We are probably all familiar with the concept of a healthy economy. In the age of 24 hour news, discussions relating to the health of the national and global economy are constantly being fed into the public consciousness. But how is the economic thinking that underpins contemporary capitalism affecting the way in which we think about our own health?
Health is an issue that has never been far away from my own thoughts. Health, or rather, sickness, has been an all too real part of my and my families life for as long as I can remember. It is only really in the last year or so however, that I’ve really started to think about the relationship between our own attitudes towards health, and economics. After all, health in many ways is a deeply personal subject isn’t it? Our bodies are our own, as are the day-to-day health related decisions that we make with regards to what we eat and drink, how much exercise we have, or how many cigarettes we may or may not chose to smoke.
What has capitalism and economics got to do with it you might ask? Sure, from time to time we have to go to the doctor, and some of us are unfortunate enough to have to spend some time in hospital too, and yes the money to pay for this has to come from somewhere… but aside from the occasional sage piece of advice or rapped knuckle provided by a health professional, our health – at least until we get sick – is largely something that we look after ourselves isn’t it? After all it’s mainly just common sense right? Eat your greens, make sure you don’t go to bed too late, don’t just eat crisps, put your bloody jacket on. These pieces of wisdom, designed to keep us healthy, will be familiar to most people from their own childhoods.
It all seems pretty obvious so far right? Well, maybe. But this is far from the full picture. The way in which we think about health has been heavily influenced by neoliberal governmentality. If you feel comfortable with this concept then feel free to pat yourself on the back, grin smugly and skip down the page a paragraph or two. If you don’t, then ignore the smug people rudely skipping ahead (they are going to miss out on a really fun gif) and stay with me just for a minute. You don’t even need to read either of the massive wikipedia links helpfully provided, unless you really want to.
Neoliberalism is a term that is used a lot, an awful lot. In fact it is a term that has been used so frequently and often to mean so many different things that the use of the term has increasingly come under fire from some academics. So if you are in anyway confused about exactly what neoliberalism means, you can breathe easy.. so are a lot of other people. Personally I feel like it is a concept that still has a lot of mileage left in the tank.
Neoliberalism is a school of political and economic thought which favours the expansion and intensification of markets, while at the same time seeking to reduce government intervention to a minimum. Neoliberal policies tend to favour the deregulation of markets, the cutting of public spending on social services and the privatisation of state owned enterprises, goods and services. If this sound familiar to anybody, it is probably because we in the UK and US have been living against the backdrop of a neoliberal project that, beginning under the leadership of Margaret Thatcher and Ronald Reagan in the late 1970s and early 1980s, has continued to evolve on both sides of the Atlantic until the present day. Nor are we the only lucky buggers to have been given this wonderful present. Neoliberal policies have been exported all over the world, from Latin America to the former Soviet Union, with the IMF and World Bank often playing the role of play-ground enforcer.
Neoliberalism is not just a economic and political project though, it also has its own moral and social philosophy which helps us to understand how it works in practise. The five core tenets of the system of neoliberal thoughts and beliefs, which we can call neoliberal ‘rationality’ are; minimal government intervention, market fundamentalism, risk management, individual responsibility and inevitable inequality. We will come back to these areas again when we get back to looking at the relationship between neoliberalism and health but that is enough neoliberalism for now… phew.
Now lets bring on governmentality! First I have to nod my metaphorical cap to Michel Foucault, a chap who knew a thing or five, and the man who came up with the concept of governmentality – and yes it sounds so much nicer with a french accent – but lets just get on with it shall we? Governmentality is the conduct of conducts, with the first use of the word conduct referring to what the guy with a stick at the front of an orchestra does when he is conducting, and the second referring to the way in which we all behave or ‘conduct’ ourselves. And that’s it! Governmentaliy is basically just the regulation or steering of behaviour… and I told you there would be a gif.
Not so bad right? In terms of what we are talking about here, governmentality refers to a ‘soft’ form of governance. A means of enacting power whereby the governors – without needing to revert to anything as nasty as the use of force or even the passing of laws – are able to control the behaviour of a population through a multiple range of often unnoticed strategies and techniques.
There, we made it! Putting it all back together again, when I talk about neoliberal governmentality, what I am actually talking about is the way in which the core tents of neoliberalism – as outlined above – are shaping the way in which we, the everyday Joe and Jane Bloggs of the world, think and behave with regards to different things, with the thing in this case being health!
