Tag: Sociology health and illness

An unachievable utopia in nursing practice? Utopia will not be paid for by the ‘Greedy Bastards’

The Politics of Nursing: Care is expensive: get used to it.  

Introduction

By now many nurses will be feeling a mixture of despair and insult they have received following the many reports into poor quality care. These feelings can lead to disenchantment, disengagement and disillusionment with both politics and health care delivery. Jane Salvage (1985) suggested that nurses ‘wake up and get out from under’ and while recognising that for some this past entreaty to engage politically may further entrench those feelings, the need for nurses and nursing to do so has not diminished. As Stuckler and Basu (2010) argue, government policy becomes a matter of life and death as ‘Austerity is killing people’. Nurses are part of the front line in promoting health and caring for those who are ill or living with chronic conditions. Their work is therefore framed by politics and political decisions. The bottom line is that there is a ‘bottom line’ to care, societies prioritise resources depending on their values, however there is not a level playing field in this regard. Care is under resourced, undervalued and often invisible. As millions of people in the UK, and billions across the globe, experience a daily struggle to both give and receive care Nursing must ally itself with the progressive forces which seek to redress the balance forces of power which currently results in gross inequalities in health and poorly funded care provision. In this article I wish to remove the ‘flowers from the chains’ so that we more clearly see what holds us back from progress in care giving.

The Politics of care

This summary of a recent article by Curtis (2013) is worth reading as it sets up what some are experiencing as they struggle to reconcile care and the cultures that surround it:

“Nursing faculty are facing challenges in facilitating student learning of complex concepts such as compassionate practice. There is currently an international concern that student nurses are not being adequately prepared for compassion to flourish and for compassionate practice to be sustained upon professional qualification…..nurse teachers recognise the importance of the professional ideal of compassionate practice alongside specific challenges this expectation presents. They have concerns about how the economically constrained and target driven (my emphasis) practice reality faced by RNs promotes compassionate practice, and that students are left feeling vulnerable to dissonance between learned professional ideals and the RNs’ practice reality they witness”.

A key point made in the article is that of the requirement for strong nurse leadership in clinical practice to deal with those factors that make care and compassion difficult to practice fully. That being said, no amount of good leadership will address the basic problem of the cost of caring: ‘who pays?’ Poor quality care is the fault of the person giving it, personal accountability for neglect and abuse cannot be sidestepped. However, we need to bring our sociological imaginations to bear so that we can more fully understand the antecedents to abusive institutional care. These include poorly funded care provision for a low status Cinderella service.

Too much of the discussion of the failings in care do not take into account the political economy of care in societies and the historical antecedents that have brought us to where we are. Instead, we get discussions around changing ‘cultures’. Reconciling professional ideals to actual practice is very difficult given the organisational cultures many nurses work in, and the almost grudging support given to nurses by the political system set up by what Graham Scambler (2012) calls the Corporate Class Executive (CCE) and the Political Power Elite (PPE). The bottom line, and that is a phrase the CCE recognise, is that care costs money. One of the critiques of the Mid Staffs tragedy was that corporate self-interest was put ahead of patients’ safety (Francis (2013).

There have been many reports regarding the health and social care of elderly people and it seems to be that their needs are outstripping both private and public provision for them. J K Galbraith coined the phrase ‘private affluence-public squalor’ to describe the mismatch between what is resourced in the private sector and the public:

There’s no question that in my lifetime, the contrast between what I called private affluence and public squalor has become very much greater. What do we worry about? We worry about our schools. We worry about our public recreational facilities. We worry about our law enforcement and our public housing. All of the things that bear upon our standard of living are in the public sector. We don’t worry about the supply of automobiles. We don’t even worry about the supply of foods. Things that come from the private sector are in abundant supply; things that depend on the public sector are widely a problem. We’re a world, as I said in The Affluent Society, of filthy streets and clean houses, poor schools and expensive television. I consider that contrast to be one of my most successful arguments”. (interviewed in 2000).

Galbraith first wrote about this process in 1958.

