Tag: social determinants of health

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/

 

 

 

 

 

 

Planetary and Public Health – its in our hands ?

From public to planetary health: a manifesto.

The Lancet (Horton et al, 2014) has just published  a manifesto for transforming public health.

You can read the full one page easy to read manifesto here.

This is a call for a social movement at all levels, from individual to the global, to support collective action for public health. Public Health has been widely defined in this manifesto and draws upon the ideas of Barton and Grant’s health map which has climate change, biodiversity and global ecosystems as the outer ring of the determinants of health.

The current definitions of public health, for example from the Faculty of Public Health,  draw upon Acheson’s 1998 definition “The science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society”.  However this definition may now be outdated as there is no mention of environmental or ecological determinants of health and no express action on planetary health at all.

Therefore this manifesto is an implicit call to redefine what public health means. Currently you can read the FPH’s approach to public health and fail to consider issues around climate change, biodiversity loss or the crossing of planetary boundaries which delineate a ‘safe operating space for humanity‘. This needs changing.

The main points within this manifesto  include a definition of ‘planetary’ , rather than ‘public’ health which they argue is an “attitude towards life and a philosophy for living… emphasising people not diseases, and equity not the creation of unjust societies”.  There is a strong focus in the manifesto on the unsustainability of current consumption patterns of living, based on the harms this has on planetary systems. They argue “overconsumption…will cause the collapse of civilisation”. Jared Diamond is worth a read on the collapse of civilisations,  and this argument is in line with his analysis.

Interestingly, an overt political statement is introduced: “We have created an unjust global economic system that favours a small wealthy elite over the many who have so little”. They attack the idea of progress, and of neoliberalism  including ‘transnational forces”, for deepening this ecological crisis and for being socially unjust. There is also a hint of the ‘democratic deficit‘ in which trust between the public and political leaders is breaking down.

The call is for an urgent transformation in values and practices based on recognizing our interdependence and interconnectedness, a new vision of democratic action and cooperation.  A principle of ‘planetism’ is invoked which requires us to conserve and sustain ecosystems upon which we rely.

Finally they suggest that public health and medicine can be independent voices of conscience who along with ’empowered communities’ can confront entrenched interests.

So far so good, and in a one page document the detail is necessarily missing.  The principles outlined in this manifesto and the analysis focusing on neoliberalism and ‘entrenched interests’ point us in a direction. However, there is now a need for a map.

I am not convinced that public health, medicine and certainly not nursing, is sufficiently politically aware of the scale of the issue and the sheer force and dynamic of capitalism to even begin constructing the map. That may be an unfair criticism because the education of health care professionals is ‘ahistoric’ and ‘apolitical’ by nature,  they simply lack a sociological or political imagination underpinned by a critical theory of capitalism. And for good reasons.

However, if doctors and nurses are to engage with this manifesto and to debate and argue for an alternative world view, then there is an urgent need to understand the forces railed against them. This manifesto rightly points out the political nature of the issue and the authors no doubt have a clear idea what they mean, however I doubt very much if the majority of healthcare professionals really understand, or even perhaps care about,  the concept of neoliberalism.

In the UK we will be having an election in 2015, in which we will be offered similar versions of the system that is causing the mess. There will be little in the way of mainstream reporting or argument on radical alternatives to consumption or finance capitalism. Indeed parties will be arguing over who can best manage the system.  The only exception will be the Green party who are a fringe party, in terms of votes.

As an example of the scale of the problem, consider Bill McKibbens’  ‘three numbers‘ argument: 2 for two degrees, the threshold beyond which we should fear to tread; 565 gigatons of CO2 we might be able to put into the atmosphere and have some hope of staying below or around 2 degrees; 2795 gigatons which is the amount of carbon in current reserves, but is the the amount of carbon we are planning to burn!  Further, the wealth of investors is tied up in this number and would evaporate like petrol in a hot day should we globally decide that this reserve should stay in the ground. This is an example of an entrenched interest backed by neoliberal politics which is antithetical to global and governmental regulations. The current TTIP negotiations which is trying to establish a free trade area between the US and the EU,  possibly exemplifies the powerlessness of states in the face of lawsuits by corporations if George Monbiot is correct. TTIP is a public health issue and forms part of the backdrop to this manifesto.

I welcome this manifesto, and would urge public health bodies to become overtly political in their statements about public health, perhaps revisiting Acheson and redefining public health to include planetary health.

Following that observation, a new publication published in February 2014, appears to address the politics in an overt way. The Lancet – University of Oslo Commission on Global Governance for Health argues in a document called ‘The political origins of health inequity: prospects for change’ : “Although the health sector has a crucial role in addressing health inequalities, its efforts often come into conflict with powerful global actors in pursuit of other interests such as protection of national security, safeguarding of sovereignty, or economic goals.”

This then sets up political determinants of health which sit alongside the social determinants of health. Whether it goes as far as critiquing the underlying dynamic of various forms of capitalism remains to be seen.

Indur Goklany and Daniel Ben-Ami on health, climate change and progress: A necessary corrective to Costello et al’s climate change health ‘propaganda’, or co-opted apologists for the neoliberal hegemony?

Introduction

 

The health impacts of climate change have been much discussed internationally, however there is some disagreement about the magnitude of those effects, when they will occur and what the right course of action is. Underpinning those disagreements is a joint uncritical acceptance of the fundamental structure of the political economy of late modern capitalism (neoliberalism), with the differences being around whether climate change requires more immediate public policy intervention or whether capitalism will address the health issues though economic development. In other words, both use the frame of reference of capitalism to argue for more market freedom v statist intervention. This paper seeks to outline the arguments over the health effects of climate change while rooting that discourse within wider often background taken for granted political economy. Two writers, Indur Goklany and Daniel Ben Ami will be used to represent the critical camp in riposte to Costello et al’s 2009 Lancet paper on climate change and health.

 

Climate change ‘debate’

 

The Intergovernmental Panel on Climate Change 5th Assessment Report (IPCC 2013) argues that scientists are 95% certain that humans are the ‘dominant cause’ of global warming since the 1950’s (McGrath 2013). Thomas Stocker, IPCC co-chair stated:  “…in order to limit climate change, it will require substantial and sustained reduction of greenhouse gas emission…” (BBC 2013). Despite this, there is continuing doubt, denial and a focus on uncertainty in many countries, especially in news media, that Climate Change is human induced and that it requires radical shifts in public policy. See for example Delingpole (2013) in the United Kingdom and particularly in the United States and Australia (Painter 2013). The UK’s Owen Paterson, secretary of state for environment, food and rural affairs, told the 2013 Conservative party conference not to worry about global warming. “I think we should just accept that the climate has been changing for centuries.” (Syal 2013). Previously on BBC television’s ‘Any Questions’, he repeated ten discredited claims about climate change (Mason 2013).

