Next week I’m participating in a panel at Durham, and organised by Durham’s Wolfson Research Institute and Demos, on the them of ‘Grimmer Up North’, and discussing health inequalities.. Here’s some thoughts.
A good starting point is to ask why health inequalities exist. Is it because some people can’t physically access safe and hygienic food, housing, leisure and work? Well, yes, that is still a problem. Some social housing is terrible, and people are facing some difficult choices as a result of the changes to the benefit system the government introduced (not least the ‘bedroom tax’, which is really a reduction in benefits where people have more space in their houses than the government believes they need). So we still don’t have good housing for everyone, and some people are undoubtedly under considerable financial pressure – turn on daytime television and watch the ‘payday’ loan companies advertise to you at rates which, frankly, I can’t believe are legal. So poor housing and financial pressures – not a good place to start from if you want to live a long, healthy life.
But surely all of this is a matter of choice? If people worked harder (or got a job) and ate decent food, smoked less, drank less booze, wouldn’t the health of the nation improve immediately. Well, yes and no.
The liberal view of us is that we are all (unless the state or something else coerces us) free individuals who make our own choices. Economics takes this one step further in saying we are rational too. Our laws suggest we are responsible for our actions, taking a not dissimilar view – we are responsible for our choices. Now, as a myth to live by, this isn’t a bad one. I can’t imagine a world where I am allowed to do whatever I like to whomever I like – that would be pretty awful for everyone else (and for me!). However, it’s probably not quite right.
Our sense of self, the thing that is meant to be the rational chooser, is probably a myth (that word again). Both recent neuroscience and philosophy suggest we are fragmented and split as either our brain simply doesn’t function this way, or our mind is subject to a range of irrational tendencies that don’t really fit with the individual, rational model. We are hugely influenced by those around us, we massively discount the future in favour of the present, kid ourselves that we are better than we (by most external measures) are (do you know people who think they are below-average drivers or have a poor sense of humour?). In short, we don’t really correspond to the model of individual behaviour that we tend to assume applies to us (which is, of course, another example of how big the problem is!).
At the same time as this, we aren’t the cultural dupes that some sociologists make us out to be. People, even when doing things that appear pretty destructive, aren’t fools. We are, however, habitual creatures. Can you imagine how awful it would be if we had to think about everything we did? No wonder we go onto cruise control when we drive our cars, or eat, or drink, or when we are with friends…..and often, as a result, do things that aren’t terribly healthy as a result.
So where does this leave us? Well, we know that significant health inequalities exist (I gather life expectancies have the largest range by district in both London and Glasgow), that there are good grounds for suggesting a North-South divide exists (Danny Dorling’s work suggests it begins North of Lincoln, South of Grimsby) and that assuming people make rational, individual choices is not going to lead to good policy.
My own view is that we need to try and remember a little compassion, and to stop thinking of people who engage in a range of practices that are harming their health (be they obesity, or drinking, or smoking or whatever else) not as idiots, or as fools, but as a sign that we (as a society) are going wrong.
How is it that there are, literally walls of cheap booze available in our supermarkets, and that every time I go to the counter in some shops I’m offered massive slabs of chocolate at discount prices? Why do we celebrate drunkenness and regard it as normal in our city centres on a weekend? Why are our emergency health services over-run with people who have drunk to excess on Friday and Saturday nights? What are we doing that makes this everyday, not the exception? Why do we castigate the poor as irresponsible spongers when our society grows ever less socially mobile? Why do we tolerate social mobility declining at the same time as the rich grow richer?
We need to think again about health inequalities, and about the way we talk about them. We need, in the language of Annemarie Mol, a logic of care. This isn’t just about sympathy and empathy, although those are clearly important. It’s about saying (and meaning it) that we are ‘in this together’, and agreeing what we need to change things better for all of us. And then doing something about it.
Liberal ideas about choices and people are all about ‘me’. But we’ll never deal with health inequalities that way – we need ‘me’ to make society work, even if it doesn’t really reflect what we know about the way our brains and minds work. To deal with health inequalities we need to deal with ‘we’, not ‘me’. We need to start caring about them, and about each other. We need to challenge lazy assumptions by policymakers, and start engaging with one another about some of the behaviours that harm us and individuals, and harm others along with way. That is really caring.
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