As governments embrace austerity policies, this tendency for capitalism to funnel resources, research and development into goods and services that make a return while ignoring public provision for those things that do not have immediate impacts on improving shareholder value or the price of stocks, increases. Care is seen as a cost and not a benefit to those who decide where the investments should be made. Private care companies will provide care with an eye to the balance sheet. This results in hiring under educated and poorly trained staff who too often lack supervision and development in high patient to staff ratios (Salvage 2012). The NHS is no different, but is also now handicapped by various factors making its provision seemingly expensive for society. While the current (2013) Chancellor states that NHS spending will be ringfenced, the true position is that care straddles both health and social care sector provision and is thus characterised by means testing.  It is accepted fact that our population is ageing with forecast increases in dementia and diabetes, health and social care services will experience increased pressures as demands and frailties rise. The argument is about who is going to pay for the provision of care?

Frail elderly people need a lot of care and that care is expensive. Let us not forget our history – why the NHS was set up (Abel Smith 2007), who struggled to get it in into place and why, and the functions women especially played in the private sphere (Elshtain 1981) of care both for children and the elderly. Modern Industrial society was both capitalist and patriarchal with care firmly in the private domain. No state funding as we would recognise it was provided because this was expensive. Patriarchal attitudes would not define it as ‘proper’ work and so could be left to women. The Parish, Poor laws and workhouses were the backstop for those unable to fend for themselves, for those without the family, and that often meant women, looking after them. The working class had to struggle to get health and education properly funded. Enlightened Victorian philanthropists and entrepreneurs realised that if they wanted workers to keep working then recreation and education had to be provided. This provision was despite the capitalist dynamic for profit, not because of it.

We have come a long way as social democratic pressures finally provided the NHS and Education, as the elites also were won over to the need to provide care. The ‘One nation’ Tories at least understood that a prosperous society had to take care of all of its members, of course there was some self interest in this – we needed soldiers who were fit for the battlefield, and we needed healthy workers for the factories. This is a simplistic history as it is more nuanced than this. However, over the last 30 years or so we have seen reversal of this enlightened social democratic outlook on care and public health and care. The need for care is increasing but this is occurring just when the elites are pulling back from their responsibilities. They look at what state provision will cost for high quality elder care and are frightened.  They also have a visceral loathing of state provision…because it costs them money through taxes they do not want to pay. They say it is because the state is inefficient and anti-democratic, that state provision is the road to serfdom. Suffice to say that the current involvement of the CCE with the PPE is extremely antidemocratic but their right wing press cheerleaders have not spotted it or prefer to ignore it.   Seamus Milne  has eloquently exposed how corporate power is corrupting politics.

The neoliberal capitalist agenda (Crouch 2011) requires the state to pull back from earlier involvement on education and health. The CCE and the current PPE have swallowed an ideology that simply accepts private provision = good, public provision = bad. This is why we are seeing the conditions of an affluent society being characterised by a hugely increasing wealth gap. This agenda also allies itself with patriarchal views on the proper role for women – get back in the kitchen girls and look after the kids…and now, of course, Gran as well.

Austerity is now the smokescreen for dismantling of the state provision for care. Does this mean that lack of compassion is directly related to neoliberal policies?  To accept that is to think in an overly simplistic cause effect relationship. Societies are more complex than that.  Of course poor quality care pre dates capitalism and the NHS, however capitalism (and its often hidden twin patriarchy) sets the agenda and the organisational forms and institutional arrangements in which care takes place. This now means as budgets get cut and savings asked for, nurses will be asked to provide more for less. This has been always the case; nursing work as womens’ work (Hagell 1989) has largely been invisible emotional labour (Smith) which has been poorly paid and supported, instead their rewards have been patronising labels such as ‘Angels’. Nurses know what they need to provide care and they can do it if given supportive organisational cultures and the power to actually direct, organise and manage care properly.

As Roy Lilley argued on nhs.managers.net:

(The Francis report 2013) talks about ‘culture change’. Effectively making the people we have make the services we’ve got, work better. On that basis Francis fails. What we’ve got doesn’t work. Never will.  Think about it; nearly all the quality problems the NHS faces are around the care of the frail elderly. Why? Because the NHS was never set up to deal with the numbers of porcelain-boned, tissue paper skinned elderly it is trying to cope with. The NHS’ customer-base has changed but the organisations serving them have stood still.

and…

“Fund the front-line fully, protect it fiercely, make it fun to work there, that way you’ll make Francis history.”

