Tag: inequality

The richest 1,000 people have more wealth than the poorest 40% of households (UK)

The richest 1,000 people in the UK have more wealth than the poorest 40% of UK households. The 1,000 richest saw their wealth increase by a staggering £82.5 billion last year, the equivalent of £226 million a day, or £2,615 a second.

The Equality Trust has found that this increase in wealth of £82.5 billion could:

Pay the energy bills of all 25.6 million UK households for two and a half years. Cost = £79.15 billion OR

Provide 5,143,819 million Living Wage jobs , or 2,923,333 million jobs paid at an average salary for a year. Cost = £82.476 billion OR

Pay the grocery bill for all of the UK’s users of food banks for 56 years . Cost = £81.5 billion OR

Pay two years’ rent for 4.5 million households (4,528,000 households) . Cost = £72.1 billion OR

Pay for 68% of the budget for the NHS in England Cost = £81.6 billion
Pay for 4 years of adult social care in England . Cost = £78.8 billion.

This totally unearned bonanza needs justifying somehow. It arises merely from the structure of wealth ownership, tax laws, and property holdings. The beneficiaries had to do little beyond what they currently own or do to enjoy this largesse.

One justification for the support of the current social structure of wealth ownership and control is that these people pay in absolute terms a good deal of tax. If you are destitute at least you don’t pay tax. Consider however that if one paid tax on income on say, £1,000,000, under current tax rates you would still get £540,676 per year. You pay nearly 44% of your income.

The median in the U.K. in 2017 is £27,000. Thus you take home £21, 641. You pay 20% of your income. You take home 4% of what the high earner does.

The millionaire pays as much tax in one year (£458,000) as a the median earner would (£5,200 pa) in 88 years. This is of course ‘inequality’.

So for every 1 person receiving £1,000,000, you’d need 88 on the median. Impossible of course due to what median means. The top 1000 get, receive, not ‘earn’, considerably more than what to them what would be a miserable £1,000,000 pa.

Those who earn up to the £150,000 threshold of 40% take home £90,176. Each extra pound they then get is taxed at 45%. What if that tax rate was 90%? This would mean someone getting £200,000 would receive £90,176 up to the £150,000 threshold and then another £5,000 taking it to £95,176. Someone getting £1,000,000 would after tax get £90,176 + £98,500 = £188,676.

The price of a loaf of bread would be the same.

So even at 90% marginal tax rates over the threshold, a millionaire would not have to worry about paying utility bills. Yes they pay more tax, but what’s left for them is hardly destitution. I digress. Millionaires to the 0.01% are paupers. Billionaires can avoid paying any taxes at all.

A second justification is that they are the ‘wealth creators’ and so deserve it all. I will not unpick this here because the rebuff is as obvious as the claim is spurious.

A third justification is that changing this structure would lead to economic chaos and left wing totalitarianism. This sets up a false dichotomy of either keeping hold of wealth or descent into tyranny.

A fourth justification is that the wealthy need to get ‘rewarded’ as they operate in a competing market, and that pay rates merely reflects market forces at work? Well, indeed but should that really be a plea to hold on to vast amounts of wealth? Are you really saying that you are miffed because someone else gets £5,000,000 pa while you get a ‘paltry’ £2,000,000 ?

There is a fifth technical justification – the Laffer Curve:

“In economics, the Laffer curve is a representation of the relationship between rates of taxation and the resulting levels of government revenue. Proponents of the Laffer curve claim that it illustrates the concept of taxable income elasticity—i.e., taxable income will change in response to changes in the rate of taxation.

The Laffer curve postulates that no tax revenue will be raised at the extreme tax rates of 0% and 100% and that there must be at least one rate which maximizes government taxation revenue. The Laffer curve is typically represented as a graph which starts at 0% tax with zero revenue, rises to a maximum rate of revenue at an intermediate rate of taxation, and then falls again to zero revenue at a 100% tax rate. The shape of the curve is uncertain and disputed.

One implication of the Laffer curve is that increasing tax rates beyond a certain point will be counter-productive for raising further tax revenue. A hypothetical Laffer curve for any given economy can only be estimated and such estimates are controversial. The New Palgrave Dictionary of Economics reports that estimates of revenue-maximizing tax rates have varied widely, with a mid-range of around 70%. Generally, economists have found little support for the claim that tax cuts from current rates increase tax revenues or that most taxes are on the side of the Laffer curve where additional cuts could increase government revenue.

Although economist Arthur Laffer does not claim to have invented the Laffer curve concept, it was popularized in the United States with policymakers following an afternoon meeting with Ford Administration officials Dick Cheney and Donald Rumsfeld in 1974 in which he reportedly sketched the curve on a napkin to illustrate his argument.”

See: Laffer Curve

If all else fails, fall back on classic economic models which are of course nothing more than mathematical representations of actual human behaviour in particular social and political contexts. They do not operate like the laws of physics. Hence they can easily change given different contexts.

With these vacuous and self serving justifications, the 1% keep the status quo going. Every society needs a unifying myth, and the powerful 1% need one even more so. Monarchy, Nation State, and ‘Free Market’ Capitalism (note: not financial/rentier/crony capitalism) are used as unifying myths to merely cover wealth and privilege. It is why right wing politics intuitively support monarchy, church and the flag because if those are dismissed by critics then that only leaves the theory of free market neoliberal capitalism as a defence against ‘the underclass’.

You decide if this level of wealth appropriation is good for social cohesion and health inequalities.

Poverty Privilege and Health

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

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

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

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

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

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

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

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

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

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

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

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

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

The losers get sick.

The losers get poor.

The losers get defeated.

The losers get mad.

The losers get even.

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

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

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

Inequality, the Gini coefficient, does it matter?

Inequality (Income) and the Gini Coefficient.

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

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

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


Gini Coefficient and the Palma ratio

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


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


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


Larry Elliot (2017 see link below) argues: “The ONS’s estimate of the Gini coefficient comes from its annual publication The Effects of Taxes and Benefits on Household Income (ETB). This shows that inequality peaked at around 0.37 at the end of the 1980s, was still at around 0.35 in the mid-2000s, and has fallen to around 0.32, according to the latest available data.Turn to the DWP and it is a different story. The Gini coefficient is higher than it is according to the ONS (0.35 before housing costs) and on an upward trend.”

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


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


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


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

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

Reasons, say the IFS include:

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


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

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

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

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

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

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


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



Update 2017: Income inequality is getting wider. If the stats count what counts.






Choose your parents

Alejandro Nieto.

Bernal Heights. San Francisco.

What has the death of a young man, shot by four police officers in a park in California got to do with with understanding health outcomes in the United Kingdom?

Mary Sue and Miriam. Two women born at similar times whose grandparents came from the same small town in the United States. One will be going to an Ivy League University while the other struggles with drugs and hopelessness writing on her Facebook page ‘Love hurts, Trust is dangerous’.

What links them is that Alejandro and Mary Sue ‘chose the wrong parents’, while Miriam chose wisely, a Harvard professor for a grandfather (Robert Putnam), and University educated parents.

Their cases illustrate that health and well being is ‘structured but not determined’, that to truly understand their life chances we have to consider the transformations in society that impact on the choices made and opportunities open to individuals and their families.

