Neoliberal governments and health inequalities: a fantasy paradigm

While it can be politically expedient for governments to engage with health inequalities, in a neoliberal world they struggle to realistically propose actions which will substantially reduce them – such as tackling power inequalities, patriarchy-sustaining institutions or class inequality. A dominant ‘policy paradigm’ prioritising economic growth restricts even their ability to imagine alternative, equitable scenarios. In this context, politicians, policy makers and some researchers have devised a parallel fantasy world in which proximal, downstream and easily tackled exposures are put forward as viable solutions to health inequalities (and sometimes even positioned as the causes). The consequence of this is a widespread public sector culture in which well-meaning policy-makers, practitioners, researchers and the public collude in sustaining a ‘cargo cult’ around the ‘worship’ of health behaviourism.

It’s now widely accepted that health inequalities – unfair, unjust differences in health determinants and outcomes within and between populations – have serious immediate and long-term negative impacts on individuals and societies. As a result, many governments have at least a rhetorical commitment to reducing of health inequalities. It is rare for national inequality reduction strategies to include any analysis of the causal pathways that result in health inequalities and rarer still for them to suggest interventions that seek to tackle the fundamental causes of health inequalities. Instead, most policy approaches (even the few that acknowledge material and structural causes) put forward lists of ‘downstream’ (proximal) health determinants, such as smoking, unhealthy dietary choices, poor housing conditions, or failure to use contraception, whose social patterning – ie, greater prevalence among working class people – is itself presumed to represent the cause of the relevant inequality.

There are however persuasive reasons to believe that health inequalities will only be reduced as a result of deeper analysis and more fundamental policy change. Health inequalities are increasingly viewed as an outcome of material, social and cultural inequalities across societies, which are in turn the product of inequalities in power, income, wealth, knowledge, social status and social connections. Viewed from this perspective, sustained long-term reductions in health inequalities are dependent on strategies that engage effectively with these fundamental causes.

The long-term persistence of health inequalities provides additional justification for reviewing the action required to achieve health equity. Differences in health and survival between more and less advantaged groups have persisted across centuries. Only the immediate causes of those inequalities have changed: premature death among disadvantaged groups is now primarily the result of long-term conditions like cancers and cardiovascular diseases rather than infectious diseases, as was formerly the case. What remains unchanged is that it’s still the more disadvantaged folk who die prematurely.

Despite this, even policies designed to improve the health of disadvantaged people have little or no impact on long-term health inequalities. One obvious explanation for this is that politicians are attracted by policy options which focus on accessible ‘targets’ and which can be implemented in the short timeframe prior to the next election. It’s far easier to focus on exhorting downstream ‘lifestyle changes’ such as encouraging people to smoke less, eat more healthily, drink less alcohol and exercise more, than it is to legislate for ‘midstream’ policies like standardised (plain) packaging of cigarettes, restrictions on the content or marketing of unhealthy food and alcohol products, or the provision of more cycle lanes – let alone engaging with power inequalities or the other upstream causes listed above. Furthermore, in a capitalist society, where liberal macroeconomic policy prioritises economic growth (at a national level) and profit-maximisation (at a corporate level), there is an inbuilt incentive to ‘blame the victim’ rather than to tackle problems caused by economic policies or corporate actions.

The example of the UK
In the UK, as in other countries with a history of welfare state development, the public sector occupies an important role in the determination of health inequalities. This is reinforced by a centralised style of government which allows little local flexibility on the part of public authorities in the way they allocate the social determinants of health – such as access to social housing, education, state benefits, or health / public health services and policies. Devolution strategies currently under way in England will not substantially change this, because their main focus is on devolving responsibilities rather than the power to generate resources.

As a result, local public services such as the National Health Service (NHS) and local government – and so-called voluntary ‘third sector’ services which have also become providers of health and social care, as governments ‘roll back the welfare state’ – have increasingly ‘sung to the government’s tune’ in their engagement with health inequalities.

In the UK, this is especially the case in the period since 1997, as the Thatcher Conservative government (1979-90) refused to engage in any way with health inequalities and its successor, the Major Conservative government (1990-97) acknowledged only ‘variations’ – and even here, its strategic focus was explicitly restricted to Whitehall and NHS policy.