And there you have it. Do the austerity addicts think it is the proper role of the state to fund the front line. No, they hanker after a US style private provision with the family, the big society volunteers and women to take up the slack. That will not wash in a hospital ward or a care home full with frail elderly patients.

Nurse educators and their students do not work in a socio-political vacuum. However, one would think that they do if the content of curricula and the learning experiences planned are anything to go by. Indeed any discussion around political economy, patriarchy and capitalism is liable to be met with surprise, apathy, disdain apart from those engaged in teaching the social sciences in nursing. I would argue that nursing cannot shy away from addressing these questions. Nurses as women, who experience the requirements to care in both their domestic and public lives, bear the brunt of the demands of a society which needs that care to be done but is unwilling to fully fund it. It might be fair to suggest that since about the 1980’s both feminism and social democratic politics took their eyes off the ball or felt that because progress had been made the struggle was nearly over.  It is not. We need to argue for the social value of care and against privatised individualised provision which falls unfairly on the shoulders of those who often do not have the resources to provide it.

Caring is not sexy – it is not fancy infrastructure projects, it does not make millions at the click of a mouse;  hedge funds and private equity firms don’t crack champagne bottles over the needs of the frail elderly. Care is unglamorous emotional labour, involves often dirty body work, offering little in the way of recognition and prizes – there are no Golden Globes, Oscars or Baftas. There is no end point, no project that is completed and shown off, no bonuses to be earned. ‘Top’ Universities show off their ‘top’ professions: law, medicine, business and science whose courses are oversubscribed due to professional closure and the high salaries they attract. The children of the elite are groomed and public schooled to ensure they attend the ‘right University’ and study the ‘right’ subject while eschewing nursing, which struggles to gain academic credibility and value among society and Russell group elites, while its core concept is seen to require no education at all.

Nurses are in a political struggle whether they realise it or not. For the sake of all us who will require care, don’t let the greedy bastards grind us down

 

 

 

 

 

References:

Abel Smith, B. (1992) The Beveridge Report: its origins and outcomes. International Social Security Review 45 (1-2) pp5-16

Curtis, K. (2013) 21st Century challenges faced by nursing faculty in educating for compassionate practice: Embodied interpretation of phenomenological data.   Nurse Education Today, http://www.nurseeducationtoday.com/article/S0260-6917%2813%2900170-6/abstract

Elshtain, J. (1981) Public Man, Private Woman: Women in Social and Political Thought. Princeton, NJ: Princeton University Press

Scambler, G. (2012) Elements towards a Sociology of the Present. December 6th http://grahamscambler.wordpress.com/2012/12/06/elements-towards-a-sociology-of-the-present/

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.

 

What implications do the differences between a social and medical model of health have for the nursing profession?

What implications do the differences between a social and medical model of health have for the nursing profession?

 

(note the hyperlinks in the text)

 

This short paper will address biomedical, social and ecological models of health.

 

Medical model:

First of all we need to be clear what we mean by these terms. A medical model (sometimes called a biomedical model) is based on knowledge about the biological causes of disease. This approach uses the sciences such as physiology, pathophysiology, pharmacology, biology, histopathology and biochemistry. A detailed knowledge of the human anatomy is required as well as detailed knowledge of:

·         Aetiology (in the United States  they spell it Etiology).

·         Epidemiology.

·         Signs and Symptoms.

·         Diagnosis.

·         Investigations and clinical examinations.

·         Treatment options and management plans

for a very wide range of conditions and diseases.

The focus is often on the individual ill patient, and it seeks to cure through the application of medications and/or surgery.

Many doctors in practice however adapt and supplement this basic approach to consider issues such as lifestyle, patient preferences and wishes in their treatment options. This might be termed a biopsychosocial model. Options for treatment also include referral to other professionals such as physiotherapists and dieticians and some doctors refer to complementary therapists.

“While disease dominates biomedical thinking, the biopsychosocial model incorporates social, psychological and emotional factors in diagnosis and treatment. It recognises that illness cannot be studied or treated in isolation from the social and cultural environment. Whereas the biomedical model prioritises professional knowledge, the biopsychosocial model expects health carers and doctors to acknowledge and take into account users’ circumstances.

