Tag: World health organisation

Climate Change, Health and Capitalism

Climate Change, Health and Capitalism The debate on climate change and health in the context of Ecological public health: A necessary corrective to Costello et al’s ‘biggest global health threat’, or co-opted apologists for the neoliberal hegemony?

Abstract

The threat posed to global health by climate change has been widely discussed internationally. The United Kingdom public health community seem to have accepted this as fact and have called for urgent action on climate change, often through state interventionist mitigation strategies and the adoption of a risk discourse. Putting aside the climate change deniers’ arguments, there are critics of this position who seem to accept climate change as a fact but argue that the market and/or economic development should address the issue. Their view is that carbon reduction (mitigation) is a distraction, may be costly and is ineffective. They argue that what is required is more economic development and progress even if that means a warmer world. Both positions however accept the fact of growth based capitalism and thus fail to critique neoliberal market driven capitalism or posit an alternative political economy that eschews growth. Ecological public health, however, appears to be a way forward in addressing not only social determinants of health but also the political and ecological determinants. This might allow us to consider not just public health but also planetary health and health threats that arise from growth based capitalism.

 

Keywords Ecological Public health, climate change; risk discourse; capitalism; neoliberalism;

The health impacts of climate change have been much discussed internationally1,2,3,4  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 tacit and sometimes uncritical acceptance of the fundamental structure of the political economy of growth capitalism – neoliberalism5 , with the differences being around whether climate change requires more immediate public policy and health professionalintervention6 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 either more market freedom or statist intervention based in a risk discourse. 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 UCL-Lancet paper on climate change and health. While the focus is on climate change, other factors such as biodiversity loss, chemical pollution, ozone depletion, ocean acidification, all threaten the ecological systems we depend on7. These issues are also associated with our current growth based economic structures.  The ecological public health discourse will not be discussed at length here, but might provide a newer perspective linking global political structures, critiques of growth based capitalism and public health.

The Climate change ‘debate’

 

The Intergovernmental Panel on Climate Change 5th Assessment Report (AR5)8 argues that scientists are 95% certain that humans are the ‘dominant cause’ of global warming since the 1950’s9,10 . Despite this, there is continuing doubt, denial and a focus on uncertainty,11,12,13,14,15   that Climate Change is human induced and that it requires radical shifts in public policy.   This doubt sits in opposition to many in the medical16and public health domain17. The World Health Organisation18,19  accepts IPCC assessments and considers climate change to be a ‘significant and emerging threat’ to public healthwhile previously ranking it very low down in a table of health threats20,21. In the United Kingdom, Costello22 et al 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 map23 has in its outer ring ‘Climate Stability, 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. WHO24  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, one that underpins 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, Stakaityte25 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 growth25 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 uncertainty27 .  Attention also should turn to philosophical positions on political economy in which the dominant neoliberal hegemony28,29 attempts to build and maintain a sceptical view30,31  in the media on climate change and on alternative, including no growth, economic models32,33,34  because neoliberalism 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.   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’ defined as 2085-2100. This means addressing Goklany’s argument, especially, on the ranking of health threats and Ben Ami’s argument on progress. For Goklany the health threats this century are not from climate change, nor will they be. For Ben Ami, the answer lies in any case of more progress based on economic growth and development.   In this there is some support from the latest IPCC report 35 (p3)  which states   “the present worldwide burden of ill health from climate change is relatively small compared with other stressors and is not well quantified”.   The report also states that rapid economic development will reduce health impacts on the poorest and least healthy groups, with further falls in mortality rates.  In addition, they argue36 (p4), alongside poverty alleviation and disaster preparedness, the most effective adaptation measures are:   “basic public health measures such as the provision of clean water, sanitation and essential healthcare”.   A key point is that climate change and extreme weather events affects the poor disproportionally and that37 (p3)   “until mid century climate change will act mainly by exacerbating health problems that already exist”   So there is an emphasis on economic development and poverty alleviation by the IPCC, thereby accepting the basic tenets of growth capitalism, alongside mitigation and adaptation, to deliver them.   However, McCoy38  et al points out that by 2100,  ‘business usual’ emissions growth will see increases in levels of CO2 in the atmosphere giving a 50:50 chance that global mean temperatures will rise by more than 4 degrees, which they argue  is   “incompatible with an organised global community”.   However, they stop short of a critique of the political economy of growth capitalism that drives C02 emissions39,40,41.   Both Goklany and Ben-Ami’s faith in human progress is based on inductive reasoning, ignores the key statistical problem of exponential growth on a finite planet, 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’, climate change will not be the major threat to public health, however this line of reasoning might support 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 risk42,43 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.   Goklany44 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 issues45.   Daniel Ben-Ami46 forwards this argument. 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. Humanity should strive to achieve more in terms of economic development so that everyone should have access to a Ferrari if they want it.   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.   In 2009 Costello et al 47(p1693)  argued that ‘climate change is the biggest global health threat of the 21st century’ . Goklany48,49 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. Goklany50  pointed out that climate change was ranked only 21st out of 24 global health threats. Goklany’s rebuttal data comes from the World Health Organisation51 ‘World Health Report 2002’ and the Comparative Quantification of Health Risks 200452and he used results from “Fast Track Assessments” (FTAs) of the global impacts of global warming53,54 .   Costello, Maslin and Montgomery 55  in reply to Goklany argued that     “The ranking of climate change at 21st out of 24 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 papersshowing that about 1 trillion tonnes56 is probably the cumulative limit for all carbon emissions if we wish to stay within the 2°C “safety” limit57, and that, without action, we shall exceed this limit before 2050.  They also cite a paper by Schneider58 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. They argue that this a risk threshold, way beyond which people would buy insurance.   Goklany59  in 2012,  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.  His position in 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 AR560, 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. 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 and argues that the last time the world was 2 degrees warmer, sea levels were 5 -10 metres higher.   On what to do, Goklany61 (p69)  argued in 2009 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….”   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 growth capitalism and neoliberal hegemony62.   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 some63 consider that it is too late for mitigation and that adaptation to a warmer world is now needed. Goklany64  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).   Goklany argues 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 to 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 limits65, transgressions which will not support a ‘safe operating space’ in the new era, the ‘anthropocene66,67 .   Risk Discourse.   Goklany68 argued in 2012   “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 IPCC69(p22) has since written 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”.   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 future 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, e.g. house fires, and for the long term, e.g. pensions. 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. Painter70 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.         Goklany is correct to point out that currently health threats arise from poverty and underdevelopment. In this assessment he is in accord with the WHO social determinants of health approach and the IPCC AR5 WGII71.  Costello et al have not dismissed this and public health experts would probably accept a similar position. A focus on the social determinants of health and the political determinants of health72 needs to run alongside mitigation or else the good work could be undone by a low probability, according to Goklany,  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 growth economic model or call for alternative economic ‘no growth’ or circular models73,74. 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 dominant discourse of political economy seems to be either more or less tweaking with capitalist growth models rather than a sustained examination of alternatives.There are voices, now however, pointing public health in another direction. Horton et al75 call for a new social movement in a ‘manifesto from public to planetary health’, to support collective action on Public Health, introducing the concept of ‘planetary’, rather than just ‘public’ health.  As with Lang and Rayner’s76  discussion of Ecological public health, there is a strong focus on the unsustainability of current consumption. Interestingly,  an overt political statement is introduced in the ‘manifesto’: “We have created an unjust global economic system that favours a small wealthy elite over the many who have so little”77 p847. They attack the idea of progress, and thus implicitly growth based neoliberalism, for deepening this ecological crisis and for being socially unjust. The call is for an urgent transformation in values and practices based on recognizing our interdependence and interconnectedness, and 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. In the same vein, Ottersen et al78 are explicitly political on the links between health inequity, globalisation and the current system of global governance, including the actions of ‘powerful global actors’ and while they do not use the term ‘growth based capitalism’ or ‘neoliberalism’, the tone of the report makes it quite clear that there is a need to address global governance and an analysis of power. The domains of Public Health, Medicine and Nursing may be insufficiently politically aware of the scale of the issues, and the sheer force and dynamics of capitalism79, that impacts on human health. This might be due to the (necessary?) ‘ahistoric’ and ‘apolitical’ education of health care professionals, resulting in a lack of a sociological or political imagination underpinned by a critical theory of capitalism. However, adopting the perspective of Ecological Public Health or seeing the world through a ‘sustainability lens’80 might move more health practitioners and policy makers into critique and action on current economic and political structures that result in health inequities, and indeed, if some are to be believed, that threaten western civilisation81,82.