 

This sits in opposition to many in the medical and public health domain. The World Health Organisation accepts IPCC assessments and considers climate change to be a ‘significant and emerging threat’ to public health (WHO 2013 a,b), while previously ranking it very low down in a table of health threats (WHO 2009). In the United Kingdom, Costello et al (2009) argue that climate change is a major potential public health threat that does require major changes such as action on carbon emissions. In addition, Barton and Grant’s health map (2006) has in its outer ring ‘Climate Change, Biodiversity and Global Ecosystems’ as key determinants of health and supports the WHO view that alongside the social determinants of health, health threats arise from large scale environmental hazards such as climate change, stratospheric ozone depletion, biodiversity losses, changes in water systems, land degradation, urbanisation and pressures on food production. WHO (2013c) argues:

 

“Appreciation of this scale and type of influence on human health requires a new perspective which focuses on ecosystems and on the recognition that the foundations of long-term good health in populations rely in great part on the continued stability and functioning of the biosphere’s life-supporting systems”.

 

It is this call for a ‘new perspective on ecosystems’ that indicates why there is a backlash that underpin long standing critiques of the link between climate change, environmental issues and human health. Many of those critical are libertarian, anti state conservatives defending the neoliberal hegemony of free market dogma which ‘new perspectives’ may threaten.  For example, Stakaityte (2013) argues:

 

“Free market proponents are quick to point out that the whole climate change issue has been used to stifle freedom and to expand the nanny state – and they are right. If the climate is changing, and if humans really are responsible, the market will adapt”.

 

The WHO call for a ‘new perspective’ however is not a radical critique of neoliberal capitalism or a call for its replacement by other political economies. It sits within an overarching acceptance that capitalism is the only economic model, and that only its particular current form requires changing, for example by investments in green technologies.

 

Critical discourse over such an important issue is crucial. Argument should proceed over matters of empirical facts, within discourses of risk and an understanding of scientific uncertainty (see Painter 2013). Attention also should turn to philosophical positions on political economy in which the dominant neoliberal hegemony (Crouch 2011, Plehwe et al 2006) attempts to build and maintain a sceptical view in the media on climate change and on alternative, including no growth, economic models (Jackson 2009) because it is antithetical to ‘nanny state’ intervention implicit in public health ‘upstream’ analysis.

 

Health Impacts of climate change and the policy response

 

Indur Goklany and Daniel Ben Ami respectively are noted writers on the topic and both are in the sceptical camp regarding what to do about climate change. Both however appear to accept the fact of climate change, they just don’t agree with the focus on carbon reduction targets. They are both far more nuanced in their arguments than other commentators such as the UK’s James Delingpole; Andrew Bolt of Australia’s Herald Sun and Steve Molloy of the United States’ Fox News. However, Goklany is associated with the Heartland Institute, but care should be taken not to debunk his thesis merely because he publishes at that anti climate change organisation.

 

For the health community that makes decisions on what the main threats to health are, there is a need to carefully weigh up the evidence for threats to population health in the short, medium and long term, or what Goklany calls the ‘foreseeable future’. This means addressing Goklany’s argument, especially, on the ranking of health threats and Ben Amis’ argument on progress. For Goklany the health threats are not from climate change, nor will they be for the foreseeable future. For Ben Ami, the answer lies in any case of more progress based on economic growth and development.

 

Both Goklany and Ben-Ami’s faith in human progress is based on inductive reasoning, ignores the key statistical problem of exponential growth, and may be over confident that limits have been correctly identified or can be overcome. Goklany might turn out to be empirically correct that in the ‘foreseeable future’, defined as 2085-2100, climate change will not be the major threat to public health, however this line of reasoning gives support to the denial of climate change in particular and obscures the requirement of addressing the sustainability of current economic structures. It also sidesteps addressing the language and discourse of risk (Haggett 2010, Painter 2013) which includes considering that human action should not be based on total certainty but on the assessment of the probabilities of high and low impact events. However, the position taken by both writers is that humanity needs more capitalist economic and technological development even if that results in a warmer world.

 

Goklany (2012) argues that humanity, in developing and using fossil fuels, both freed itself from the vagaries of nature’s provision and also has saved nature from humanity’s need to turn more of it into cropland. The inference from this argument is that we ought to continue to use fossil fuels to further human progress and to save nature from ourselves. Increasing global GDP, i.e. a wealthier world, would also be better equipped to deal with future global warming issues (Goklany 2007). This is inductive in that it assumes that this past pattern of innovation will be repeated in the future.

 

Daniel Ben-Ami (2010) also forwards this argument in ‘Ferrari’s for all –a defence of economic progress’. He points out that we are living longer and healthier lives than ever before thanks to economic development and growth. Therefore, inductively, we need more growth. The book is also based on the idea that humanity is apart from nature – human exceptualism – and is capable of enormous technical, cultural and progressive ingenuity. Humanity should strive to achieve more in terms of economic development so that everyone should have access to a Ferrari if they want it.

 

It is a counter to what he terms ‘growth scepticism’, i.e. the “tendency to undermine economic progress by indirect means” (p3). If populations are to be in better health and free from poverty then the only answer is more of the same. Those who suggest climate change is a health threat do not address this economic and development argument head on, there may be implicit acceptance of the current economic models of development. Instead there is a focus on the magnitude of climate change per se as a health threat rather than the economic structures which may drive climate change and other unsustainable practices such as deforestation.

 

Costello v Goklany

 

So, Costello et al (2009a) argued that climate change is the biggest global health threat of the 21st century’ (p1693). Goklany in the same year replied and argued that climate change is not the number one threat to humanity and questioned whether it is “the defining challenge of our age” (Goklany 2009a). Costello replied to Goklany’s riposte again in 2009, but Goklany in 2012 further rebutted that claim.

 

Goklany argued Costello et al made their claim about climate change in 2009 without a comparative analysis of the magnitude, severity and manageability of a range of health threats at that time and therefore ranking it as the No 1 threat is untenable. Goklany (2009c) argued that climate change was ranked 21st out of 24th global health threats. Goklany’s rebuttal data comes from a World Health Organisation World Health Report 2002 and Comparative Quantification of Health Risks 2004 and he uses results from “Fast Track Assessments” (FTAs) of the global impacts of global warming (Arnell et al 2002, Parry 2004). In his 2012 article he also cites Parry (1999) and the World Health Organisation’s 2009 Global Health Risks.

