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Public health, health inequalities and neoliberalism

Academia, Current Research, David Blane

Public health, health inequalities and neoliberalism

Photo by Darko Stojanovic. © Dec. 10, 2014. © CC0 Public Domain via Pixabay.

Photo by Darko Stojanovic. © Dec. 10, 2014. © CC0 Public Domain via Pixabay.

By David Blane

Neoliberalism is bad for your health.  That was the take-home message from Professor Paul Bissell, the invited speaker for the Institute of Health & Wellbeing’s Maurice Bloch seminar series on April 20th 2015.  Prof Bissell began his talk by summarizing the now familiar arguments of Richard Wilkinson and Kate Pickett, from their book The Spirit Level.  Their main thesis, supported with considerable empirical evidence, is that those advanced capitalist countries with the greatest income inequality do worse across a range of health and social outcomes compared to those that are more equal (a case also made in a recent IHAWKES Election Special guest blog by Professor Andy Gumley).

This epidemiological work, together with that of Professor Sir Michael Marmot, has been hugely influential in shaping how we think about health inequalities in the developed world.  But, as Prof Bissell points out, none of these bodies of work use the word ‘neoliberalism’ to identify the processes driving growing income (and health) inequalities (the causes of the causes, if you will).  Furthermore, while Wilkinson and Pickett do include the role of ‘shame’ in their psychosocial explanation for health inequalities, they do so without reference to a large and growing body of relevant sociological literature.  In what he described as a ‘fraternal critique’, Bissell outlined why he believes these omissions to be problematic.

What is neoliberalism?

First, it’s worth considering what we mean by neoliberalism.  Put simply, neoliberalism is an ideology that favours the free market economic model, with its emphasis on privatisation, deregulation, and fiscal austerity.  In the neoliberal view, any interference with the ‘normal’ functioning of the market – for instance, by the welfare state – is to be avoided or minimised.  But Bissell acknowledged that it is a contested concept and, citing Evans and Sewell, that it can be thought of in at least four ways: as economic theory, as political ideology, as policy paradigm and as social imaginary.

It is the latter conceptualization that Bissell worked with in the rest of his talk – that the neoliberal ‘social imaginary’, extolling values of entrepreneurship, self-reliance and individualism, has infiltrated all aspects of modern life and, by doing so, has produced more spaces for shame and more opportunities to deny the human need for dependence on others – what he calls the ‘no legitimate dependency’ thesis.

Drawing on the work of Thomas Scheff, Andrew Sayer and Tracy Shildrick, Professor Bissell reflected on the different ways that shame has been discussed: shame as being (potentially) present in all social interaction; chronic shame as a form of structural humiliation; people responding to shame either by blaming themselves or turning against an imagined ‘other’.  He made a distinction between these portrayals, based on empirical sociological work, and that of Wilkinson and Pickett, who view shame as an emotional response to acute events of social comparison.  Bissell sees this as being too passive, with little sense of the potential for resistance to shame, on which more later.

No legitimate dependency

Prof Bissell went on to present findings from a qualitative study that he was involved in, employing biographical-narrative interviews with a group of women from Salford to understand their experiences of inequality. An unexpected finding from these interviews was the prominent and damaging discourse that they labelled as ‘no legitimate dependency’, whereby (virtually) all forms of dependency were disavowed or ‘othered’ in various ways, leading to stress, anxiety and unhappiness.

“For the least affluent with the least resources, this closing off of the legitimacy of seeking support (welfare, material or emotional) results in the greatest burdens falling on those most unable to shoulder them. When failure results, this can only be understood as a reflection of individual merit or effort – to seek to explain it any other way is further evidence of one’s own moral and practical deficits.”

There were other unanticipated findings.  First, that shame was present primarily in relation to children, bodies and homes, rather than explicitly in relation to income.  And also, that the social comparisons that were made were more likely to be horizontal, between people in the same social position, than vertical, as might be expected.  Of note, Bissell pointed out that these interviews took place between 2009 and 2010, before the Coalition’s austerity programme and its demonization of welfare dependence.

 A catastrophe yet to come?

Prof Bissell ended his talk on a note of cautious optimism.  He expressed concern that the language of ‘resilience’, adopted by many public health professionals, is simply preparing individuals and communities for the new post-crash era of ‘undead’ neoliberalism that is now ready to cast off its supposition of economic equilibrium and its triumphalist narratives of the welfare-generating properties of the omniscient market and simply seek[s] to fashion ways to make individuals, communities, systems and organizations fit for [the] rigors of the catastrophe yet to come.”

 Thankfully (!), he also gave more hopeful examples of resistance to shame and ‘collective imaginaries’ that could be protective (see, for instance, the work of Michèle Lamont or Reynolds and Brady), albeit cautioning that traditional institutions of solidarity and collectivity, such as the welfare state and trade unions, are themselves under attack from neoliberalism.

 So what can health researchers do?

As far as health research is concerned, Bissell proposed a public sociology of understanding shame under neoliberalism.  At the very least, we would do well to challenge the overwhelming tendency for ‘lifestyle drift’, where recognition of the need for action on upstream social determinants of health inequalities slowly drifts downstream to focus on individual lifestyle factors.  PhD student and IHAWKES blogger Anna Isaacs made some excellent suggestions of ways to challenge this ‘cognitive dissonance’ in last week’s blog.  Do you have other suggestions?  Or more examples of research that has successfully approached a health problem at multiple levels?

I’m going to give the last word on this to Wilkinson and Pickett, who have clearly taken on board Bissell’s ‘fraternal critique’ and have turned their attention in a recent BMJ editorial to how 21st century capitalism is failing us.  They suggest that perhaps “our salvation lies in a thorough going democratic transformation of capitalism.”  What do you think?

*For further reading on neoliberalism and health, see Graham Scambler, David Coburn, and Glasgow researchers Chik Collins and Gerry McCartney (all cited by Prof Bissell during his talk).

**For more information about the Maurice Bloch seminar series, see this link: http://www.gla.ac.uk/researchinstitutes/healthwellbeing/events/mauriceblochannuallectureseries/

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