The Blair Labour government came to power in 1997 after 18 years in which Labour had, in opposition, frequently and consistently emphasised the importance of addressing health inequalities. Indeed, Labour’s – and England’s – first Minister for Public Health, Tessa Jowell, travelled the country in the summer of 1997 telling public health audiences that they ‘should feel free once again to use the word inequalities’ – something they had effectively been prevented from doing during 18 years of Conservative government, as a result of the centrally dominated public sector culture.

But while the NHS public health services and local authorities now had ‘a new song to sing’ regarding health inequalities, it was very clearly a two-part harmony. Following the publication by the Labour government of the Health Inequalities Decennial Supplement (1997) and the Acheson Inquiry report (1998), both of which were wide-ranging and relatively radical in their review of health inequalities trends and research, a series of government pronouncements and strategies emerged over the next decade which, while impressive in their rhetoric around ‘wider determinants of health’ were in reality largely focused on individualistic interventions such as behaviour modification programmes. Local public health and health promotion practitioners had very little encouragement or flexibility to address ‘upstream’ issues.

In addition, from 2010, a further dimension was provided by the Labour government’s equalities legislation which prohibited discrimination on the grounds of age, disability, gender reassignment, marriage and civil partnership, race, religion or belief, sex, and sexual orientation in the provision of public and private services and of employment. These welcome civil rights policies were accompanied by a new range of equalities staff, tools and training programmes, which occasionally duplicated and frequently caused confusion with existing inequalities tools and methods, especially when equalities staff moved beyond civil rights to engage with outcome inequalities – typically at an individual rather than population level.

What existed, then, during the period of Labour government (1997-2010) and has continued since, under the Conservative – Liberal Democrat Coalition (2010-15) and the current Conservative (2015 onward) government, was a government-driven NHS, local authority and third sector ‘fantasy paradigm’ which positions health inequalities as ‘fixable’ via interventions and policies to address lifestyle differences between population subgroups – in particular, between social classes. This is despite the fact that – as a recent synthesis of systematic review evidence demonstrates – these kinds of interventions tend to exacerbate, rather than reduce health inequalities. .

This fantasy paradigm is promoted and reproduced by a large body of well intentioned and often idealistic state / third sector employees, who have developed diverse plans and projects and who spend public and other funds on primarily downstream, chiefly outcome-focused activities, in the name of reducing health inequalities – inequalities that are largely unaffected by these methods.

An equally large body of quantitative knowledge in the form of indicators, targets, monitoring tools and other performance measures has been developed to assess this programme of activity. The frequent demonstrations of failure are typically explained with reference to the ‘challenging and persistent nature’ of health inequalities. Especially notable are the former Coalition and current Conservative governments’ continuing rhetorical attachment to the reduction of health inequalities despite these same governments’ systematic dismantling of the public sector which often provided the only external support for people experiencing poverty, disadvantage and inequality.

Towards an end to fantasy
At the time of writing, there are few if any signs of an end to politicians’ infatuation with their health inequalities fantasy paradigm in the UK or elsewhere (a parallel ‘health disparities’ fantasy paradigm exists in many other high income countries, notably the US). We are four austerity-driven years from an unpredictable UK general election and can only hope that raising awareness of these issues will stir a little truth into the toxic cocktail that passes for government.

I gratefully acknowledge the constructive comments of Dr Katherine Smith on an earlier draft. An extended version of this discussion can be seen in: Scott-Samuel A, Smith KE. Fantasy paradigms of health inequalities: Utopian thinking? Social Theory & Health 2015; 13, 418-436. doi:10.1057/sth.2015.12

Alex Scott-Samuel

8 thoughts on “Neoliberal governments and health inequalities: a fantasy paradigm”

  1. Core to the neoliberal thesis is that individuals are responsible for themselves and therefore “structural” issues such as housing are out of the discourse. As individuals are deemed self-responsible, they then, logically, must reap the consequences of their actions. This plays to the arguments of “freedom” “Democracy” and “self-determination” all of which are motherhood and apple pie poster-terms for neoliberalism. Cleverly, anyone opposing these obviously desirable ideals is in some way trying to take something away from the people…and a reactionary attitude to things like appropriate taxation, shared responsibility and community (but when you get further into these terms people start to feel a little queasy as they recognize there are good things about some of these. They just don’t follow the logic back to source). Since Thatcher this has fed the idea of government accepting little if any duty of care for the conditions within which populations thrive, other than by deregulating to “release the powers of creativity” and “free-enterprise”,”level the playing field” and “remove distortions”. Again, these phrases further restrict the very terms that can be used, and define the limits of truth. Of course, health care provision is much more lucrative than prevention and development, containing huge opportunities not only for legal profit but also fraudulent theft. In the USA, some US$80-98 billion is fraudulently acquired by the very companies now moving into the NHS. Leopards and spots come to mind. The PR industry is a hugely important element of the neolib project and it’s no surprise that the present UK government comprises a fair shake of former PR employees (plus a failed marmalade salesman). One element of responding to this involves reclaiming the terms of debate and discussion by doing precisely what was done originally when these discourses were introduced. We need to generate a clear and widespread language that needs to be positive (“Equality of opportunity”, “fairness” for example) and have the same motherhood and apple pie appeal. It is an important strategy to redefine the discourses in use. (My 2 cent’s worth).

