Health, Wealth and the Politics of Inequalities
No society can surely be flourishing and happy, of which the far greater part of the members are poor and miserable.
Adam Smith (1776), The Wealth of Nations, 1, 8
The first time I walked over to the melancholy village of Shiaba on the South side of the Ross of Mull we passed a group of a dozen or so people, Canadians. Some were in tears. In the mid-nineteenth century the village had a population of over 100 crofters served by a school and chapel, until 1847 when the Duke of Argyll issued eviction notices to clear the land. There was more money to be made from sheep farming than from renting it to crofters (http://www.mull-historical-society.co.uk/daily-life/habitations-ruins/shiaba/). The residents were forced to move, some to mainland Scotland and the large cities to work in factories, others to the Americas. The Canadians were descendants of residents of Shiaba; they had been visiting their ancestral home for the first time. Reading about the Highland Clearances and the Irish Famines in the mid-nineteenth century opened my eyes to a brutal fact: the lives of most of us are governed and dominated by forces over which we have little control. The urge to accumulate more and more wealth is one of the most powerful of these forces.
Just for a moment put yourself in those crofters’ shoes. Try to imagine the desolation, heartbreak and sorrow they must have experienced, natural human emotions in response to the loss of their homes, community and livelihoods that today would be labelled depression to be treated with antidepressants or psychological interventions like cognitive therapy (CT) or positive psychology.
My first visit to Shiaba was the mid 1980s, and I was four or five years into my first consultant psychiatrist job in Manchester. The City that had been the cradle of the Industrial Revolution was struggling to replace traditional work in factories and mills with the new service industries, banking, insurance, telecommunications, advertising and marketing. As Thatcherism ripped out its industrial heart, the country struggled to come to terms.
There was great poverty in the neighbourhoods of Hulme and Moss Side where I worked. There still is great poverty although it has been massaged elsewhere around the City. It became clear to me very quickly that most of the people I saw didn’t require psychiatric or psychological treatments. They need secure employment and fair pay, decent housing and schools, and safe neighbourhoods.
One of David Ennals’ (the outgoing Secretary of State for Social Services under the Callaghan Labour government) last acts was to commission an inquiry into health inequalities under the late Professor Sir Douglas Black . When Thatcher came to power in 1979, Ennals’ role was taken over by Patrick Jenkin, and the final version of what came to be known as The Black Report landed on his desk in April 1980. In the words of The Lancet, it received a ‘frosty’ reception . The BMJ spoke of the new Government’s ‘…shallow indifference…’ towards the report , which it attempted to suppress. Fortunately over 200 copies were distributed and eventually published as Inequalities in Health: The Black Report.
A dozen or so years later when the Department of Health (1995) reviewed progress on health inequalities, it published its report under the title Variation in Health: What can the Department of Health Do? .It is worth flagging up a subtle semantic shift here. This was not a rhetorical question. There was a growing sense that there was indeed little that the Department could do to reverse trends in health inequalities linked to growing income inequality. I’ll return to this later.
The most recent epidemiological examination of the links between inequality and health is of course Wilkinson and Pickett’s The Spirit Level . Their analysis ties poor health, poor mental health, and a wide range of indices of social dysfunction such as teenage pregnancies, crime and lack of social cohesion to income inequality across the countries of the Global North. Countries like the USA and UK that have high levels of income inequality have higher levels of health inequalities as measured by, for example, life expectancy. Countries that have low levels of income inequality, such as the Scandinavian countries and Japan by and large have lower levels of health inequalities.
The Spirit Level has been attacked by those on the political right, such as The Tax Payers’ Alliance, The Democracy Institute and the Policy Exchange. The Tax Payers’ Alliance was set up by a libertarian group of Conservative MPs in 2003 critical of the Conservative Party’s attempts to match the Blair Government’s spending plans, and the Party’s failure to commit to reductions in public spending. The Alliance has been highly critical of Wilkinson and Pickett’s work . In turn Wilkinson and Pickett have set out a detailed rebuttal of these, and other, criticisms .
The issue here concerns the interests served by those on either side of these arguments. Wilkinson and Pickett are quite open about their support for the socialist policies of Jeremy Corbyn. Their signatures headed a letter of endorsement for the new Labour leader on his election in 2015 [ix]. In view of this one might, perhaps a little tritely, paraphrase their work as science in the service of social justice. However, their critics claim that Wilkinson and Pickett’s left-leaning political bias has influenced their interpretation of ‘neutral’ and ‘objective’ scientific facts. But in fairness we have to consider whether political bias is also apparent those who attack the The Spirit Level. Whose interests do they serve? Why, the wealthiest 10% who possess 85% of the world’s wealth ; the chief executives of the large multinational corporations who employ their workers on zero-hours contracts, oppose unionisation, and pay little or no taxes in the UK. This (neoliberal) political influence on the interpretation of the epidemiological evidence is never acknowledged.