 

Costello et al (2009b) in reply to Goklany argued that “The ranking of climate change at 21st out of 26 risk factors was made at a time when global temperature rise was only 0·74°C, and when the effects of climate change on the other risk factors was unclear” and they claimed that there has since been substantial changes in our understanding of climate change risks. They cite two papers showing that about 1 trillion tonnes is probably the cumulative limit for all carbon emissions if we wish to stay within the 2°C “safety” limit, and that, without action, we shall exceed this limit before 2050.  They also cite a paper by Schneider (2009) who raised the prospect of worst case scenarios: warming at 3°C gives a 90% probability that Greenland will melt, raising sea levels by many metres, and that on present evidence and trends there is a 5—17% chance that temperatures will go up by 6·4°C by 2100, “a risk way above the threshold at which people would usually buy insurance”.  Goklany’s position (2012) is that the 2 degree target is irrelevant in any case and he seems happy to accept a 4 degree rise.

 

The 2013 IPCC report AR5, while accepting a pause in warming over recent years, argues that climate change is a continuing very serious issue and now post dates this difference in Goklany and Costello’s arguments which are based on data from 1999 to 2009. This will need constant revision as more scientific data is published. The IPCC WGII contribution on ‘impacts adaptation and vulnerability’ is due to be reported in March 2014. The report makes it clear that even if greenhouse gas emissions are stopped right now climate change will persists for many centuries, much of it will be irreversible characterised by impacts such as sea level rises. The last time the world was 2 degrees warmer , sea levels were 5 -10 metres higher.

 

On what to do, Goklany (2009c) argues that ’Societal resources devoted to curb carbon dioxide and other greenhouse gas emissions will be unavailable for other…more urgent tasks including vector control, developing safer water supplies or installing sanitation facilities in developing countries….’ (p69). However this sets up a false dichotomy. The decision to spend on carbon reduction is not an either/or one. There are myriad spending decisions being made, and those choices are made from a raft of competing priorities. One could equally argue that resources devoted to nuclear armaments and other military spending is unavailable also for these other urgent tasks. So to focus on emissions reduction as the spending that diverts funds away from addressing other pressing health issues is a biased view. Goklany could argue for an end to subsidies for the fossil fuel and nuclear industries, reductions in military spending, changing the international tax regimes to access wealth deposited in offshore accounts, or the introduction of a Tobin tax on financial transactions. These are admittedly biased positions and may be seen to be too left wing, and ideologically incompatible with current the neoliberal hegemony (Crouch 2011).

 

Whether funding spent on carbon reduction actually works in terms of human welfare and is less expensive than alternatives, is a valid question but has to be seen in a wider political discourse about spending decisions. His points regarding the need for poverty reduction via sustainable economic development and advancing our adaptive capacity would possibly bring broad agreement. In any case some consider that it is too late (Peters et al 2013) for mitigation and that adaptation to a warmer world is now needed. Goklany (2009b) uses the term ‘focused adaptation’ meaning taking advantage of the positive benefits of warming. If sea levels are to rise by 5-10 metres this is beyond the foreseeable future and so we should focus on economic growth and development to adapt to those future scenarios rather than wasting time resources and energy on emission curbs. However, this seems somewhat an anthropocentric view taking in little regard for biodiversity loss and ocean acidification. Both of which are also threats to human health

 

Ben Ami and Goklany put faith instead in ‘secular technological change’. This believes that

 

1) Existing technologies will become cheaper or more cost effective.

2) New technologies that are even more cost effective will become available.

 

They may well be correct. They argue the potential health threats may be addressed through human ingenuity based on economic progress and economic progress is best served by accepting the IPCC worse case scenario which would result in greater per capita GDP and thus release capital for adaptation (figure 1).

 

 

 

 

Figure 1: net GDP per capita, 1990-2200, after accounting for upper bound estimates of losses due to global warming for 4 IPCC scenarios. The warmest is A1FI (4 degrees C) and the coolest is B1 (2.1 degrees C) (source Goklany 2012)

 

 

Figure 1, therefore, indicates that if humanity has a choice, it ought to strive for the developmental path corresponding to the richest IPCC scenario (A1FI  – 4 degrees C above 1990 by 2085) notwithstanding any associated global warming. Because this increases adaptive capacity and poverty would be eliminated. Other health risks that rank higher than global warming are also associated with poverty and would thus also be eliminated. Poverty related diseases contribute to mortality and morbidity 70-80% more than warming. Mitigative capacity would be increased, therefore health improves with economic and technological development, and development encourages the ‘environmental transition’.

 

This is a very risky strategy which future generations will have to judge the merits of. There is gathering evidence beyond climate change suggesting that humanity is already transgressing other environmental limits, transgressions which will not support a ‘safe operating space’ as we enter a new era, the ‘anthropocene’. (Rockstrom et al 2009).

 

Risk Discourse

 

Goklany (2012) further argued “This paper does not address hypothesized low-probability but potentially high consequence outcomes such as a shutdown of the thermohaline circulation or the melting of the Greenland and Antarctica Ice Sheets, which have been deemed unlikely to occur in the foreseeable future by both the IPCC and the US Global Change Research Program, among others”, although the IPCC has since (2013) stated that it is “very unlikely that the Atlantic Meridional Overturning Circulation (part of the global thermohaline) will undergo abrupt transition or collapse…however, a collapse beyond the 21st century…cannot be excluded” (IPCC 2013 SPM-17).

Goklany, in not addressing these risks, appears to dismiss the need for ‘risk discourse’ to frame public debate relying on ‘kicking into the long grass’ serious consequences of climate change.

 

‘Risk’ is already an essential part of everyone’s experience, including in the world of insurance, health and investment. It is not uncommon for people to insure against low probability but high impact events such as house fire, or critical illness. People also invest for the long term, for example in a pension that might take over 40 years to pay off. It is thus arguable that the thermohaline shutdown and ice sheets melts may well be just the sort of low probability but high impact events that humanity ought to be insuring against and taking measures to prevent through carbon emissions reductions. Painter (2013) suggests therefore that elements of risk discourse would provide a better frame for debate than disaster and uncertainty frames, which are both more prevalent in news media.

 

Space precludes an examination of the concept of exponential growth and the requirement to produce resources to meet the needs of potentially 9-10 billion people by 2050. Costello et al’s position seems to be that climate change will stress ecosystems before we have time to adapt and that both direct and indirect affects will adversely impact on global health. They are not so sanguine about our ability to live within our limits.