Alejandro was born to Mexican immigrants who came to San Francisco in the 1970’s. His mother worked all her life while his father took on most of the child care duties. San Francisco has a history of immigrants from other parts of the US as well as from elsewhere. Being Hispanic in California is ‘normal’ but not to the white, male, educated tech engineers from Silicon Valley who have moved to the area en mass ushering in gentrification and myopia. Alejandro was described to the Police as probably ‘foreign’ who had a gun, his red jacket marking him out as a gang member. All of this was supposition and assumption. Alejandro had lived in Bernal Heights all of his life, the gun was a taser, carried because he worked as a security guard. His red jacket was a sports jacket, the colour of the local sports team the 49’ers. Those doing the describing were white tech engineers making assumptions about behaviour. Indeed, Alejandro was holding a taser, but he had just been harassed by a dog barking and jumping up at him to get at his chips. The dog owner was 40 feet away, distracted by a ‘jogger’s butt’ and unable to keep his dog under control.

The police arrived, and shot him, one unloading over 20 bullets and had to reload.

Alejandro, Mary Sue and Miriam live at a time when the United States is experiencing growing inequalities in wealth, segregation in its communities, family instability and a collapse of both good working class jobs now being followed by a squeeze on middle class opportunities. While the wealth of the 1% has increased based on their increased share of wealth being created – they are getting an even bigger slice of the pie, working class incomes have stagnated. Mary Sue’s grandfather used to have a decent income from a solidly working class job, now gone leaving ‘flexible’, low paid insecure work.

As economies restructure, as cities adapt to new social conditions, people experience changing social structures that enhance or diminish their chances. The white Ivy League tech engineers are likely to know only other white Ivy Leaguers, to come from Ivy League parents, went to the same schools and know only their own kind in a networked bubble of privilege, social myopia and self satisfying smugness. They don’t know the ‘other’ and can thus label a sports fan as a gang member with in this case lethal consequences.

Perhaps representing their views:

“I know people are frustrated about gentrification happening in the city, but the reality is, we live in a free market society. The wealthy working people have earned their right to live in the city. They went out, got an education, work hard, and earned it. I shouldn’t have to worry about being accosted. I shouldn’t have to see the pain, struggle, and despair of homeless people to and from my way to work every day.”


So ‘free market society’ justifies the breakdown of community, segregation, inequality, fear and mistrust. Wealth is ‘earned’ rather than a result of circumstances (right time, right family, right ethnicity, right gender, right neighbourhood, right education, right opportunities and often the inheritance of not only financial but social and cultural capital). Indeed, no one should have be be accosted, no one should see pain and struggle and despair, but don’t blame the victims of unjust social, political and economic systems. Don’t blame the dog for barking when someone’s kicked it.

Alejandro’s ‘personal trouble’ (being shot) is now a public issue. When only one young man is shot by police, we might consider the character of the man and look to him as an individual for reasons and solutions. When hundreds of young men are being shot by police this individual analysis is no longer useful, we must look to social structures, to link personal stories to this point in time in this particular society.

Miriam can look forward to a bright future, she experienced great parenting, great education backed up of course by well resourced material assets. Mary Sue, is a single parent with no education, self harm, a drug habit and abusive partners. Her child will very probably not go to Harvard. Alejandro made the mistake of being born Hispanic and thus a potential threat to the White denizens of a newly gentrified neighbourhood.

If you are struggling to apply this to the UK context, you don’t know the truth and you lack the ‘sociological imagination’.

Alejandro’s story is in Rebecca Solnit ‘Death by Gentrification’. Opinion. The Guardian. March 22nd 2016.
Mary Sue and Miriam’s story is in a talk by Robert Putnam to the RSA in London, March 2015, on ‘Inequality and the Opportunity Gap’. https://www.thersa.org/discover/videos/event-videos/2015/10/robert-putnam-on-inequality-and-opportunity/#

Tory Bollocks

Ian Duncan Smith, on the Andrew Marr show Sunday 6th December 2015, in response to Tristram Hunts’ argument for the Labour Party to focus on Inequality, and not just income inequality but on wealth and assets, argued that 1) we need a healthy economy to pay for public services such as child support and 2) that income inequality was falling.

The first is the standard response to such issues. It is the justification for switching government support towards lowering taxes on business, inheritance, the rich (the 0.1%), land and investing in research and development, and of course lowering spending on ‘non productive’ sectors of the economy, i.e. the sick, disabled, unemployed and pensioners. The low paid should not have government support either, as this is actually a subsidy to employers. Low pay in this view also acts as an incentive to work harder, to get education or take up opportunities in order to break out of poverty. In addition, low pay is a result of global competition and is the market in action. Government involvement distorts the ‘natural’ workings of the market. A healthy economy then results from low taxes and minimal regulation in business activity. A 0% tax on capital is thus the ideal, because it is argued that it is capital investment that creates jobs.

There is also an assumption, a belief, that the economy as it stands today cannot afford public services at the current level. This is based on a particular view of what the ‘economy’ is, i.e. that it is that which is described in the budget by government taxes, receipts and expenditures. Wealth in the form of assets and land, is outside of this economy and is in a sense sacrosant. The former, it is believed, means that there is little money and what there is requires redirection towards wealth creation rather than social redistribution. The former also now has to be in surplus, the government receiving more than it spends. This will be achieved it is hoped by cutting spending and hoping for growth in the economy.

This view of the economy is also grounded in a mystification – that we can actually talk of the ‘economy’ as existing as a thing in itself. This model has no conception that the economy is a set of social relationships characterised by powerful social actors who can shape those social relationships to suit their purpose. The economy is nothing but a set of social relationships grounded in the material reality of people meeting their needs through the exercising their capabilities. The above view that the economy has to be in surplus, and that land and wealth in private hands is outside of that process, is the result of a set of decisions made by powerful social actors largely because it suits them to think this way.

How else to explain Prince Charles’ enormous personal fortune via historical land rights manifest in the Duchy of Cornwall? How did he come to own all of that property? Well, in 1337 Edward III established the Duchy. It now consists of 53,000 hectares of land in 23 counties. Who gave Edward III those property rights in the first place? The long established historical rights merely masks that in the last instance land was fought over and paid for in blood or subservience or both.

In Scotland, Andy Wightman argues in The Poor had no lawyers. Who owns Scotland and how they got it:

“The land on which many of our lairds sit was stolen in the 17th century, but these ill-gotten gains were protected by acts which maintained their hegemony after the rest of Europe ditched feudalism and concentrated land ownership.”

Shakespeare knew about blood and land (King John, Act 1 Scene 1):


“Philip of France, in right and true behalf

Of thy deceased brother Geffrey’s son,

Arthur Plantagenet, lays most lawful claim

To this fair island and the territories,

To Ireland, Poictiers, Anjou, Touraine, Maine,

Desiring thee to lay aside the sword

Which sways usurpingly these several titles,

And put these same into young Arthur’s hand,

Thy nephew and right royal sovereign”.


“What follows if we disallow of this?”


“The proud control of fierce and bloody war,

To enforce these rights so forcibly withheld.”

Just as land ownership is a residue of past blood feuds, so in a way is much of current wealth ownership. It is  a result of non productive wealth extraction bestowed merely by accident of birth, inheritance, and a rentier economy (Picketty, 2014, Sayer 2015).

IDS implies that ‘the economy’ is not healthy enough to withstand tax on wealth and income. He fears that wealthy people will leave the UK and take their wealth with them. In the case of land, that would be an interesting spectacle. It suits him to focus on the economy as defined in the budget, in which he can argue that the economy is in debt and still running an annual deficit. His class are not affected of course by any of this, but they do fear for their investments and asset values. The therefore have a visceral interest in the status quo, change for them might mean losing huge amounts of their asset values. They have got used to ‘earning’ or rather extracting so much money that the numbers have become meaningless in terms of normal human needs. A billionaire can only eat so much bread, and it costs the same as it does for a pauper. As Nick Hanauer argues, how many pairs of jeans does a billionaire need?