  2. Powerful reminder to all of us that the struggle to reduce the social inequalities is on. As Alex indicates tackling inequalities, which include reducing the inequalities in power, is not easy as those who have power are unlikely to willingly surrender their powers. It is dissapointing that 1997 -2010 labour Government which sympathised with the struggle to reduce the inequalities missed the opportunity to make real impact at the determinants level.

  3. I congratulate Dr. Alex Scott-Samuel for this contribution. In a way it harks back to Aaron Antonovsky’s idea of health as a continuum. As we know, Antonovsky focused less on the ‘pathogenic’ health model, and more on the causes of health – the salutogenic model or ‘salutogenesis’. Aaron Antonovsky was not a doctor but a medical sociologist, at a time when the ‘ruling paradigm in Public Health focused on disease and risk factors’. He turned his research interest to ‘social class and health and later to the impact of stress on health’. His thesis was that ‘it was more important to focus on peoples’ resources and capacity to create health than the classic focus on risks, ill-health and disease’. His thesis seems to be reflected in earlier WHA “Declarations” which, with ‘globalization’ having taken center stage, seem to have been all but discarded. The article throws light on the conceptual differences in the idea of ‘public health’ across the Atlantic divide. I’m afraid that in the absence of a paradigm shift in the prevailing global economic model, which treats just about everything as a commodity, there may well be little hope for achieving greater equity in health – a term that is often cleverly and conveniently confused with ‘health-care’.

  4. WTF. First of all please.. can you speak my language you “educated” people with all your big words got something to say to each other? You must not be speaking on my behalf because you speaking to each other about me, a Black woman who grew up in the ghetto that has to watch her family get killed or die young. I probably am going to die to early too because I grew up on hog fat. I grew up drinking and drugging to celebrate anything (Self medicating). There ain’t no way you all or them gonna get anything right. We know the shit ain’t right,we can’t talk like you,yet we know. Who are you guys and how are you going about educating us. Talking amongst yourselves. Shit ain’t equal since day one. We live it! Do you have an interpreter so I can break it down in our language so my folks can get mad too. You got a liason who can translate these articles for us. I don’t even know what a neoliberal is. How was I supposed to go to school like you? Hell, we too busy trying to live one more day….numb. Hanging on to every little lie that makes us feel human. You people enjoy your platform. I guess you trying to do something. The very thing your doing though, I mean,you even have the privilege to talk about it. It probably makes you feel way better. That’s good kinda. I would just like these articles and comments to be available for Black fried food eating smoking crack heads,, Native fry bread eating alchoholics, Mexican taco eating gangster hop heads and poor white folk meth addicts. Oh, I’m sorry not politically correct? I’m keeping it one 100….general. These are the folks you all are “fighting” for right? Find a way to get here.Then you doing something. All you all need to put your money together ( most of you got way more money then ten of us put together. Buy one family some good food. Do you know how much it cost to eat healthy? Of course you do. Learn our language,then write a verse about this shit and give it to jcole to spit. I know you can do most of you all went to school for at least 4 years and paid thousands of dollars..
    Couldn’t you make the same sacrifice to really educate yourselves,while doing even just one family some justice. Find a way to get here otherwise your just regurgitating what has been taught to you by you. It does us absolutely no good cause we are not coming down to where you are. Some of us (poor souls ..sell outs)have. That is because they believe that their human value can be designated by mocking the oppressor. It is even sadder to see. Mskes me wanna throw up. They hurt too…Im sure they can afford the bill if they go to the doctor for their pain. The doctor can’t fix their whole selves…us. They (the few)living a lie too. Most of us want to go down to where you are but we got no way to get there. I dont want us to want to go there. I want us to get us. What you say may make since, you want to give each other high fives. Oh, you know a little about our language,ha ha.

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