 

 

Conclusion

 

Goklany is correct to point out that currently that health threats arise from poverty and underdevelopment. In this assessment he is in accord with the WHO social determinants of health approach. Costello et al have not dismissed this and as public health experts would probably accept a similar position. A focus on the social determinants of health to address poverty needs to run alongside carbon reductions or else the good work could be undone by a low probability but high impact event such as the melting of the Arctic Ice. They differ on when climate change will be a health threat and importantly on how to address it. Goklany and Ben Ami appear to be on the market driven economic development model as the answer whereas Costello et al argue for more immediate state and public intervention in addressing climate change. All however do not critique the fundamental neoliberal economic model or call for alternative economic ‘no growth’ models (Jackson 2009).  There is little doubt that we are running an experiment with the climate, there is agreement that this will impact on global health but the answer seems to be either more or less tweaking with capitalist growth models rather than a sustained examination of alternatives.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

 

 

Allen MR, Frame DJ, Huntingford C, et al. (2009) Warming caused by cumulative carbon emissions towards the trillionth tonne. Nature pp 458: 1163-1166

 

Arnell N.W, et al. (2002) The consequences of CO2 stabilization

for the impacts of climate change. Climatic Change 53 pp 413-446.

 

BBC (2013) Climate change threatens our planet, our only home.http://www.bbc.co.uk/news/science-environment-24292615 accessed 1st October 2013

 

Ben-Ami, D. (2010) Ferrari’s for All – In defence of economic progress.  Policy Press. University of Bristol.

 

Costello, A., et al (2009a) ‘Managing the health effects of climate change’, The Lancet, 373, pp. 1693 – 1733.

 

Costello, A., Maslin, M., and Montgomery, H. (2009b) Climate change is not the biggest global health threat  – author’s reply. The Lancet. 374 9694 pp 974-975

 

Crouch, C. (2011) The strange non death of neoliberalism. Polity Press Bristol.

 

Delingpole, J. (2013) Global warming believers are feeling the heat. The Telegraph. http://blogs.telegraph.co.uk/news/jamesdelingpole/100238047/global-warming-believers-are-feeling-the-heat/

 

Goklany I. (2007) Is a Richer-but-warmer World Better than Poorer-but-cooler Worlds? Energy & Environment, 18 (7 and 8) pp1023–1048

 

Goklany I. (2009a) Is climate change the “defining challenge of our age”? Energy Environment, 20 pp 279-302

 

Goklany, I. (2009b) Climate change is not the biggest global health threat. The Lancet, 374 9694 pp 973 – 974.

 

Goklany, I. (2009c) Global Health Threats: Global Warming in Perspective. Journal of American Physicians and Surgeons 14 (3) pp 69-75 available at http://www.jpands.org/vol14no3/goklany.pdf

 

Goklany, I. (2012) Is climate change the number one threat to humanity? October 17th, available at http://wattsupwiththat.com/2012/10/17/is-climate-change-the-number-one-threat-to-humanity/

 

Goklany, I. (2012) Humanity Unbound: How Fossil Fuels Saved Humanity from Nature and Nature from Humanity. December 19th Policy Analysis, No. 715, Cato Institute, Washington, DC. Available at SSRN: http://ssrn.com/abstract=2194659

 

Haggett, C. (2010) Discourses of Risk: the construction of responsibility and blame: using discourse analysis to understand contested risks and the management of blame and accountability. Lambert Academic Publishing.

 

Intergovernmental Panel on Climate change (2013) Summary for policy makers. WG1 AR5 September 27th. IPCC

 

Jackson, T. (2009) Prosperity without growth. The transition to a sustainable economy. Sustainable Development Commission. http://www.sd-commission.org.uk/data/files/publications/prosperity_without_growth_report.pdf

 

Mason, J. (2013) UK secretary of state reveals his depth of knowledge of climate change (not!). Skeptical Science. http://www.skepticalscience.com/paterson-on-climate.html

 

Meinshausen M, Meinshausen N, Hare W, et al. (2009) Greenhouse-gas emission targets for limiting global warming to 2°C. Nature pp 458: 1158-1162

 

McGrath, M. (2013) IPCC climate report: humans ‘dominant cause’ of warming. 27th September. http://www.bbc.co.uk/news/science-environment-24292615 accessed 1st october 2013

 

Painter, J. (2013) Climate change in the media. Reporting risk and uncertainty. I.B. Tauris and Co. Reuters Institute for the Study of Journalism, University of Oxford.

 

Parry M.L. and Livermore M., eds. (1999) A new assessment of the global effects of climate change. Global Environmental Change 1999, 9 S1–S107

 

Parry M.L, ed. (2004) Special issue: an assessment of the global effects of climate change under SRES emissions and socio-economic scenarios. Global Environmental Change.14 pp1-99.

 

Parry M, Palutikof J, Hanson C, Lowe J. (2008) Squaring up to reality. http://www.nature.com/climate/2008/0806/full/climate.2008.50.html

 

Peters, G., Andrew, R., Boden, T., Canadell, J., Ciais, P., Le Quere, C., Marland, G., Raupach, M. and Wilson, C. (2013) The Challenge to keep global warming below 2 degrees C. Nature Climate Change. 3, 4-6 doi:10.1038/nclimate1783

 

Plehwe, D., Walpen, B. and Neunhoffer (2006) Neoliberal Hegemony. A global critique. Routledge. London.

 

Rockström, J et al. (2009) Planetary boundaries: Exploring the safe operating space for humanity. Ecology and Society [online] 14, 32. www.ecologyandsociety.org/vol14/iss2/art32

 

Schneider S. The worst case scenario. Nature 2009; 458: 1104-1105

 

Syal, R. (2013) Global warming can have a positive side, says Owen Paterson. 30th September. The Guardian  http://www.theguardian.com/environment/2013/sep/30/owen-paterson-minister-climate-change-advantages

 

Stakaityte, G. (2013) Libertarianism and (climate) science denial. The Libertarian. http://the-libertarian.co.uk/libertarianism-and-climate-science-denial/

 

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Making our own histories – we can change things if we want to and are free to.

Musing on the freedom to act in society, and on the nature of capitalism and its pernicious effects upon us, it might do to consider that we are free to change and we are not free to change. Capitalism at once exists and acts and feels like a cage while at the same time does not exist and is also only a product of our own imaginations and our social relationships that we have chosen to engage in. This matters because real lives are affected by the decisions that others in positions of power take, and they take these decisions as if capitalism is immutable, all pervading, inevitable…as a fact of life. This then justifies the use of batons, tear gas and surveillance drones in civil society and in putting down protest, and it justifies fixing the legal, financial and political framework so that big money fulfills big money’s needs.