There are many clever people using mathematical models and economic ‘laws’ such as ‘the ‘Laffer curve’ and ‘Say’s law’ but again they overlook the basic premise of social relationships that actually underpin economic activity.

Is there there enough money in the economy to fund social and health care, education, research and development in green technologies, poverty relief…?

Putting aside very important questions about what money actually is, focus instead in taken for granted wealth and assets. This is in the private sector and off limits to government because the 0.01% ensure it is. The scale of their wealth is staggering:

  • The richest 1% of the world will own as much as everyone else by 2016.
  • 85 richest people are as wealthy as the poorest half of the world.
  • The highest paid 3000 people in the UK pay more income tax than the bottom 9 million. this is lauded as ‘the rich are more than paying their way’. What would you rather choose, a tax rate of 90% on your annual income of £1,000,000 or a 0% tax rate on your annual wage £10,000? This means that….
  • 30,000 income tax payers in the UK contribute £18.8 billion in income tax (2014), while one third of tax payers contribute less than those 3,000.
  • In the US the bottom half have no wealth.
  • Perhaps 8% of the world’s wealth ($7.6 trillion – thats $7,600,000,000,000) sits in tax havens.
  • The UK’s tax gap may be as high as £122 billion each year.
  • The top 1,000 people in the UK have £547.126 billion. Thats £547,126,000,000.
  • We don’t know who owns land in England in detail, but one estimate is that 70% of us own about 5% of urban land. Who owns the rest?
  • About 0.6%of the UK’s population own 50% of rural land (2010). perhaps we should consider a land value tax?

“Roads are made, streets are made, railway services are improved, electric light turns night into day, electric trams glide swiftly to and fro, water is brought from reservoirs a hundred miles off in the mountains – and all the while the landlord sits still… To not one of these improvements does the land monopolist as a land monopolist contribute, and yet by every one of them the value of his land is sensibly enhanced”.

Who said this? Was it some Marxist revolutionary? Or was it in fact Winston Churchill?

The fact is, the money is there, it can also be created. We just choose not to access what is often on offshore tax havens, or to create the money that is required.

As for IDS’s second point. It is not even worth debating.

Want to thank a War Veteran?

Most politicians in the established parties are merely the outward looking face of the 0.1% or, as Professor of Sociology Graham Scambler calls them, the “Capitalist Class Executive”. I prefer his other term for them: the “Greedy Bastards”. Politicians who currently support the activities of the GBs form part of the ‘Political Power Elite’ and are the public facing wing of the GBs. Obama et al in the US; Cameron, Clegg and Miliband in the UK; Abbott in Australia.  In the UK they form part of the ‘Establishment’ while the other parts of the Establishment merely acquiesce  and squabble among themselves about the size of the crumbs falling from the GBs’ table.

The real people to punch are the self satisfied, smug, post imperialist, authoritarian, narrowly educated but often from ‘elite’ universities, usually white and overwhelmingly male plutocrats and oligarchs, the ‘focused autonomous reflexives’ , embedded in globalised corporate networks who believe in their own propaganda about their innate superiority, achievements and right to rule over the underclasses, women, inferior ‘races’ and of course nature.

Their comic, and not so funny, face in the UK is Boris Johnson.

These men usually share an ‘autocratic father metaphor’ and base their politics around core beliefs:

1. The world is a dangerous place and always will be, because evil exists.

2. The world is hard and difficult because it is competitive.

3. There will always be winners and losers.

4. There are absolute right and wrongs.

5. Children are born bad, in that they only want to do that which feels good rather than that which is right.

6. Children therefore have to be made to do the right thing.

7. This world therefore needs a strong strict father who can: protect the family in a dangerous world; support the family in a dangerous world and teach children right from wrong.

Their wealth, they believe, gives them a superior position because they ‘earned’ it based on their own hard work and innate cleverness drawing often unconsciously from the assumptions above.  They are ready to defend it with other people’s lives and the desecration and destruction of the ecosystems on which the rest of us rely. Chapter 1 of Naomi Klein’s latest book is a chilling read and fleshes out some detail on the attitudes of many US CCE’s and their apologists, to climate change. Polly Toynbee and David Walker also illustrates their attitudes in a UK context.

These are the boys to make us think again. Their defence of their wealth and power is wrapped up in words about freedom and democracy and the “American way of life”. This acts as a smokescreen because in reality, as Klein shows, those who inhabit ‘Richistan’ are only concerned about themselves, their class, their privileges and are now actively protecting themselves against climate change, social unrest based in inequality and global jihad. They do so with the blood of others.

The soldiers you see above have been dragooned into this unholy class war.

Veterans are often the saps who, through necessity or through unexamined ideological traps, are the tools of the GB’s. Believing in higher motives such as camaraderie, or poorly thought through notions of democracy, they engage now in fighting the GB’s battles, suffering the costs at hourly pay rates the GB’s would not bother to raise their bloated carcasses out of bed to receive.

To add injury now to insult, we now have to face a medieval Caliphate, largely of our own making.

A young man near you may be sent to die for a cause he knows nothing about other than lies, distortions and false premises. Joining the British military always had its dark side, and apart from fighting Hitler has always been about establishing imperial power to allow extractive capital to freely go about its business. The UK now has a long established military culture, it’s loftier manifestation being the ‘heroes’ trope, and a more base manifestation is our infantile clinging to nuclear weapons.

I met two young boys on the Dover-Calais ferry who had just joined the army, what else is there for them? Without privileged networks, or education, or wealth, their chances of getting ahead in civilian occupations are greatly reduced as they metaphorically jostle with sharper elbowed upper middle classes and the children of the elite who have a stranglehold on plum careers. They also compete with the Precariat, ‘Gringo’s and ‘Endies’ who fill the employment figures making the recession seem better than it actually is.

These two had been sent on a tour of the WW1 battle fields and cemeteries. They were learning military history as part of their basic training. Writing up their notes, one commented on the virtues of discipline in the trenches. I don’t think he’d seen ‘Blackadder Goes Forth’. So, with the best of motives and the least of opportunities, we are preparing two very young men to face lunatics with scimitars, or “ten thousand Watutsi warriors armed to the teeth with kiwi fruit and dry guava halves at Umboto gorge”. Fresh faced and poorly educated they might become veterans relying on a non existent mental health service to sort out their PTSD while their Etonian educated ‘superiors’ worry about the stock market and the price of a bottle of Chateau Lafitte.

Want to thank a veteran? Give, not ‘loan’,  an education, provide some proper mental health services and an economy orientated to the needs of the many not the few.

marxism and health care

Marxism and Health Care

You can also find this paper on my academic website:






Introduction. 2


1. An outline of Marxist philosophy. 3


2. From a philosophy to health. 9


3. The Social Determinants of Health and the health worker’s role. 11


References. 14


A worker’s speech to a doctor. 15





The philosophers have only interpreted the world in various ways; the point is to change it”.    Theses on Feuerbach. XI  Marx K  c 1888


This paper is in three parts:


1)    An outline of Marxist philosophy.

2)    A discussion of its application to health.

3)    The Social Determinants of Health and the health worker’s role


Finally, Bertold Brecht’s poem ‘A worker’s speech to a doctor’ is presented for reflection.


This outline of Marxist philosophy focuses on 3 key ideas:


1)    Material Conditions. To understand our experience as human beings we must begin with rooting that experience in the material conditions of everyday life.