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Figure 1: net GDP per capita, 1990-2200 for 4 IPCC scenarios. The warmest is A1FI (4 degrees C) and the coolest is B1 (2.1 degrees C)       Author’s statement

Funding: none

Competing Interests: None declared

Ethical approval: Not required. This is a review paper.

 

“NOTICE: this is the author’s version of a work that was accepted for publication in Public Health. Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication. A definitive version was subsequently published in PUBLICATION, [VOL#, ISSUE#, (DATE)] DOI

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/

 

World Health Organization. (2002) World Health Report 2002—Statistical Annex. Available at: http://www.who.int/whr/2002/annex/en/index.html

 

World Health Organization. (2004) Comparative Quantification of Health Risks. Geneva: World Health Organization; Available at: www.who.int/healthinfo/global_burden_disease/cra/en/index.html

 

World Health Organization (2009). Global Health Risks. Geneva: WHO. http://www.who.int/healthinfo/global_burden_disease/global_health_risks/en/index.html

 

World Health Organization (2013a) Climate change and human health. http://www.who.int/globalchange/en/index.html

 

World Health Organization (2013b) Health topics. Climate Change. http://www.who.int/topics/climate/en/

 

World Health Organisation (2013c) Global environmental change. http://www.who.int/globalchange/environment/en/index.html

 

Undignified Care

The report into poor care at Mid Staffordshire NHS trust is due very soon.

Undignified care.

Why do patients, particularly older patients, experience indignities such as being denied wearing their glasses (“in case you roll over on the pillow and break them”) or being made (forced?) to sit in an armchair (“you know you get dizzy and might fall”). One reason is because of the increasing use of a particular approach to risk management and its procedures that characterise not only society, as exemplified by the ‘high-viz jacket’ phenomenon, but also by healthcare organisations.

This paper on http://plymouth.academia.edu/bennygoodman/Posts

discusses a research report and the implications for care and care management in the NHS and other organisations that links a particular way of thinking, risk management and poor quality care.

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/

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.

 

 

 

 

 

 

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