In response to a recent email exchange I engaged in, a suggestion was made to me that there is a tendency to ‘objectify’ capitalism in many discussions – to make it seem indeed like a cage – a thing that has its own almost material existence and ‘essence’. This means that we may talk about capitalism as if it has objective existence and also a fixed nature. Capitalism is, in Emile Durkheim’s phrase, ‘sui generis’ – ‘of its own kind’. This derives from thinking that capitalist society over time replaces individuals with others, yet the ‘essence’ of society will not necessarily change. Over the course of a few decades, many individuals die and are replaced, however, the society retains its distinctive character. It is a thing of itself existing independently of individuals. An entire society that is built in this manner has its own ‘essence’. It has this ‘essence’ before any individual currently living in it is born, and is therefore “independent of any individual” existing almost as an ‘objective fact.’ We acknowledge this objective existence when we use such phrases as “Society today is worse/better than it was back in the day when…”

Some commentators might use different labels for capitalism. For example ‘casino capitalism‘ or ‘responsible capitalism‘ which reflects thier differing understandings of what capitalist society might be like. This tendency to label and to treat it as an objective fact, however, may overlook the fact that capitalism, like any ism, is dynamic and on the move. Historically that has been true: we have seen mercantile capitalism, industrial capitalism, post industrial or financial capitalism. Nonetheless and however it has been labelled, we must remember that capitalism is not an ‘objective fact’, although it can certainly feel that way especially to those who feel the full force of economic decisions made in far away board rooms.

Capitalism is a dynamic ever changing social system which finds expression and manifestation in human social relationships. The ‘objectivity’ of capitalism is a chimera; we may reify it and miss the essential nature of human decision making and social relationships that underpins it. Susan Strange argued “economists simply do not understand how the global economy works” due to a poor understanding of power and an over-reliance on abstract economic models. In other words, economist are apt to treat capitalism and the working of markets based on a false premise: that there is a objective system that can be understood theoretically using mathematics and a theory of self interested utility maximising rational actors, the ‘homo economicus’ of JS Mill and Adam Smith. To be fair to Smith he tempered this view in his Theory of Moral Sentiments.

What economists often miss is that what we are talking about here is a set of human relationships characterised by an imbalance of power.

“Men make their own history, but they do not make it as they please; they do not make it under self-selected circumstances, but under circumstances existing already, given and transmitted from the past” (Marx). What have ‘we’ been given and transmitted from the past? Anti capitalist sentiment such as some of us in the sustainability or others in the Transition Towns movements express, are confronting Big Oil, and a cluster of high carbon social systems (John Urry) which are based on certain capitalist relations of production. ‘We’ ignore capitalist class relations at our peril. ‘We’ may confront power elites who have made, and are trying to continue to make, history in their own image: how that history will pan out depends on our collective and individual responses to Power, e.g. the Military-Industrial-Security complex, the World Bank, IMF, OECD, G8, Davos, Bilderberg (?), EU and other Regional blocs, the Trioka, the Corporate Class Executive and the Political Power Elite. We, e.g. ‘anti-capitalists’ or the Transition Towns or Environmentalists, are trying to remake history; history as we please, but within a certain socio-political context and power play not of our choosing. We do not have ‘self selected circumstances’ and that is what makes capitalism feel like a cage. Ask yourself: who has the guns?

For an example of circumstances being shaped by the powerful, note how successful the right wing press has been in sowing the seeds of doubt in the population about climate change,  and also for blaming the poor for their position while supporting austerity in the midst of one the greatest transfers of wealth from poor to uber rich (the 0.01%) we have seen, and the movement of private bank debt to sovereign public debt. There is ample evidence that the neoliberal agenda, which unites many of groups mentioned above, are antithetical to a ‘no growth economy’ and to social democracy.  In the West, there is only one game in town: growth based on neoliberal economics.

There are countervailing voices, e.g. Paul Hawken’s ‘Blessed Unrest’,  but some are increasingly despairing, Will Hutton articulates this well.

The post financial crash shifts of 2008 are playing out, but we don’t know in 10 years what this will look like. So far however, report after report shows the wealthy elite entrenching their power and wealth* while the occupy ‘movement’, the indignados, the precariat, come under increasing demonisation, e.g. skivers v strivers, surveillance and crack downs, using para militiary type tactics. The monolith of Capitalism stands while we crash against it.

Capitalist social relationships are backed by ideology and often force. Some argue it is the best of a bad lot, and that like democracy it is the worse system we have except for all the others, that it is the only game in town. Marx himself marvelled at its ability to produce abundance. However, is this really the best we can do? Is this really the best world in the best of all possible worlds? Growth capitalism, and there is no other sort, is leading us towards ecological disaster, while the social determinants of health result in inequalities in health whereby millions die prematurely and needlessly because of our socio-political arrangements.  Many of us bluster and blog and rage and rant and protest, some of us quietly get on with living differently, remaking our social relationships as best we can.

We are free but everywhere we are in chains.

 

*the richest 1,000 persons, just 0.003% of the adult population, increased their wealth over the last three years by £155bn. That is enough for themselves alone to pay off the entire current UK budget deficit and still leave them with £30bn to spare.

marxism and health care

Marxism and Health Care

You can also find this paper on my academic website:

http://plymouth.academia.edu/bennygoodman/Papers

 

Contents

 

 

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

 

 

Introduction

 

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”.

 

 

 

References

 

 

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.

 

How responsible am I for my health?

To answer this question, we need to understand what determines health and to focus on the social determinants. There are of course biological determinants, for example familial hyperlipidaemia which may have genetic antecedents, however to discuss biology is to make the original question redundant. To move on to personal responsibility for health I take the position of the ‘social determinants of health’ approach which argues:

 

“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” : http://www.who.int/social_determinants/en/

 

Inherent in that description is the idea that the society in which you grow up ‘acts’ upon you and thus determines your health. Emile Durkhiem (1895) wrote about what we might think of as ‘social forces’ acting upon us; the sociologist, he suggested, is to  ‘treat social facts as things’ which are

 

“a category of facts which present very special characteristics: they consist of manners of acting, thinking, and feeling external to the individual, which are invested with a coercive power by virtue of which they exercise control over him” (p52).

 

Note the use of the word coercive power, which suggests that society coerces us into a particular manner of thoughts, feelings and behaviours. We are, in this view,  crudely determined by the society we grow up in. It is fair to say that social theory has moved on from crude determinism.

 

What however is still being discussed is the degree to which we exercise our own ‘agency’; our ability to act upon our own autonomous thinking, feeling, manners, customs and norms as free ‘agents’. To that we also consider the degree to which social ‘structures’,  family, schools, occupations, socio-economic status, gender and ethnicity, act upon us and constrain social and individual action. This sets up the agency-structure dichotomy. Many sociologists tend to emphasise social structure as guiding behaviour while historians emphasise agency in human affairs. We need to come to an understanding that gets away from crude models of the either/or of structure or agency.