Medicine practised within a biopsychosocial framework acknowledges the links between socioeconomic deprivation and adverse health. It also considers issues such as improving access to health services and reducing health inequalities as a legitimate and appropriate function of health service provision.”

(source: http://openlearn.open.ac.uk/mod/oucontent/view.php?id=398060&section=1.7)

Thus a biopsychosocial model is a link between the medical approach and the social model of health.

Box 1: This extract is taken from the Open University.

Models of healthcare delivery: the biomedical model:

Biomedicine is also known as allopathy, conventional medicine or modern western scientific medicine).  In the UK biomedicine dominates contemporary and official understandings of health and forms the basis of the NHS and other western health care systems. While the biomedical model is considered the epitome of scientific, objective, reproducible medicine, the actual delivery of health care may be somewhat different in practice. The following statements about biomedicine thus represent an idealised, necessarily artificial version of this model.

·         Health is predominantly viewed as the ‘absence of disease’ and as ‘functional fitness’.

·         Health services are geared mainly towards treating sick and disabled people.

·         A high value is put on the provision of specialist medical services, in mainly institutional settings, typically hospitals or clinics.

·         Doctors and other qualified experts diagnose illness and disease and sanction and supervise the withdrawal of service users from productive labour.

·         The main function of health services is remedial or curative – to get people back to productive labour.

·         Disease and sickness are explained within a biological framework that emphasises the physical nature of disease: that is, it is biologically reductionist.

·         Biomedicine works from a pathogenic (origins of disease) focus, emphasising risk factors and establishing abnormality (and normality).

·         A high value is put on using scientific methods of research and on scientific knowledge.

·         Qualitative evidence (given by lay people or produced through academic research) generally has a lower status as knowledge than quantitative evidence.

(Source: adapted from Jones, 1994 in http://openlearn.open.ac.uk/mod/oucontent/view.php?id=398060&section=1.6)

 

The Social Model

The social model of health focuses on the social distribution of health and illness between different groups (e.g. death rates which vary between social classes).  The social model is interested in the social causes of ill health best illustrated by the Social Determinants of Health (World Health Organisation 2008) approach.

The Social determinants of health

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.

Responding to increasing concern about these persisting and widening inequities, WHO established the Commission on Social Determinants of Health (CSDH) in 2005 to provide advice on how to reduce them. The Commission’s final report was launched in August 2008, and contained three overarching recommendations:

Responding to increasing concern about these persisting and widening inequities, WHO established the Commission on Social Determinants of Health (CSDH) in 2005 to provide advice on how to reduce them. The Commission’s final report was launched in August 2008, and contained three overarching recommendations:

1. Improve daily living conditions

2. Tackle the inequitable distribution of power, money, and resources

3. Measure and understand the problem and assess the impact of action

The WHO Conference Secretariat has now put together the full Report of the World Conference (66 pages with color pictures). A 16 page summary Report is also available. World Health Assembly adopts the Rio Political Declaration on Social Determinants of Health. A resolution endorsing the Rio Political Declaration on Social Determinants of Health was adopted in May 2012 by WHO Member States at the Sixty-fifth World Health Assembly (WHA) in Geneva, Switzerland.

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

 

 

Barton and Grant (2006) have developed  a ‘health map’ which illustrates the global, environmental as well as the social antecedents for health:

 

http://eprints.uwe.ac.uk/7863/2/The_health_map_2006_JRSH_article_-_post

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.

 

Note that the outer ring includes the ecosystem so this firmly locates human health within the ecology of the planet. Therefore health stems from the biogeophysical environment in which humans live and are an inescapable part of. This perspective which sees no separation of humanity from ecology suggests that no one can be healthy in an unhealthy environment. This might take the position that if the oceans are increasingly acidic, resulting in fish species loss, then by definition human populations are not healthy either.