2)    Dialectical Materialism. Those material conditions of everyday life are characterised by conflicting social forces, the outcome of which ‘determines’ our experiences.

3)    Alienation. A result of our current material conditions of life is that we are alienated from our human self, from each other and from the nature of work.


These 3 lead us to consider that a fuller understanding of human health involves an analysis of the material conditions of living and its effects on health and illness; an understanding that competing and powerful groups shape those material conditions and that this shaping of material conditions results in alienating experiences and behaviours that lead people to make unhealthy lifestyle choices. These collectively are the ‘causes of the causes’ of ill health.


Marx never wrote explicitly about health problems, or the role of health professionals, his was an analysis of the progressing conditions of man in the pre modern (feudal, agrarian) and the modern (industrial) era, but it is in this analysis that we find the above ideas that may speak to us of some of the causes of a modern malaise.


The malaise is this. We live in an epoch of unprecedented wealth; financial, material and intellectual. The success of capitalism and technological advances, such as the internet, facilitate both the movement and development of capital and knowledge. Life expectancy and infant mortality have gone in the right directions. We live longer and in better health. Marx himself wrote very favourably about the ability of capitalism to be innovative and creative in furthering human progress.


However, alongside this wealth is continuing material poverty, a poverty of spirit as well as seemingly insurmountable problems: climate change, pre enlightenment religious fervour linked to terrorism, drug/alcohol abuse, and war. The United Nations struggles to contain inter state conflict and to deliver the promises of the Millenium Development goals. Alongside the huge increases in wealth, is the vastly increasing inequality in both social conditions, and inequalities in health and wealth of the global population. The gains ushered in by modernity are increasingly going to a wealthy ‘elite’ despite a growing middle class in many developing countries. We might be getting richer but we are not necessarily getting happier, and as austerity policies bite, many people are getting stressed, anxious and even suicidal.


Far from ushering in an era of global peace and prosperity the dominant mode of production, i.e. capitalism, is in urgent need of revision in order to meet the challenges the global community faces. If it does not do so, it might face what Jürgen Habermas called a ‘crisis of legitimacy’ as publics become less accepting of the social problems and the democratic deficit it seems to entail.


It is this cultural and economic critique that (neo) Marxist writers such Theodore Adorno, Louis Althusser, Jurgen Habermas and Antonio Gramsci have drawn attention to. In the 21st century these neo Marxist thinkers have been joined by writers who do not openly call themselves Marxist but they draw upon Marxist thinking, notably the idea of the material conditions of life affecting health e.g. The Black Report 1980 and the Marmot Review 2010; ideas around alienation affecting mental health, see Oliver James’ selfish capitalism;  and that of a ruling class elite see Graham Scambler’s ‘Greedy bastards hypothesis’.



1. An outline of Marxist philosophy



Condensing Marxist philosophy into a few paragraphs is just not possible. Therefore what follows is a snapshot, an interpretation (a thesis) open to critique and refutation (an antithesis) which may lead to a synthesis which in its turn may be challenged.


In 1844 Marx began collaborating with the affluent industrialist Friedrich Engels who was fresh from working as a mill manager in Manchester where he had been much affected by the poverty of the workers. The result was first The Holy Family and then in 1846 The German Ideology.


Marx’s understanding begins with the acceptance, his first premise, that it is the material conditions of man which conditions everything else, including man’s consciousness and his ‘ideas’. Thus his philosophical position is that of metaphysical naturalism.


‘The first premise of all human history is, of course, the existence of living human individuals. Thus the first fact to be established is the physical organisation of these individuals and their consequent relation to the rest of nature.’ (Marx and Engels 1846).



The focus is on the ‘physical organisation’ of human existence. Supernatural explanations (God or gods) for the condition of humanity are not needed. It is this premise that has led many, especially in the United States, to reject Marx from the outset as it is atheist in nature. History does not progress through ‘ideas’ alone, or though Allah’s or God’s will, or as a manifestation of Hegel’s ‘Geist’ (Spirit), but through the changing material conditions of existence, and the struggles of humanity to pacify the conditions of their existence. Look to how human beings in their physical existence organise themselves in their struggle to exist in a material physical world, as a starting point for social analysis.



‘In the social production of their existence, men inevitably enter Into definite relations, which are independent of their will, namely relations of production appropriate to a given stage in the development of their material forces of production. The totality of these relations of production constitutes the economic structure of society, the real foundation, on which arises a legal and political superstructure and to which correspond definite forms of social consciousness. The mode of production of material life conditions the general process of social, political and intellectual life.


It is not the consciousness of men that determines their existence, but their social existence that determines their consciousness.’ (Marx 1859).


Marx suggests that primarily we need to feed, drink, clothe and house ourselves and to do so we must enter into social relationships to achieve this. An examination of history reveals the form of those social relationships (the serf-lord, the working class-bourgeoisie) that exist in a particular economic mode of production (pre-agrarian, feudal and then capitalist). It is the ‘mode of production’, currently capitalism, that ‘determines’ the form of social relationships, and the ways we think. Therefore the feudal serf-lord relationship was swept away with the rise of industrial capitalism, it simply could not continue to exist as a dominant way of organising social life. One could no longer think as a feudal lord when the feudal mode of production disappeared, just as a feudal lord could not think like a merchant capitalist trading in goods across the globe because that mode or production did not yet exist.










Key concepts 

Means of production: land, tools, technologies

Forces of production: labour power and knowledge of technologies

Relations of production: the totality of social relationships that people must enter into to survive.

Mode of production:  a combination of the forces of production and relations of production.  Two modes are feudalism and capitalism.





In a society where there is no social provision for health, such as that in pre 1948 Britain, and which the dominant thinking is that all goods and services should be provided by private individuals rather than governments, then it is very difficult to think of a national health service paid for by taxes. This idea came about as part of the class struggle in industrial Britain when workers who could not afford to pay for doctors, finally got around to demanding health care irrespective of ability to pay. In the United States many people have accepted the idea that state provision for health is akin to Marxism and communism. The anti-Obama rhetoric on this issue is very clear on this point. Those with an interest in private medicine and those with a visceral hatred of state provision for anything, mounted a very successful campaign tapping into ordinary Americans love of individuality and scepticism about state involvement.


The form of the social relationships of production, e.g. proletarian – bourgeoisie, workers-ruling class, are defined by the mode of production. In the modern industrial era, this relationship is characterised by who owns and controls capital (the main means of production) and who does not (and only has their labour to sell).


This gives us the second concept: Dialectic Materialism. This suggests that if an understanding is required as to why we have the laws we do, the social relationships we have, the politics that are played out, the forms of artistic production and expression, and the health care systems that are in place, we have to understand our material existence based on the economic mode of production. This material existence includes the opposition of social classes that, through conflict and struggle in relationship to each other, gives rise to a new social order that in time may itself be challenged. Start with material conditions and then see that there are ‘dialectics’ or opposing social forces/classes at work. The sort of society you get results from the interplay of these two classes.


The dominant class in any historical era gets to set the agenda. If the subordinate class accepts the ruling class’ view on the proper social order then society ‘settles’ for a while. However, as the forces of production change with the development of new technologies for example, this impacts on the social relations of production, thus eventually changing the mode of production. This change of mode of production from feudalism to capitalism for example is not inevitable. Many so called ‘primitive societies’ have had sustainable social structures with an unchanged mode of production i.e. hunter-gatherer, for centuries. Marx realised however that capitalism was an extremely dynamic mode of production capable of unleashing upon the world social and technological revolutions never before seen or experienced.