If you are convinced by the evidence of a relationship between income inequality and poor health, and you believe that compassion and a concern for social justice are at the heart of the practice of medicine, then it follows that the solution to inequalities in health rests in the creation of a fairer, more socially just society through fiscal and economic measures aimed at income redistribution, and political and economic policies aimed at strengthening workers’ rights through, for example, encouraging union membership. If on the other hand you believe in the value of free enterprise, the market and ‘trickle down’ economics then you will of course oppose The Spirit Level’s interpretation of the facts.
My recent work has become much more concerned with the politics of health and mental health. This has always been an important issue for me, witness an early attempt to articulate it with Marius Romme and Jaap Hamelinjk. But since the financial crash of 2008 – 2009, and the tightening of austerity by Coalition and more recently, Conservative, governments the baleful influence that neoliberalism has had on our health and emotional well-being has become all too apparent. Indeed there is a strong view in public health circles that neoliberalism is bad for our health . There is also an emerging view that the discourse of health inequalities is unhelpful because it shifts attention away from income inequality that underpins poor health . Perhaps in 1995 the Department of Health threw its hands up in desperation; what indeed could it do to rectify health inequalities? Framing the poor health of the majority of the population as health inequalities primarily serves the interests of politicians, economists and transnational corporations who are desperate to preserve the status quo at all costs.
In the coming weeks I will be writing a series of blogs based in my recent work . The focus will be neoliberalism and health. What is neoliberalism? What are its links to austerity, and why has austerity been so destructive of health and well-being? What role do psychiatry, psychology and therapy play under neoliberalism? In particular, whose political interests do these disciplines serve. Much of the focus here will be on the policy of Improving Access to Psychological Therapies (IAPT) and its gallimauphrey of interventions. Finally, I’ll try to draw some tentative conclusions. My website has now been updated for you to leave your own comments.
Virginia Berridge has given a fascinating account on the website of the Socialist Health Association of how the Black Report came to be set up . accessed 5 Aug 2019
See ‘Inequalities in Health’ The Lancet Sept 6 1980, 2, 8913, 513.
See ‘An Endangered Species’ British Medical Journal1980 Dec 20; 281, 6256, 1662–1663
Black, B., Morris, J., Smith, C. & Townsend, P. (1982) Inequalities in Health: The Black Report (Eds P. Townsend & N. Davidson) Harmondsworth, Penguin Books.
Department of Health (1995) Variations in Health: what can the department of health and the NHS do? London, Department of Health.
Wilkinson, R. & Pickett, K. (2009) The Spirit Level: Why Equality is Better for Everyone. London, Allen Lane.
See,https://www.taxpayersalliance.com/fact_checking_the_spirit_levelaccessed 5 August 2019
 The Global Wealth Report for 2018 found that ‘While the bottom half of adults collectively owns less than 1% of total wealth, the richest decile (top 10% of adults) owns 85% of global wealth, and the top percentile alone accounts for almost half of all household wealth (47%).’ See https://www.credit-suisse.com/about-us/en/reports-research/global-wealth-report.html page 9. Accessed 8 August 2019.
Thomas, P., Romme, M. & Hamelinjk, J. (1996) Psychiatry and the Politics of the Underclass. British Journal of Psychiatry, 169, 401 – 404.
Schrecker, T. & Bambra, C. (2015) How Politics Makes Us Sick: Neoliberal Epidemics. Basingstoke, Palgrave Macmillan.
Lynch J. (2017) Reframing inequality? The health inequalities turn as a dangerous frame shift. Journal of Public Health; 39: 653–60.
Thomas, P. (2016) Psycho politics, neoliberal governmentality and austerity, Self & Society, DOI: 10.1080/03060497.2016.1192905
Thomas, P. & Knight, T. (2019) Happiness, Austerity and Malignant Individualism. AHPB Magazine for Self & Society2, Winter 2018 /19, 13 – 21.
 Knight, T. & Thomas, P. (2019) Anxiety and depression in the age of austerity: public health’s problems with IAPT. Perspectives in Public Health, 139, 3, 128 – 130
 Thomas, P. (2019) Neoliberalism: What is it and why it matters. Chapter 1 in (eds. C. Jackson and R. Rizq) The Industrialisation of Care: counselling, psychotherapy and the impact of IAPT. Hay-on-Wye, PCCS Books.