 

Agency

 

To take the position that we are 100% responsible for one’s health status requires the ability to make choices free from external constraints…to act and behave in a manner that enhances our health status unencumbered by external forces, such as lack of clean water or the advertising and availability of certain products, that would ‘act’ upon us. We must, in this view, be free agents, indeed in this view, we are free agents, able to make autonomous decisions. It also requires us to be able to be critically self reflective of internal thought processes (our ‘inner conversations’) and subconscious desires that lead us into unhealthy behaviours. Not only must we be critically self reflective so that we come to understand our inner motives but we must also be able to act upon that knowledge. When we reach for a bottle of sugared water in a supermarket which is packaged to appeal to a particular lifestyle, but which has no health benefit whatsoever and indeed is linked to dental caries if consumed in place of plain old water, we do so in the full knowledge of its health effects and we do so as uncoerced free agents.  To be 100% responsible we need to be 100% free agents of our destinies. This is the agency end of the argument.

 

 

Structure

 

On the other hand we note that social inequalities are linked to distinct patterns of mortality and morbidity that often follows socio-economic status. These patterns are what we call ‘health inequalities’,  and so we come to think that society is working upon us to create patterns of health and illness. This is the crude ‘structure’ approach, which draws from material deprivation theories of ill health. It is if being of a lower social class acts upon us as a social force. Danny Dorling (2013) certainly suggests that health and social inequalities are not two separate entities but ought to be seen as one phenomenon, that is not to say however that Dorling adheres to structural determinism.

 

 

Structure-Agency

 

Graham Scambler (2013) asks us to consider ‘agency’ as well in a more nuanced understanding of our responsibility for health and to do this he refers to the work of Margaret Archer and the idea of ‘inner conversations’.

 

Scambler argues:

 

“Humans…are simultaneously the products of biological, psychological and social mechanisms while retaining their agency…socially structured without being structurally determined” (p147).

 

Who, and what, we are arises socially, as well as from our physical biological selves and as well as from our psychological thinking and motivations. Society structures who we are without determining who we are. Your family life structures you – it gave you language, culture, hopes and aspirations but does not determine these aspects of your self. There is room for agency.

 

We need to consider how our ‘inner conversations’ shape our responses to how we see and feel the way external social structures such as our families, and cultural powers, such as occupational positions or the food industry, act upon us. These responses then result in our social behaviours and values. That is why similar social structures produce similar patterns of behaviour but does not determine them. As an example, take dialect and accent. Social structures ‘determine’ whether you will grow up speaking with a particular accent but does not make it fixed. A child does not actively choose to speak certain words in a certain way, but as with many in their peer group, it almost looks as if they were determined to do so. The same goes with later health choices.

 

Added to that is the structure of opportunities a society provides children with. In a social world where cigarettes are seen to be the norm, and also are imbued with notions of adulthood, it is not surprising that many children ‘choose’ to smoke. Agency however means that some children are free not to smoke and choose not to. Some will cite trying it and being put off by taste, but not all. Their ‘inner conversation’ tells them to get past that barrier. The social structure of norms and expectation around smoking is tempered by agency, the freedom not to act in this case. So why and
how do we exercise agency in social circumstances? This is a question to return to below, first another example.

 

In ‘Oranges are not the only fruit’ – a coming of age novel, Jeanette Winterson describes how growing up a lesbian in a strict religious family acted upon her choices and feelings without determining the outcome, she did not grow up to be a member of her family’s Pentecostal church and to renounce her sexuality. Her ‘inner conversation’ resulted in a rejection of the strict religious lifestyle and belief system. In her case her behaviours and values were socially structured but not determined. Of course in many other families children do acquire the religion of their parents, their inner conversations lead them in what looks like a deterministic way.

 

So we need to see that agency works within a context, e.g. a religious family, in which the social outcome is structured by that family but not determined by it. How does happen? Lets consider the structure of family.

 

  1. The family provides the external, objective, situation and context which the free agent is then confronted with. The agent does not have a choice about this. The family provides situations of constraint and opportunities for the ‘agent’.  Lets change that term ’agent’ for ‘child’. This objective situation operates in relation to…
  2. …the child who has their own internal, subjective, concerns in relation to physical nature, social realities and cultural practices. In Winterson’s case this subjective concern involved her awaking sexuality which ran counter to the family’s religious teaching. Her inner conversations told her something, and of course this is where biology might intervene.
  3. The action undertaken by Winterson was partly produced by her ‘reflexive deliberations’, i.e. her internal thinking about the situation and her own concerns. Children determine their choices of practical action in relation to their objective circumstances. Some choices will require quite deep reflexive thinking and commitment, especially if the inner conversation is saying something like “I feel sexual attraction to girls” in the face of objective situations, i.e. the family, which says “same sex attraction is sinful’.

 

In Wintersons’ case her agency trumped social structure.

 

 

Let’s consider a health example using the same steps:

 

 

  1. The family buys mainly processed foods from supermarkets, they do not use local organic farmer’s markets as they are viewed as expensive and require a drive that is further away. In addition the parents buy sugared water as it is cheap and not seen as unhealthy. This is the objective context that structures the child’s responses.
  2. The child’s own inner subjective concerns do not entail a detailed analysis of the food production, manufacturing, distribution and marketing process. The child experiences tasty, often sweet and satisfyingly available foods. The inner conversation says “I like this” and takes note of what peers and family say and do.
  3. The child’s action does not involve a rejection of the food choices but actively embraces them. In this case the inner reflexive deliberations do not run counter to either family values or social values and requires little in the way of critical reflection.

 

Social structure in this case provides the contexts for agency not to challenge it.

 

 

These two very short examples, illustrate the interplay between structure and agency and how behaviour is ‘structured but not determined’. However, one may understand how forceful structures may appear to be in shaping the individual responses. I think this is what is meant by the use of the word ‘social determinants’ in the ‘SD of health’ approach.

 

So far, this is not so complex to understand. We know that social structures do not determine behaviour otherwise there would not be any social change. However we also recognise the power that certain social ‘forces’ have in reproducing cultural practices such as religious observance or eating habits.

 

Modes of reflexivity

 

We need to then consider the interplay between structure and agency and consider why in one case agency ran counter to social pressures, but not only ran counter it overcame them. Is the inner conversation that is driven by sexuality particularly powerful? Scambler’s point regarding the interplay of biology, psychology and social structures is important to remember when considering this.