Health is then social and ecologically determined, experienced within the social relationships in a material world. No one lives alone and so it is in the coming together in communities and societies that we fashion the determinants of health. There is a biological basis for some individuals, however genetic determinants (e.g. in cystic fibrosis) operate at this individual level and are manifest in a relatively minor way. This is not to deny that for the individual the medical condition is anything but minor, but health on population levels are not determined thus. Even genetic manifestations are at times made worse or better by the social conditions in which the individual finds themselves. Poverty has a knack of making underlying biological problems much worse. Climate change may also make both poverty and the health status of populations worse.??

Social Conditions??

If health is socially determined by social relationships, what are the current forms of social relationships that give rise to certain patterns of health, illness and disease? We know from studying inequalities in health that socio-economic conditions and relative social status determine populations’ health status including measurable outcomes such as life expectancy and the under 5 mortality rate. Other social relationships such as gender and ethnicity also affect health status. I would argue that major influences upon global health are the socio-economic relationships which are based on a certain forms of political economy, i.e. capitalism.

Implications for Nursing:

The following is a gross simplification, a continuum if you like, of the two typologies. In practice a nurses will develop their own mix of the two approaches:

Biomedicine focuses on the ill individual, social models focus in healthy populations. A biomedical nurse would use mainly the medical sciences to help cure the individual , A social model nurse would draw from various disciplines (sociology, psychology) to promote health and well-being of populations. A biomedical nurse would be drawn to acute care, especially critical care while a social model nurse may be drawn to primary care and public health. A biomedical model seeks to change the individual,  A social model nurse would seek to change society. A biomedical nurse has little need for history and politics, a social model nurse understands her history and political action.  A biomedical nurse has little need to use a sociological imagination, a social model nurse needs to develop her sociological imagination.

A biomedical nurse may ignore ‘non-scientific’ approaches to cure, a social model nurse might value alternative and complementary approaches. A biomedical nurse wants to cure, a social model nurse wants to care. Biomedical nurses implicitly positively acknowledge higher stuts of medicine, a social model nurse gives no privileged status to medical practice. biomedical nursing mirrors male ways of thinking, social models open themselves up to female and post-colonial ways of thinking.

 

 

 

 

A note on ‘econursing’ or an ecological model of health.

Taking on board Barton and Grant’s health map, acknowledging for example the health impacts of climate change,  and the building upon a social determinants approach, an ecomodel would emphasise that human experience cannot be understood as separate from nature. Philosophically it critiques the dualist assumptions that see nature separate from humanity, what has been called ‘human exceptualism’. This is the position that sees us as exceptions from nature, we are separate from it, and nature is open for domination and control for the benefit of humankind. From an eco-perspective, this is extremely damaging to human health and to the health of the planet, more than that, they are the same thing.

Benny Goodman 2012

How might social factors influence experiences of health & illness?

…and ‘How might this be relevant to the work of the nurse’?

 

 

What do we mean by social factors? This term covers a multiple meanings, but lets start by thinking about what people and society do and the categories we place ourselves, and others, into. A social factor then is something that might have an effect on us as we go about our daily lives as social actors. Emile Durkheim in ‘The Rules of Sociological Method’ (1895) wrote about ‘social facts’ as almost having a life of their own:  “treat social facts as things” existing outside of our individual consciousness. The common categories or factors include things like:

 

 

Socio economic status.

Ethnicity.

Gender.

 

We might also want to consider social structures such as:

 

Family.

Leisure, Work and Occupations.

Education.

Politics.

Military–Industrial Complex.

Religion.

Consumer-Industrial Complex.

 

Before we proceed just consider how the above social structures have changed over time.

 

The following will discuss obesity and a heart attack using our sociological imagination. I will then consider the relevance for nursing.

Obesity

 

To illustrate how any of these affect health we could take the issue of Obesity. Why are populations globally all getting fatter over the past couple of decades? A biological explanation founders in that it requires some biological mechanism that has changed for billions of people. Evolution does not work that fast. As there are differences between groups of people and individuals there is something psychological and or sociological happening.

 

It might be linked to one’s socio-economic status, as we know that poverty and economic and social deprivation are correlated to increased weight in populations. McLaren (2007) argues that obesity is a social phenomenon. That is to say it is just not a physical or biological condition to be explained or dealt with only in physical terms (e.g. the injunction to eat less and exercise more). Action on obesity includes targeting both economic and sociocultural factors. McLaren illustrates the varying social patterns involved in level of obesity in this review of studies.