Modern, globalised (post-industrial/financial and industrial) capitalism shapes our lives in deeply profound ways and it is to the nature of the 21st century form of capitalism that we should look to understand our modern social world and the world of ideas. Historical Materialism is the application of dialectic materialism to history and sociology. It is the view that social, political, artistic and cultural life is determined mainly by the material facts of economics and the forms of social relationships thus created, and not God or by human reasoning alone.


The health care system within capitalism results from this dialectical interplay between the social classes. Capitalism has now provided technologies and advances which allow for many different relationships and forms of health care to emerge, but at its heart is the relationship between its social relations of production: labour (proletarians) and capital (bourgeoisie). The exact nature of the health system differs from country to country, but it results from whichever social force is best able to set the agenda.


Currently, Capital, in the form of private sector corporations,  is dominant and channels funding, or withholds funding, for health care though its various spheres of influence.  If private sector corporations can influence Nation States to allow them to provide health services for a profit they will do so. If working class, i.e. labour, interests insist that health care is provided free at the point of delivery paid for out of general taxation, and that idea wins out, we end up with an NHS. In the UK, private sector corporate interests have successfully introduced market forces into a publicly funded state health system. In the United States, private sector health interests have blocked anything but the most basic of public funding for health. In many other countries the interplay between capital and labour has resulted in mixed public/private provision.



A defining characteristic of capitalism, Marx suggested, is that it alienates man from himself, from the true nature of work, from others and from nature. Alienation is suggested as a third concept in understanding modern existence, especially in terms of mental health and ideas of well-being. Anyone who only has their labour, skill or knowledge to sell in return for a wage or salary may reflect on the alienated meaning of their existence. Billions of workers are engaged in low pay, repetitive, precarious and zero contract hours to produce ‘stuff’ that ultimately is unsatisfying and which paradoxically leads to the consumption of more ‘stuff’ as a means of escape. There is now discussion of a ‘new dangerous class’ – ‘the precariat’.


Alienation may be partially moderated by consumption and by accepting the dominant ideas of what is the ‘good life’. In Roman times this was understood by the Emperors’ provision of bread and circuses. The plebeians needed distraction to prevent them from seeing the true nature of their subjugated existence. Soap operas and celebrity culture may have a similar function today. Other ways of ameliorating this alienation is through organised religion or a spiritual quest, or one can resort to easing the anomic pain with drugs and alcohol. We might also engage in art or philosophical musings to escape the feelings of disconnection from ourselves, our work, each other and from nature.


The ‘poverty of philosophy’ is its concerns with abstractions, ideas, ‘facts’ or consciousness devoid of their material context. That is, a philosophy or any understanding of how the world works which does not take into account the material conditions that man finds himself and the power relationships that result, is an empty philosophy. Removing the analysis of power relationships allows the ‘Ruling Class’ to promote their own interest in the form of ‘Ruling Ideas’. Therefore, encouraging people to ‘find themselves’ without a class analysis lets the ruling class completely off the hook because this requires no changes whatsoever in the mode of production. Capitalism can embrace any amount of ‘new age’ philosophy as long as that philosophy does not challenge  the basic power structures of wealth accumulation and distribution.


The counter culture in the 1960’s was initially threatening.  In being inviting young people to ‘drop out’, and with the advocacy of using LSD, capitalism would be deprived of workers who would shoulder their share of the burden. Of course the actual argument was couched in terms of ‘drugs are bad for you’, which is seen an easier sell to otherwise rebellious youth rather than ‘drug use may make you question the system’ which is not, and may actually be quite an appealing reason to take drugs.


The class which has the means of material production at its disposal, and which has control at the same time over the means of mental production, and over thinkers, as producers of ideas, can sell and promulgate those ideas as the ‘right ‘ones. The ruling class can regulate the production and distribution of ideas and define them to serve their own causes. ‘Liberty’ to the ruling class means something quite different to those who have nothing but the shirts on their backs. This does not mean there will not be rebels in thought and deed, only that ruling ideas tend to become ‘taken for granted’ and ‘common sense’ and anyone not willing to take part in selling their labour is then classed as deviant or criminal. Thus we have social and political issues with ‘out groups’ such as travellers, chavs, skivers v strivers. Countervailing voices are pushed to the margins and tolerated as long as they don’t do a anything practice to change things.


Escaping from these social relations of production is increasingly harder to do as more and more people in a globalised economy become part of the overall mode of production we call globalised capitalism.


To keep it that way, the ruling class, identified by Scambler as the Corporate Class Executive and the Political Power Elite, has at its disposal a Repressive State Apparatus: Police, Military, Executive government,  and an Ideological State Apparatus: newspapers, broadcast media, the churches/mosques. These act as agents of social control trying to prop up the legitimacy of current power structures and the structures of rewards and punishment. Ruling class interests are better served if the subjugated classes accept their position themselves and regulate themselves by accepting, as natural, the ruling systems. Democracy in this schema is a chimera, the State (party politics) exists mainly to serve the interests of the ruling class:


‘the modern Cabinet is but the executive committee for managing the affairs of the entire bourgeoisie’ (Communist Manifesto).


Ideas, and the definitions of ideas, such as the ‘rule of law’, ‘market forces’, ‘free trade’, presents particular class interests as being in the general social interest. It is as if these ideas float down like manna from heaven untainted by the need to serve a particular class interest. This may lead to hegemony, the political, social, ideological, economic dominance of one class over others in a system in which all are supposedly equal. A result of which may be that the subjugated class, by accepting the tenets, ideas and concepts of the dominant class has a false class consciousness, i.e. a false understanding of their true social position and interests. That is how you get low paid workers supporting social security cuts for low paid workers. Turkeys voting for Christmas.


The goal of philosophy should therefore be to reveal the true nature of abstract concepts e.g. parliamentary democracy and a health service, as arising from the material existence of those who produce them and the struggles of opposing social forces.



Reflecting on such a critical philosophy leads to certain questions. It may be argued that Marxism assists in developing a necessary critical perspective in that it’s key concepts asks us to engage in criticism which has:


‘plucked the imaginary flowers on the chain not in order that man shall continue to bear that chain without fantasy or consolation but so that he shall throw off the chain and pluck the living flower.’ (Marx 1843-4, p 244).


There is a need to get beyond the illusory to the real, to separate fantasy from reality, to free empirical butterflies from under the wheels of philosophical fantasy. Marxism argued that there is a material reality, often hidden by delusion, deception and class interests.


We may suggest that in the current era a global multinational corporatist class exists for whom such concepts of the maximisation of profit, shareholder value, the extraction of natural resources on an industrial scale and the value placed on market solutions to various social, political and health issues are dominant. It wants and needs a healthy workforce only as long as the costs are not threatening to profits. Hence the health needs of poverty stricken, war torn Africans are not a priority. The health care needs of unproductive members of society: children, students, the elderly, the sick, learning disabled and mentally ill, are a costly burden to be born if possible by individuals and families. This in practice means care is to be undertaken by women supported by patriarchal notions of biological determinism of female nurturing.

Capitalism allowed the welfare state to exist on sufferance in the UK and not all in the US. Now that it has decided that the welfare state is too costly in the UK, it is withdrawing state support as quickly as public opinion will allow it to go. Corporate class interest does not need this cost burden. It prefers privatising and individualising risk rather than being asked to support public health delivery systems. The ideology it sells includes an over emphasis on individual lifestyles choices as part of the ‘responsibility deal’. You are fat because you over eat. Simple. The solution? Stop eating. Simple.