 

Margaret Archer (in Scambler 2013) argues that the interplay between our internal concerns and our social and environmental contexts is shaped what she calls a ‘mode of reflexivity’. A ‘mode of reflexivity’ is the manner in which we think about our thinking, our ‘inner conversations’ that then shape our actions. Archer outlines 4 ‘ideal types’ of modes of reflexivity which she drew from empirical studies:

 

  1. Communicative reflexivity: our inner conversations require confirmation and communication with others before we act. We all do this but for some people this is the dominant mode and it requires that we must pay attention to what others are thinking and take this into account,  and action will be based on what those others are thinking. These others may be peers, family and the local people, hence the tendency to social immobility. A student nurse who is dominated by communicative reflexivity will consider what their peers and mentors are thinking and will want to act in such a way as to fit in. Consensus is sought after.
  2. Autonomous reflexivity: our inner conservation requires no confirmation with others, they are self sustained and lead directly to action. Here we have a ‘lone inner dialogue’  which then leads to action. If this is dominant then the person will not seek or require the involvement of others. Autonomous reflexives might use communicative reflexivity but it is not strictly necessary. A student nurse thinking in this way will act upon their own deliberations and not always require consultation or considering others’ thinking. Outcome rather than consensus is important. Was Winterson, in relation to her sexuality, exercising autonomous reflexivity?
  3. Meta reflexivity: our inner conversation is subjected to criticism and we critique whether effective action in society is possible before we act. This is about self monitoring, our thinking about how we think, and when dominant results in self questioning such as ‘why did I say that?’, ‘why am I so reticent to say what I think?’. We may be self critical and concern ourselves with the moral worth of what we do. Values more than consensus or outcome is important. Students nurses are introduced to the idea of critical reflection but it is debatable whether they are skilled at this by the end of a three year programme.
  4. Fractured reflexivity: our internal conversation intensify the disorientation and distress we already feel and this leads to inaction. Some children, brought up in abusive and neglectful homes, may only develop fractured reflexivity and thus turn in on themselves and withdraw.

 

 

This typology delves further into the nature of agency and explains how society and its structures might provide a framework for action but the inner conversation indicate how that structure ‘determines’ action. In the example above we might hypothesis that Winterson was an autonomous reflexive, perhaps driven by nascent sexuality that was so at odds with her family socialisation. It is a moot point to consider that if Winterson was a dominant communicative reflexive, whether her resistance would have been quite so forceful.

 

The child who eats junk food sitting in front of the TV who is also a communicative reflexive may be ‘determined’ to be obese. Their inner conversation engages with the voices and thinking of their peers who may all be doing the same thing and who consider that this diet is typical and ‘normal’. Children of course may not have developed meta reflexivity, they may not have been taught to do so either by family or school. They may therefore lack critical self reflection. Indeed some child rearing practices may see critical self reflection as self indulgent and not helpful to learning the skills and knowledge needed to make one’s way in the world. Children who are fractured reflexives may be so because of fractured and disorientating childhood experiences and thus be in too fragile a psychological state to consider their own abilities to take action.

 

The life chances, and thus health choices, that result from choices do so from within people’s social position in which they exercise Autonomous, Communicative, Meta and Fractured reflexivity. Given an abusive childhood, lived in material deprivation, and without the benefit of escape via public school and University education, a child’s life chances are in this sense determined. If that child was an autonomous reflexive early in life they might grow to be to fight against disadvantage, however it might be the case that very early childhood development experiences are linked to certain modes of reflexivity. We don’t know. However, even an autonomous reflexive will struggle against damaging patterns of life they have no option but to choose from.

 

So to explain why people act differently in similar social situations may be partly down to the inner dominant mode of reflexivity. Their choices however are still structured. A child cannot choose to go to Eton and thus up their chances of becoming Prime Minister. A Duchess does not have to choose between paying a utility bill or buying food for her children. Neither can she ‘choose’ to become a prostitute. Her structure of opportunities however make it far easier  to make healthier life choices in terms of diet and exercise but perhaps, not when it comes to eating disorders. A different social structure provides a very different context for those decisions.

 

We still do not know why a person, however, ‘chooses’ a mode of reflexivity. What makes one child an autonomous reflexive and others communicative? Social structures provide the context in which these modes operate and so offer objectives choices in which to exercise them. As we do not know the relationship between the physical material brain and consciousness it is no surprise that we can’t yet determine in the last instance why people develop a certain cognitive structure of thinking. However, Susan Gerhardt in ‘The Selfish Society’ outlines the importance of early childhood development and the development of empathy which seems to link with communicative reflexivity as it takes account of others thoughts and feelings. Autonomous reflexives may develop out of a different childhood experience.

 

So, are we 100% responsible for our health? Of course not. Ask a child in Syria right now. The external social world has force, and sometimes that comes armed.

 

 

 

 

 

References.

 

 

Dorling, D. (2013) Unequal health. Policy Press. University of Bristol

 

Durkheim, E. (1895) The Rules of Sociological Method. New York. Free Press.

 

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.

Twat.

Our social environment encourages obesity

our social environment encourages obesity

Your health depends in where you live

Your health depends in where you live

Defining Health

Defining Health

 

WHO definition of Health

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.

The Definition has not been amended since 1948.

This is a pretty idealistic view of health and does not take into account people with a mental or physical disability, who by the above definition are not healthy. Athletes who took part in the Paralympics in London in 2012 may disagree with the above as perhaps would Stephen Fry, who publicly discussed his own Bipolar disorder. The word ‘complete’ is controversial

However it allows us to list the:

Physical

Mental

Social

These 3 aspects of health take us beyond a biophysical definition.

 

There are other classificatory systems in existence such as the WHO Family of International Classifications, including the International Classification of Functioning, Disability and Health (ICF) and the International Classification of Diseases (ICD). These are commonly used to define and measure the components of health.

The WHO’s 1986 Ottawa Charter for Health Promotion further stated that health is not just a state, but also “a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities.”

So in this charter, health is seen as a ‘resource’.

The WHO also defines mental health as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”.

Again this might sound a bit too idealistic in that people with a mental illness can also live ‘normal’ (whatever that is) lives. Why are they not healthy then?

The New Economics Foundation (Aked and Thompson 2011) argue that there are 5 ways to well-being (‘well-being’ is a component of health):

1. Connect…

With the people around you. With family, friends, colleagues and neighbours. At home, work, school or in your local community. Think of these as the cornerstones of your life and invest time in developing them. Building these connections will support and enrich you every day.

2. Be active…

Go for a walk or run. Step outside. Cycle. Play a game. Garden. Dance.Exercising makes you feel good. Most importantly, discover a physical activity you enjoy and that suits your level of mobility and fitness.

3. Take notice…

Be curious. Catch sight of the beautiful. Remark on the unusual. Notice the changing seasons. Savour the moment, whether you are walking to work, eating lunch or talking to friends. Be aware of the world around you and what you are feeling. Reflecting on your experiences will help you appreciate what matters to you.

4. Keep learning…

Try something new. Rediscover an old interest. Sign up for that course. Take on a different responsibility at work. Fix a bike. Learn to play an instrument or how to cook your favourite food. Set a challenge you will enjoy achieving. Learning new things will make you more confident as well as being fun.