 

Roberts and Edwards (2010) suggest that world-wide, over a billion adults are overweight and 300 million are officially obese. Their book ‘The Energy Glut’ suggests that how energy is both sourced, e.g. oil, and used, e.g. car driving, is directly linked to growing obesity. They suggest ‘fatness’ and climate change, are manifestations of the same fundamental cause. It is down to how oil based fossil fuel energy, after being discovered, started not only the process of catastrophic climate change, but also propelled the average human weight distribution upwards.

 

In addition they suggest that the food industry uses sophisticated marketing techniques to sell us mountains of energy-dense food whilst at the same time we are ‘functionally paralysed’. We just don’t move about as we used to, partly because the opportunities to do so diminish. This could be seen especially in the UK with increased car use, road building, living miles from work and the growth of retail outlets built out of town to exploit car use, poor public transport and poor cycling infrastructure. The accumulation of body fat is therefore a political, not a personal, problem.

 

 

 

 

 

 

 

The Information Centre has published Statistics on Obesity, Physical Activity and Diet: England 2012. The topics covered in the report include, overweight and obesity prevalence among adults and children, physical activity levels among adults and children, trends in purchases and consumption of food and drink and energy intake and health outcomes of being overweight or obese.

 

http://www.ic.nhs.uk/pubs/opad12

 

Key facts

         In 2010, just over a quarter of adults (26 per cent of both men and women aged 16 or over) in England were classified as obese (BMI 30kg/m2 or over). For the same period, around three in ten boys and girls (aged 2 to 15) were classed as either overweight or obese (31 per cent and 29 per cent respectively).

         In 2010, 41 per cent of respondents (aged 2+) said they made walks of 20 minutes or more at least 3 times a week and an additional 23 per cent said they did so at least once or twice a week in Great Britain (GB). However, 20 per cent of respondents reported that they took walks of at least 20 minutes “less than once a year or never” in GB.

         In 2010, 25 per cent of men and 27 per cent of women consumed the recommended five or more portions of fruit and vegetables daily.

         The number of Finished Admission Episodes (FAEs) in NHS hospitals with a primary diagnosis of obesity among people of all ages was 11,574 in 2010/11. This is over ten times as high as the number in 2000/01 (1,054).

 

 

In 2010, there were 1.1 million prescription items for the treatment of obesity, a 24 per cent decrease on the previous year when 1.4 million items were dispensed. This is the first recorded decrease in seven years.

 

 

 

Heart Attacks

 

Wright Mills (1959) wrote:

 

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

 

A middle aged man has a heart attack but he does not consider that his illness may be linked to living in the 21st century, or that the roots of his illness may lie in current society.

 

He is:

 

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

 

Lying in a hospital bed, with ECG electrodes stuck to his chest, the man may curse his luck or put his condition to being overweight, his smoking habit and lack of exercise.

 

He does not:

 

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

 

In addition he:

 

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

 

(my italics).

 

What ‘structural transformations’ (social factors) might lie behind the heart attack, or an eating disorder or binge drinking? What is a ‘structural transformation?’

 

If we think of society has having ‘structures’, which vary from society to society and which varies within the same society over time (history), we may begin to understand that society ‘works’ when individuals, groups, communities and populations decide to act out their relationships one with another and in doing so create (and are created by) social ‘structures’.  I have listed some structures on page 1.

 

In the above heart attack case what structures are there and what are those structures that lie beneath his personal trouble?

 

To help answer that question Wright Mills argued that:

 

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

 

So we need to use information and reason to start making the links between society and illness. A heart attack results from a variety of sources. Some may be genetic, but others are patterns of living which are subject to social structure. The middle aged man just happened to have been born in the 1950’s into a working class background in Liverpool. His father worked as a docker and he in turn followed in his father’s footsteps.

