with other actors, e.g. patient advocacy groups, to create alternative visions and structures to that which is advocated by neoliberals and the dead hand of managerialism.

 

 

 

 

 

 

 

Althusser, L. (1989). ‘Ideology and ideological state apparatuses’ in Lenin and Philosophy and other Essays: pp 170-186. London. New Left Books.

 

Lacan, J. (1977). Écrits: A Selection. Trans. Alan Sheridan. New York: Norton

 

Sundin-Huard D. Subject Positions Theory. Understanding conflict and collaboration in critical care. (2001). Journal of Advanced Nursing 34 (3) pp 376-382

Feminist poststructuralism as a lens towards understanding obesity.

More than meets the eye.

Feminist poststructuralism as a lens towards understanding obesity.

Firstly this paper by Aston et al (2011) opens by accepting the framing of obesity as a health emergency or ‘concern’ and it does so by referencing the World Health Organisation’s (2011) ‘global epidemic’ phrase. Thus it contributes to a value position that obesity is indeed a medical issue with negative health consequences. The position is then taken that obesity is a ‘disease’ arising out of social and environmental conditions. That is to say it accepts that obesity is a disease but that its causes are not rooted only within individuals and their behaviour but as arising from their social position and the environment they live in (the ‘obesogenic’ environment).  They argue “Obesity now represents a major public health issue” (p1188) and according to the WHO (1998) is the second most modifiable cause of ill health after smoking. Aston et al use the word alarming to describe Canada’s population where 60% are overweight or obese. The issue as to whether obesity is simply a disease that needs curing regardless whether its aetiology is individual or social, is open to question. However for the purposes of this paper I wish to explore what feminist post structuralism (FPS) can bring to understanding obesity.

Feminist Post Structuralism.

Aston et al argue that FPS seeks to understand the meaning and experience of obesity as arising from our social relationships. It also seeks to understand how power relationships work between individuals as they are constructed through social, institutional and political structures. In other words, what are the power relationships involved in for example daughter-mother family relationships “mum’s on a diet again…and my bum does look big in this!” (social); worker-employer relationships “oi!  lard arse, get off yer bum back in the office or we’ll put you on a fitness course!” (institutional);  and patient-health policy relationships “I note Mrs Jones, that you BMI is well into the overweight category…we need to reduce that to reduce your risk of diabetes and heart disease…what weight loss programme shall we use, have you seen Change for life?” (policy-political),  and how do they affect the individual’s life experiences and chances? In this context, we would seek to examine the talk between the ‘fat’ and the nurse, we would want to understand both their beliefs and values and stereotypes and how this talk and interaction (including body language) constructs the experience of being fat in this encounter. This also examines how the fat are observed and measured, what questions are asked of them and how those questions are put to them and what solutions are put forward (e.g. eat less, exercise more!).

FPS seeks to examine the personal experiences, the relationships people have, and how they understand how power operates in each social setting, be it the family, the workplace or the health clinic. This point of view (perspective) accepts that life is social and therefore our personal experiences (personal troubles) can be understood through examining how social, cultural and institutional beliefs, stereotypes and norms (public issues) affect us.

This perspective is an alternative to a medical discourse (a medical way of thinking and talking about) which accepts as axiomatic, as self-evident, that a person’s health is predominantly under the control of the individual. Therefore a good deal of research within this sort of thinking seeks to understand obesity as arising from psychological and genetic factors and examines personal behaviours  involved in weight gain.

Furthermore, health interventions and health professionals may tacitly accept this medical discourse and design interventions around changing personal and behavioural factors (e.g. ‘Change for Life’). This approach has not and will not work. It is largely ineffective in reversing population obesity. Roberts and Edwards (2010) in ‘The Energy Glut’ suggest that whole populations across the globe are ‘getting fatter’; waist circumference and BMI measurements are increasing in developing as well as developed nations. If obesity needs to be understood as part of social relationships and relationships of power at that, then we need to challenge the notion of obesity as only a personal problem (a personal trouble). Applying the sociological imagination (Wright Mills 1959) to obesity we would seek to understand the personal trouble of obesity as a public issue, relating the personal biography of the ‘fat’ individual to historical changes and social structures.

So how does FPS throw light upon this issue?

1.      By focusing on discourse.

2.      By focusing on power relationships.

3.      By focusing on subjectivity (one’s ‘subject position’) and agency.

Discourse.

One’s experience, beliefs and values are shaped by and shape the language we use about obesity. By examining how we talk about it to uncover our stereotypes and beliefs allows us to clarify our personal understanding and how we come to our understanding. When we listen to healthcare professionals talking about obesity as a disease and the need for personal responsibility for behavioural change we may believe that it is down to us to eat less and exercise more. After all that is the main message. We may even use this language to describe our battle with weight.

Power

Individuals and groups have the power to impose a discourse onto interactions. These are supported by contextual factors (where that interaction takes place, for example the GP surgery). Health policies such as Change for Life position the fat as needing to take personal responsibility.  Being overweight and its negative connotations is supported by medical research into the health risks and positions it as a ‘bad thing’. The fat can’t challenge this discourse as they don’t have a counter position. There are plenty of places where fat is seen as negative and as a disease (hospitals, clinics, surgeries, health centres, leisure and sports centres) and where it fat and fat people are excluded except as negative stereotypes (magazines, film and TV programmes, advertising, jokes, comedy).

Subjectivity and Agency.

We can come to see our subjective selves as being constructed through the above discourses and power relationships but through our agency (our ability to act) can come to challenge dominate negative or ‘disease’ discourses through dialogue, research, speaking out and open communication. So, on the one hand our subjective self can be beaten down with an acceptance that it is my personal responsibility to get thin and if I cannot then it is my fault. My subjective self may even accept the need for doing so in an attempt to align my body image with some thin ideal and as part of healthy living to prevent disease. I may accept that I am already ‘ill’ by being overweight. However by engaging my ‘agency’, my ability to act, I may challenge some of these assumptions and want evidence for the positions taken. For example, at what stage does extra weight really become unhealthy? How do I balance enjoying life with all that it offers with a rigid abstinence regime in the hope of achieving a thin ideal? Do I want to live longer as a thin person (if that is actually what may occur) if I have to count every calorie and give up beer?

“You call me fat, I feel fat, but actually I don’t think it is my fault entirely…this is not about blame or making me out to be a victim…you have to realise that the food choices I am faced with, the transport options I have are having an impact. It is not easy to change everything about my life when society continues to encourage weight gain. In any case the athletic thin ideal is unobtainable for me and I like a glass of wine and cheese, it what makes for a bon viveur”.

 

However, what is so F about FPS?

It seems clear from the paper that we need to challenge health, media, medicine and education organisations in their understanding about obesity. Society and the healthcare system has to recognise that the modernisation of our world (Wright Mills’ historical and structural changes) has set the global populations up for failure with respect to maintaining a healthy body weight through increases in opportunity for food intake and decreases in opportunity for energy expenditure, but I fail to see the feminism in this piece. What is the gendered nature of social relationships which would presumably affect women’s experiences? This paper does not make that clear. The obese in this paper are neither  male or female.

Aston M, Price S, Kirk S, and Penney T. (2011) More than meets the eye. Feminist poststructuralism as a lens towards understanding obesity. Journal of Advanced Nursing.

Benny Goodman. 2012

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