2. From a philosophy to health


In any social, cultural and political activity, a Marxist analysis thus assumes a dominant class exists which continues to own, manage and control the means of production, distribution and exchange and the production of ruling ideas. Scambler (2013) in his “Greedy Bastards Hypothesis” identifies a ‘cabal’ of wealthy and influential individuals forming the Corporate Class Executive who work with the Political Power Elite to further their own interests over that of society. His example is the introduction of the UK’s Health and Social Care Act (2012) which opens up health service delivery to “any willing provider”, such as private sector organisations. Those now charged with buying health care provision, the Clinical Commissioning Groups led largely by Doctors, will be required to open up to tender the provision of services despite the potential conflict of interest whereby many doctors also have an interest in companies who will bid for that service.


What are the ruling ideas and whose interests do they serve? A current example is the UK government’s use of ‘Skivers v Strivers’ rhetoric aimed at gathering public support for the withdrawal of the State from welfare provision. This idea argues that because of an increasing welfare bill which exists in a time of ‘fiscal austerity’, “there is no money left” to pay for a range of social security benefits. Therefore individuals and families should work more to provide for themselves, to break free from an entitlement culture and welfare dependency that has been associated with social ills. It may suit the ruling class to say that there is no money left and indeed it is strictly true if one only thinks about government money. What is left for critics to point out is that there is a great deal of money but that it is owned by a very small number of people and often in secretive offshore tax havens where it cannot be touched. One estimate puts this figure at $32 trillion.


Marxist analysis, because it highlights opposing social forces,  asks the power questions: Who sets the political and social/health agenda and why? Who are the winners and losers in a global economy and health system? How are global resources for health allocated and why? What health issues get researched and supported and why? Who has the power and who is powerless?



A Marxist take on health may suggest.


  • Poverty is now accepted as linked to health, but often was denied.
  • The material conditions of life have a causal relationship to health and illness. Therefore to improve health outcomes, improve material conditions.
  • Capitalism will invest in profitable enterprises, so how do you ensure finance capital invests in highly expensive low/no profit care services?
  • The social and political causes of illness and disease have been overlooked and under researched.
  • Once people lose economic usefulness their value drops and their health needs are poorly served. Take elder care and its provision as an example.
  • Research into health needs may disproportionally favour the health needs of affluent societies and the affluent in affluent societies because that is where the investment returns are.
  • Health services may be about keeping workers as productive and as economically active as possible. Therefore health services are designed to establish productive capacity not human flourishing or well being. So they invest in high tech hospital services with clear medical outcomes.
  • The National Health Service is accepted by the ruling class as the provision of ‘bread and circuses’. The provision of health services buys off the discontent of the workers and only came into being by Marxist influenced social democratic politics.
  • Health systems may favour the wealthy and well off by the design and delivery of services that they want. See for example ‘The inverse care law’ and the Health and Social Care Act 2012.
  • A ruling class idea is that ‘Responsibility for health is the individual’s, who must also pay for its provision’ thus diverting attention away from injurious to health working and cultural practices.
  • Healthcare professionals are either unwittingly working in a system that is largely about keeping the worker healthy or are self serving professionals getting affluent on the back of the ill, poor and the vain.
  • A professional ethic which emphasises altruism masks self interest from professionals themselves and from others.
  • The medical profession is a self serving elite profession, diagnosing the wrong problem, overlooking iatrogenic illness and often coming up with unhelpful solutions. It is too focused on downstream solutions to health problems caused upstream.
  • Defining health needs solely in medical terms distracts attention from the political and social determinants of health.
  • Medical definitions of mental illness may construct a deviant subculture than can, and has to be, controlled.





3. The Social Determinants of Health and the health worker’s role


There are three main explanations for inequalities in health.


1)    Cultural/lifestyle.

2)    Material.

3)    Psychosocial.


The first focuses on the unhealthy lifestyle choices made by people, the second focuses on the material conditions of life and the third draws in social comparisons that people make between themselves. There is a fourth – the biological/hereditarian perspective which of course has explanatory power but cannot account for the unequal patterns of health and illness we see outlined in for example “Fair Society Healthy Lives” (The Marmot Review 2010).


Marx and Engels would certainly have seen how the material conditions of the English working class in the 19th century caused the ill health and disease seen in urban slums. These material conditions are part of the social determinants of health which:


“are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels”. (World Health Organisation).


They are the ‘causes of the causes’ and help to explain, or at least ask us to consider why, people’s lifestyle choices for example smoking, are poor for their health. Marxists would look beyond simple explanations that blame poor people for smoking and seek to address why they are making those choices and who benefits from those choices. This is not to say that their choices are causally determined by tobacco companies, but it is to suggest that the interplay of material conditions, life chances and lifestyle choices are quite complex and open to subtle but powerful influences.


This too goes for obesity. Too much emphasise in getting individuals to eat less and exercise more while ignoring the production, marketing, distribution of high sugar, high calorie cheap foodstuffs through allowing industry to police itself with voluntary codes of practice is a partial solution. The context of food has also to address how we have replaced it with fossil fuels as a source of energy. We don’t walk, we drive. The automobile industry is not interested in public health, is antithetical to investment in public transport and the provision of cycling as active modes of transport.  Free market thinking in transport, leads to the insanity of Los Angeles freeways in the US, and the Beeching Rail cuts in the UK. Free markets are not always self-correcting, and when they do, they may leave a wave of ‘creative destruction’ in their wake.


Poverty and the poor material conditions of life are inextricably linked to illness and disease. It has been said that the poor are always with us and that we have had plague, famine and poverty since biblical days. Therefore the existence of ‘haves and have nots’ does not ‘prove’ Marxist philosophy.


However, understanding that the material conditions of life exist under a particular political and social structure, means understanding health in terms of poverty and how poverty is allowed to continue.  Poverty is a result of war, ideological conflict, famine and ruling ideas rather than it being a ‘natural’ state of affairs or god given. Poverty can be ameliorated if the ruling classes in each country have a mind to prioritise it as a goal.


The concept of a ruling class owning and controlling wealth and the production of ideas suggests that there is a global struggle for material well being, a struggle for the use and control of the means of production, and that the sides (classes) in this struggle are largely unequal in power and resources. There are winners and losers. Many more are on the losing side.


The losers get sick.


The losers get poor.


The losers get defeated.


The losers get mad.


The losers get even.


Health professionals focused on healing the individual sick and injured often can’t take the time to combat the forces that cause illness and injury.


‘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).


As 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’.


Global capitalism has not yet solved this crisis for humanity. Marx offered revolution as an answer, a communist society….but so far the capitalism Marx knew has evolved partly due to the dialectical forces of marxist and socialist thinking , partly due to the advances in science and technology and partly due to religious philanthropy and humanist altruism.


What to do?


Health care professionals are motivated by many things, but they fool themselves to think it is a caring ethic alone that drives their practice. Caring and healing is socially and politically mediated, shaped by forces and agendas often tacitly accepted by professionals, often unknown by professionals, often ignored by professionals. Marx calls us to remove the flowers from the chains so that we may see health and illness as they really are, rooted in the material conditions of social life.


Health care ameliorates the worse ravages of post industrial and industrial capitalism, as well as producing some wonderful technological fixes for real human problems. But its success can only be seen to be so at the individual level. If the focus is kept at the individual then the real health issues can be hidden away, for medicine historically was largely silent in the face of poverty and inequity. Health care professionals, and the research they undertake, focus too much on the needs of the rich world and on the rich in the rich world, while practice may be based on profit not need. Quick fix expensive drugs with the promise of shareholder profits are preferred to painstaking analysis and costs of putting right social and political causes of illness – the material conditions of life that bring misery.