5. Give…

Do something nice for a friend, or a stranger. Thank someone. Smile. Volunteer your time. Join a community group. Look out, as well as in. Seeing yourself, and your happiness, linked to the wider community can be incredibly rewarding and creates connections with the people around you.

Social Determinants of Health

The approach that has gained influence is that of understanding health as having social determinants (WHO 2008), while Barton and Grant (2006) have developed a health map illustrating the complex interplay of the physical and global environment, social relationships and individual biology.

The social determinants of health approach (WHO 2008) suggests ‘Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death. We watch in wonder as life expectancy and good health continue to increase in parts of the world and in alarm as they fail to improve in others’.

Thus we clearly see a link between ideas about what health is and social justice. Health is therefore inextricably bound up with how we organise our societies. It is no longer to be understood as a bio-physical concept only. WHO argues:

‘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’.

See http://www.who.int/social_determinants/en/  (Commission on Social Determinants of Health 2008).

The Health Map

see: http://eprints.uwe.ac.uk/7863/2/The_health_map_2006_JRSH_article_-_post_print.pdf

Barton and Grant at about the same time produced a ‘health map’ and argued:

‘The environment in which we live is a major determinant of health and well-being. Modern town planning originated in the nineteenth century in response to basic health problems, but in the intervening years has become largely divorced from health. We have been literally building unhealthy conditions into our local human habitat.

 

Recent concerns about levels of physical activity, obesity, asthma and increasing environmental inequality have put planning back on the health agenda. It is widely recognised that public health is being compromised by both the manner of human intervention in the natural world and the manner of development activity in our built environment (Larkin, 2003). However, taking action is not necessarily simple. The links between health and settlements are often indirect and complex. A tool to improve understanding and foster collaboration between planning and health decision-makers is badly needed’.

The health map was inspired by theories about how the eco system interacts with biological species, which is clearly seen in the outer ring. An implication of seeing health in this manner is that the individual’s health is caught up in a web of complex systems and requires the ‘health’ of all manner of interacting physical and non-physical phenomena.

Healthy Planet, Healthy Lives?

Another view firmly connects the planet to people as a unitary whole arguing that as a result an individual is not healthy if the planet is not. This critiques a dualist view of reality in which we can separate physical human bodies from the physical universe, seeing them as two distinct entities. This may seem obvious to those of us living in western societies, as this is how we are brought up to consider how the world is. This has a long tradition but other philosophical traditions make no distinction between ‘man’ and ‘nature’:

“In this century it has become clear that the fundamental social problem is now the relationship between humankind as a whole and our global environment” (Loy 1988 p 302).

David Loy (1988 p140) argues, when contrasting Eastern traditions (nondualist) with mainly Western (Cartesian) dualism, that

“….there is no distinction between “internal” (mental) and “external” (physical), which means that trees and rocks and clouds, if they are not juxtaposed in memory with the “I” concept, will be experienced to be as much “my” mind as thought and feelings”.

This then is a non-dualist viewpoint in which ‘us’ includes the biosphere, we are indivisible as human beings from all life forms and all matter.

Industrialization has required the control of nature to serve humanities purposes. This control is based upon seeing ‘the self’ in opposition to nature, which Yagelski (2011) calls  ‘the problem of the self ‘:

“My argument here is that the prevailing Western sense of the self as an autonomous, thinking being that exists separately from the natural or physical world is really at the heart of the life-threatening environmental problems we face”.

 

These problems include: Ocean acidification, fertile soil erosion, species loss and the loss of biodiversity, fish species depletion, imbalances in the nitrogen and phosphorous cycles, fresh water scarcities, chemical pollution and stratospheric ozone depletion.

Rockström et al (2009) suggest that we need to urgently consider these issues to ensure there is a ‘safe operating space for humanity’.

Another view on health stemming from philosophers such as Aristotle who discussed eudaemonia or ‘flourishing’, or Amartya Sens’ views on ‘capabilities’ as an aspect of human health welfare:

Sen argued for five components in assessing ‘capability’:

1. The importance of real freedoms in the assessment of a person’s advantage.

2. Individual differences in the ability to transform resources into valuable activities.

3. The multi-variate nature of activities giving rise to happiness.

4. A balance of materialistic and nonmaterialistic factors in evaluating human welfare.

5. Concern for the distribution of opportunities within society.

This really stretches definitions of health to include ideas around welfare and the social and economic conditions for it.

Summary

Health involves our physical selves, the biology of our bodies which does not have to ‘perfect’. However health also involves our mental well-being, our abilities to cope with the world. Health involves social relationships and communities. Health involves our relationship to eco systems and other species. Health is therefore a complex concept that can be defined in various ways according to the perspectives we care to take on it.

Aked, J., and Thompson, S. (2011) Five ways to wellbeing. New applications, new ways of thinking. New Economics Foundation. London http://www.neweconomics.org/sites/neweconomics.org/files/Five_Ways_to_Wellbeing.pdf

Barton, H. and Grant, M. (2006) A health map for the local human

habitat.  The Journal for the Royal Society for the Promotion of

Health, 126 (6). pp. 252-253. ISSN 1466-4240

Larkin, M., (2003), Can cities be designed to fight obesity, The Lancet, 362, pp1046-7

Rockström, J., W. Steffen, K. Noone, Å. Persson, F. S. Chapin, III, E. Lambin, T. M. Lenton, M. Scheffer, C. Folke, H. Schellnhuber, B. Nykvist, C. A. De Wit, T. Hughes, S. van der Leeuw, H. Rodhe, S. Sörlin, P., K. Snyder, R. Costanza, U. Svedin, M. Falkenmark, L. Karlberg, R. W. Corell, V. J. Fabry, J. Hansen, B., Walker, D. Liverman, K. Richardson, P. Crutzen, and J. Foley. (2009). Planetary boundaries: exploring the safe operating space for humanity. Ecology and Society 14(2): 32. [online] URL: http://www.ecologyandsociety.org/vol14/iss2/art32/

World Health Organization. (1986) The Ottawa Charter for Health Promotion. Adopted at the First International Conference on Health Promotion, Ottawa, 21 November 1986 – WHO/HPR/HEP/95.1.

World Health Organization (2004). Promoting Mental Health: Concepts, Emerging evidence, Practice: A report of the World Health Organization, Department of Mental Health and Substance Abuse in collaboration with the Victorian Health Promotion Foundation and the University of Melbourne. World Health Organization. Geneva

Yagelski, R. [online] Computers, Literacy and Being. Teaching with technology for a sustainable futurehttp://www.albany.edu/faculty/rpy95/webtext/

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