 

Social class is a form of social structure. Living in working class Liverpool during the 1950’s to the 1970’s means engaging in certain eating habits, wearing certain clothes, taking holidays in certain places (in the UK) and following certain football teams. And, of course, smoking. Smoking is as natural an activity as breathing, even Division One footballers smoke. The ‘metrosexual’ man does not exist yet, there are no ‘Men’s Health’ magazines, cigarettes are cheap, there are no laws banning smoking in public places. The idea of working out in a gym does not feature except in the working class boxing clubs. Olive oil and the Mediterranean diet exist only in the Mediterranean. Eating (saturated fat) red meat is masculine. ‘Jogging’ has not entered into the English language yet, exercise is for athletes or only takes place when playing Sunday football for the local pub team. Car use is becoming more common and cycling is in decline. Margaret Thatcher was soon to say that a 30 year old man on a bus is a failure so public transport is only for those who have to.

 

The social structure of this man’s early years involve lifestyles that increase his chance of a heart attack but he was not aware of all the connections. He thinks all his choices are his own, but he is unaware that choice is limited and results from those chances handed out to him. His choices are also based on imperfect information and also upon the wishes of others who want him to make certain choices (e.g. the cigarette manufacturers). If the society in which he lives offers him the choice of A, B and C and he chooses A, he may think he has made a real choice. But what if there is choice F, G and H that he is not aware of through circumstance or that history has not yet provided?

 

in 1950, one could choose to smoke anywhere and the lack of a strong public health campaign and research evidence did not point to the deadly nature of the practice. The personal trouble of smoking has to be seen in the context of that history.

 

Fast forward to 2010 and a new historical period. The public issue of millions dying of lung cancer has affected change in society and now impacts differently upon the individual. Social structures have been transformed since the 1950’s. For example, we now think of smoking not as glamorous but as a ‘filthy habit’. Men no longer congregate in pubs where everyone smokes inside.

 

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

 

Thus, the middle aged heart attack victim who has this ‘quality of mind’ would understand his present trouble as linked to the context of 1950’s Britain where working class life took smoking for granted. He knows that all his friends smoke and that the likelihood of him smoking is high, given the social context and the time in which he lives.

 

 

Nursing relevance

 

This depends on where the nurse works. In an intensive care unit or in many acute settings, it is irrelevant to the everyday clinical practice of giving physical care. In primary care however, understanding how social factors impact on people’s lives may suggest strategies for mitigating them and for engaging in health promotion and health education. The obvious is knowledge for healthy eating habits or exploring personal physical activity levels.

 

However, certain issues will require action at the community or political level. This calls into question the social and political role both for the individual nurses and for nursing as a profession. Public health is a core part of nurse education and thus understanding social causes for ill health is part of the public health role for nursing. Wright Mills argues that it is the job of the social scientist or the liberal educator to foster the sociological imagination so that people become aware of how social factors (in our case) affect health and illness. We could argue that this applies to nurses in that once we know what causes disease we might have a duty to do something about it at the social level if it is caused by social factors (i.e. the ‘Social Determinants of Health’).

 

At the very least we should be very wary of victim blaming or accepting wholesale simplistic arguments over personal responsibility, see for example Wind Cowle (2012), while at the same time we do very little to curb fast food outlets, regulate the food industry, curb car use through urban planning or encouraging active travel alternatives such as cycling. 

 

Nursing has various elements to it: giving direct patient care, working in a team, managing oneself and personal development. To that we could add the need for networking and political awareness to exercise nursing leadership. Therefore I suggest that developing an understanding of the social factors involved in health and illness can assist a nurse in developing in these various elements to various degrees regardless of where one works.

 

 

Benny Goodman 2012

 

 

 

 

References.

 

McLaren, S. (2007) Socioeconomic status and obesity. Epidemiological Reviews 29 (1): 29-48.http://epirev.oxfordjournals.org/content/29/1/29.abstract

 

Roberts, I. and Edwards P (2010) The Energy glut. The Politics of fatness in an overheating world. Zed Books

 

Wind Cowle, M (2012) The NHS needs people to be more responsible http://www.guardian.co.uk/society/2012/sep/25/nhs-needs-people-be-more-responsible

 

World Health Organisation (2008) Closing the Gap in a generation. The Social Determinants of Health. http://www.who.int/social_determinants/en/

 

Wright Mills, C. (1959) The Sociological Imagination. Oxford University Press. Oxford.

 

 

 

 

 

 

Skip to toolbar