Health care professionals need to get political and join in the example of those few brave catholic priests in South America who engaged in liberation theology. Priests, who were engaged in activities unsupported by their masters in the Vatican, often suffered beatings and death while the Catholic hierarchy preferred to keep their dissent to prayer and sacraments. Religious, political and health care hierarchies may peddle an ‘its not our business leave it to the proper authorities’ ideology, however the social gradient in health and illness continues. Health care professionals know what makes people sick. Healthcare professionals know what makes people well. Healthcare professionals could argue for the focus of research and health care delivery to be turned on those known factors that lead to illness, depression and suicide. Resources should be sequestered away from the GB’s in their offshore tax havens towards meeting the needs of people. Governments should enforce a framework that ensures investment gets channelled into directions that improves human well-being even at the expense of short term shareholder profit. An ethic of civic duty and social care ought to replace an ethic of profit at all costs and that this ethic arising from moral teachings has also legislative force. Civic society must hold to account the GB’s and reclaim democracy for the people. This last however is a visionary forlorn hope, as utopian as Marx’s own dream of a communist society based ironically on a biblical event in the Book of Acts:


“From each according to his ability, to each according to his need”.







Enzensberger H (2005) The Radical Loser Der Speigel 7th  November 2005

http://www.signandsight.com/features/493.html accessed 5th April 2013


Marx K (1843)  A Contribution to the Critique of Hegel’s Philosophy of Right. Introduction. Early Writings.


Marx K. and Engels, F. (1846) The German Ideology Critique of Modern German Philosophy According to Its Representatives Feuerbach, B. Bauer and Stirner, and of German Socialism According to Its Various Prophets.


Marx K. (1859) A contribution to the critique of political economy (Preface).


Scambler, G. (2013) GBH: Greedy Bastards and health inequalities. 4th November http://grahamscambler.wordpress.com/2012/11/04/gbh-greedy-bastards-and-health-inequalities/    accessed 8th April 2013














A worker’s speech to a doctor    Bertold Brecht



We know what makes us ill.

When we are ill we are told

That it’s you who will heal us.


For ten years, we are told

You learned healing in fine schools

Built at the people’s expense

And to get your knowledge

Spent a fortune

So you must be able to heal.


Are you able to heal?

When we come to you

Our rags are torn off us

And you listen all over our naked body.

As to the cause of our illness

One glance at our rags would

Tell you more. It is the same cause that

Wears out

Our bodies and our clothes.


The pain in our shoulder comes

You say, from the damp; and this is also

The reason

For the stain on the wall of our flat.

So, tell us;

Where does the damp come from?


Too much work and too little food

Makes us feeble and thin.

Your prescription says:

Put on more weight.

You might as well tell a bullrush

Not to get wet.


You’ll no doubt say

You are innocent. The damp patch

On the walls of our flats

Tells the same story.


More greedy bastards

The Greedy Bastards Hypothesis (GBH).


Since the financial crash of 2008, populations became aware of what a certain class of people were up to. The word class itself however had fallen out of fashion as many commentators had pronounced the death of class politics preferring instead to think of us all being concerned with various ‘identities’. So, although many people understood that ‘rich’ people had advantages this did not lead to a ‘crisis of legitimation’ – many people either agreed with Peter Mandelson’s quip ‘“We are intensely relaxed about people getting filthy rich as long as they pay their taxes.” ,  or at least ignored it as the consumer and housing bubble kept inflating. People forgot that class relations still operate whether one ignores it or not.

Graham Scambler (2012a) has not forgotten.

The hypothesis asserts that there are:  “strategic behaviours at the core of the country’s capitalist-executive and power elite. The ‘capitalist-executive’ are a core ‘cabal’ of financiers, CEOs and Directors of large and largely transnational companies, and rentiers. These individuals were perfectly capable of ‘conspiring’ but despite being involved in fierce competition rarely had a need to do so in the post-1970s neo-liberal era of financial capitalism. This cabal has come to dominate the political class”.

As it turns out, the filthy rich are not even paying their fair share of taxes. Tax cuts have not reduced deficits, the GB’s have stashed them away. The banking ‘elite’ enjoy lifestyles beyond the dreams of avarice and threaten to leave the country if we cap bonuses.

So, in effect, democratic politics has been hijacked to serve the interests of a very select few.

Scambler also listed individuals who make up this cabal in 2009.

While Liam Fox calls for a freeze on public spending for three years and a reduction in capital gains tax to 0%, and while Osborne and Ian Duncan Smith continue to take money away from poorly paid working people, the richest 1000 people in the UK have increased their wealth in the last three years by £155bn, and the global elite sit on £13 trillion in offshore accounts. Austerity is only for the ‘little people’.

Scambler (2012b) also cites how private companies will be profiting from the re commodifying of the NHS and health care, as a result of the Health and Social care Act 2012. This he says is evidence of policy based evidence rather than evidence based policy and comes about as a result of corporate interests coming before individual health. This is what Lansley meant when he talked about taking responsibility for health…i.e. take out insurance. The current ConDem coalition is pushing through ideologically driven agendas while Labour sleeps. Maybe Miliband and co. know just how complicit Blair and Brown were in furthering class interests.

GB’s are what Scambler calls ‘Focused Autonomous Reflexives’ (FAR). That is to say that the ‘inner conversations’ these people have concerning social action tend to be self-referential, the inner conversation requires no confirmation by others, they are self-sustained. They have a ‘lone inner dialogue’ which then leads to action. If this is dominant then the person will not need to seek or require the involvement of others, he knows that the correct course of action does not need others to confirm that it is so.

Scambler (2013) has developed an ideal type of the FAR whose ‘mode of reflexivity’ has various 6 characteristics:

Firstly there is total commitment. The FAR’s overriding aim in life is increasing capital accumulation and personal wealth. Nothing less will do and any drift from that commitment is relative failure. Secondly there is a Nietzschian instinct based on Hobbesian view of human nature as nasty, brutish and short in a dog eat dog world, that does not quibble about cutting corners in a ruthless determination to succeed and gain advantage. Thirdly a fundamentalist ideology underpins action, there is no room for compromise “there is no alternative”; it is a standpoint born of vested interests. Fourthly there is cognitive insurance which nullifies any cognitive dissonance that might arise. Criticism that greed and responsibility for others suffering will not be internalized, for to admit that this might be the case would otherwise begin to sow the seeds of doubt that arise from cognitive dissonance.  Fifthly there is tunnel vision; the commitment to making money sidelines other matters often in gendered delegation of these matters to others. Finally what is known as lifeworld detachment. The ‘lifeworld’ is that area of everyday life where taken for granted day to day decisions are taken. For the FAR there is simply no time for the ordinary business of day to day decision making.

This is an ideal type and in the real world men will vary in their modes of thinking which direct their action. Those who rub shoulders of the GB’s can draw their own conclusions, however their ideological bias may prevent critical self-reflection of the results of their actions as they seek to shift the blame for financial collapse and budget deficits onto the ‘feckless poor’, the benefit cheats and the skivers.

Warren Buffet once stated “There’s class warfare, all right….but it’s my class, the rich class, that’s making war, and we’re winning.”



Scambler. G. (2012b)  The Assault on ‘our’ NHS ! November 30th 2012 http://grahamscambler.wordpress.com

Scambler, G. (2012a) GBH Greedy Bastards and Health Inequalities November 4th   http://grahamscambler.wordpress.com/page/3/

Scambler, G. (2013) Resistance in unjust times: archer, structured agency and the Sociology of health inequalities. Sociology. 47 (1) 142-156

The Rich List

The Rich List.


Micheal Meacher posted the following on his blog site:

“The Sunday Times Rich List, published today and compulsory reading for anybody who wants to understand Britain’s power structure today, holds three extremely significant conclusions.   One is that the 1,000 richest persons in the UK have increased their wealth by so much in the last 3 years – £155bn – that they themselves alone could pay off the entire UK budget deficit and still leave themselves with £30bn to spare which should be enough to keep the wolf from the door.   The second, even more staggering, is that whilst the rest of the country is being crippled by the biggest public expenditure and benefits squeeze for a century, these 1,000 persons, containing many of the bankers and hedge fund and private equity operators who caused the financial crash in the first place, have not been made subject to any tax payback whatever commensurate to their gains.   This is truly a government of the rich, by the rich, and for the rich.

The third is that despite the biggest slump for nearly a century, the slowest and most anaemic recovery, and prolonged austerity stretching to a decade or more, this ultra-rich clique are now sitting on wealth even greater than what they had amassed at the height of the boom just before the crash.   Their combined wealth is now estimated at more than £414bn, equivalent to more than a third of Britain’s entire GDP.    They include 77 billionaires and 23 others whose wealth exceeds £750m.  

Despite these massive repositories of wealth, these are some of the very people to whom Osborne gifted £3bn in his recent budget by cutting the 50p tax rate.   That measure alone gave 40,000 UK millionaires an extra average £14,000 a week, at the same time as those on very low incomes in receipt of working tax credits who couldn’t find an employer to increase their hours of work from 16 to 24 a week were being deprived in the same budget of £77 a week, around a third of their income, through their tax credits being withdrawn.

In 1997 the wealth of the richest 1,000 amounted to £99bn.   The increase in their wealth over the last 15 years has therefore been £315bn.   If this increase in wealth were subject to capital gains tax at the current 28% rate, it would yield £88bn, and that alone would pay off more than 70% of the total budget deficit.   However Osborne seems to share the notorious view of the New York heiress, Leonora Helmsley: “taxes are only for the little people”.”


Now, to make the conclusion that all we need to do is tax the rich to solve the deficit problem is misguided and is not actually the point of this article. Meacher well knows the difference between the annual deficit (about £125 bn) and the national debt which he says is about £1tn. The main point to draw from this is to illustrate just how staggeringly wealthy the top 1000 people are. The trend is an ever increasing wealth gap and rising inequalities in the UK which Danny Dorling so clearly outlines. Does this matter? Well, yes. Inequalities on this scale directly lead to health inequalities and that means a social gradient in death to you and me.

Coupled with ‘where do I stand’ data and this ‘UK pay: winners and Losers’  published by the Resolution Foundation, the ‘rich list’ paints a sorry picture indeed.

So, you can justify this position by arguing that the risk deserve their wealth because they are risk takers, wealth creators, gifted, very intelligent, talented and hard working people. However, even if you accept this line of reasoning (and it has more than just a whiff of self justificatory ideology about it), does that still justify the ever increasing gap and the huge amounts of wealth they accumulate?

There are two reasons for thinking not. One is the political threat of social unrest and the other is the unequal patterns of the distribution of disease and death that result.

Danny Dorling argues that democracy works when the gap is acceptable by the people and also when they have hope of betterment themselves. I think the gap is increasingly being seen to be unacceptable and, for far too many in the UK, hope for a better and secure future is also vanishing. Inequality on this scale threatens democracy because it distorts our political system as men of wealth are buying men of power.

Inequality is also directly linked to health inequalities. The ‘little people’ are literally paying with their lives and ill health, as the WHO recognises:

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

The British are said to have a sense of fair play which if true will be sorely tested by this sort of information. The public may have been hoodwinked into believing that the last Labour government was responsible for the current plight of public finances, and indeed in not challenging or restructuring the neo-liberal experiment, they are culpable. However, let us not forget that it was the economic policies adopted by Thatcher/Reagan which gave free rein to finance capital to wreck the global financial system for which ‘the little people’ are paying in lost jobs, benefit cuts, pay freezes and dashed hopes.

Given the trillions of dollars that financial and economic mismanagement, no lets call it ‘gambling’,  has caused the global economy, remind me how many of those responsible are languishing in prisons rather than merely resigning/hiding with their pensions and payoffs intact? Where is ‘Fred the Shred’ now? What price at the bookies for seeing him in the queue for a pay day loan?  Well in 2010 it was reported that he was back in the UK paying £3.5m for a home. Back in 2009 the Royal Bank of Scotland (RBS) stated that following negotiation an agreement was reached to reduce his pension to £342,500 a year from the £555,000 and after he took out an estimated £2.7 million tax-free lump sum. It is should be pointed out that The RBS undertook an internal inquiry into Goodwin’s conduct, which found no wrongdoing. Remind me, who now owns RBS and why?

The, understandably, financially illiterate British public prior to 2008 were sold a pup. The British economy was built upon cheap credit and a housing boom financed by the ‘Masters of the Universe’ hedge fund managers in the City of London. British families in the period running up to the finacial crash did not earn enough to buy the goods and services that also provided the jobs. Henry Ford, certainly no Marxist, understood that he needed to pay his workers enough so that they could buy the cars they produced.   Those who ran our politics and financial institutions either forgot this maxim or recklessly ignored it preferring instead to ensure the gap between income and expenditures was filled by easy come easy go credit. While the champagne kept flowing,  no one cared.

The system stinks and people should know it.

Cameron today again said there is no alternative.


In an unequal world, what can I do?

In an unequal world, what can I do?


Peter Morrall (2009) argues that as health care professionals we know about the problems of the world and the issue for health for populations, but not do anything about it is an abrogation of moral responsibility. Morrall and Goodman (2012) challenge the higher education sector to engage in critical thinking to address global issues, but thinking that leads to action.


I always think of action at various levels:


Individual, group, organisation, national and international. You decide what you can do at any level. That may flow though from your increased awareness and learning.


For the UK a good start is the Equality Trust, based on the work of Richard  Wilkinson and Kate Pickett in their book ‘The Spirit Level’.  The website has excellent resources to raise understanding and awareness:  http://www.equalitytrust.org.uk.  This gives you the basic information and perhaps ideas about what might be done.



Another good source for information on a global scale is Hans Rosling’s http://www.gapminder.org  See also ‘Global Issues’ , Poverty Facts and Stats at http://www.globalissues.org/article/26/poverty-facts-and-stats

and of course the Joseph Rowntree Foundation: http://www.jrf.org.uk



So get yourself informed (consider journals and the quality press such as the Guardian) and then reflect on what you might want to do about it. There are online campaign groups through which you might voice your support such as http://www.compassonline.org.uk , a political movement, or Avaaz http://www.avaaz.org/en/ or consider one of the main political parties to lobby and support…think which ones are focused on equality and poverty as key planks in their work.


Stay sane and keep a sense of humour, learn to laugh at yourself, base positions on facts as well as expressed values, as no one likes an intense preachy ‘right on’ leftie.




Morrall, P. (2009) Sociology and Health. Routledge. London.


Morrall, P. and Goodman, B. (2012) Critical Thinking, Nurse Education and Universities: some thoughts on current issues and implications for nursing practice . Nurse Education Today (in press). 

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