By taking the key tenets of neoliberal rationality and looking at how they interact with each other it quickly becomes apparent how neoliberalism is shaping the way in which we think about health. Lets start with the idea of individual responsibility. Neoliberal capitalism is big on freedom, at least if you think of freedom in terms of a lack of ‘oppressive’ government regulation and the ‘freedom’ to chose from a whole load of different brands of crap to buy. You don’t have to look too hard to find a neoliberal economist who will try and make the outrageous claim that there is an intrinsic link between free markets and political freedom (i.e democracy) too, despite plenty of evidence demonstrating the corrosive effects of unfettered capitalism on democratic society. In fact a good case has been made to suggest that even when it comes to buying stuff, ever greater choice (or the illusion thereof) may actually be bad for us psychologically and not actually all that ‘freeing’ after all – but that is a tangent that should probably wait for another post on another day.
For now lets focus on the fact that the freedom of the individual under neoliberal capitalism is intrinsically tied to the concept of individual responsibility. This is where the different tenets of neoliberal rationality all start to work together. In a society with small government (few safety nets) and market fundamentalism, it increasingly becomes the sole responsibility of the individual to make a success of themselves irrespective of however privileged or disadvantaged their circumstances. Freed from the tyranny of the ‘nanny-state‘ and its tendency to – at least partly – level the playing field through the universal provision of social services and redistribution of wealth via taxation and benefits, greater and greater inequality therefore becomes inevitable as people are ‘free’ to fail or succeed.
This concept of freedom leads to the utterly erroneous – but, if you are a member of the elite, extremely convenient – linking of virtue and material wealth. Thus the wealthy and powerful are hailed as brilliant, hardworking and entrepreneurial (even when – as demonstrated by our friend The Donald – they would be even wealthier if they had just done nothing) while the poor and disadvantaged, who, free to succeed and yet having failed, are labelled as morally degenerate and lazy. This entire narrative is based upon the illusion of a level playing field allowing for a truly meritocratic society in which the most gifted and hard-working are able to rise to the top. The reality of course is that as the welfare state is removed, the playing field becomes more and more unfair, resulting in a greater and greater concentration of wealth and power amongst those at the very top of the pyramid and ensuring, in reality, that only the successful are free.
And this is when we finally get back to health at last. Why is it that there is a health inequality gradient so large in the UK that there is now an 18 year difference in ‘healthy life expectancy’ between women living in Richmond (72 yrs) and Tower Hamlets (54 yrs)? Is it because people in Richmond take more responsibility for their own health than people in Tower Hamlets? Or is it actually because Richmond (sorry darling, Richmond-on-Thames) is well posh and Tower Hamlets… well, is anything but. In fact, one in two kids growing up in Tower Hamlets will be growing up in poverty, which is more than three-times the ratio in lovely leafy Richmond. And there it is, socio-economic inequality is in itself a root cause of health inequalities. Essentially health inequality arises out of the fact that the wealthy are able to protect and improve their health while the poor cannot.
Despite there being a very significant body of evidence supporting this fact, a very specific form of health consciousness has emerged and become deeply ingrained within our social fabric. And this form of health consciousness often actually appears to ignore the role of socio-economic inequality on health outcomes. Since the emergence of the neoliberal project in the 1980s, there has been a drastic increase in the amount of health policy that focuses on health promotion in the public arena. While it might seem perverse to suggest that health promotion is a bad thing, it has tended to reinforce the idea that as long as individuals eat more fruit and vegetables and exercise for half an hour each day, then they will be healthy. While i’m not questioning the positive benefits of fruit and exercise on health, this line of reasoning tends to obscure the fact that poverty remains a fundamental driver of ill health, and that the material conditions of many citizens has actually deteriorated under neoliberalism, as highlighted by the emergence of what Guy Standing has called the precariat.
Health promotion has also gained popular media and corporate attention since the 1980s, and the health, wellness and fitness industries have largely succeeded in generating an obsessive preoccupation with health amongst much of the population. This has only been made possible in the context of a the neoliberal vision of the responsible citizen. The term ‘Healthism’ describes a sort of conceptual ‘cut and shut‘, representing an obsession with the body in which a hedonistic (consumerist) lifestyle is married paradoxically with a contradictory preoccupation with ascetic practices aimed at the achievement or maintenance of the appearance (if not always the actual reality) of health, fitness and youthfulness.
Once again we see how the different tenets of neoliberal rationality combine. The shifting of the burden of responsibility for health from the shoulders of the state to the individual has occurred alongside the growth on an industry built around the consumption oriented aesthetic of health. The selling of ‘health, the lifestyle’ at $150 per pair of yoga pants ignores the real determinants of health and makes a mockery of the crucial role of socio-economic inequality. While the enormous amount of time, money and physical effort ‘health conscious’ individuals are investing suggests a narcissistic obsession with self, this investment is instead portrayed as the duty and obligation of the good citizen, and as an expression of prudence and conscientiousness. Most perniciously of all, this shifting of responsibility provides a tacit justification for the shrinking of state provided health services and the concomitant cherry-picking by the private healthcare sector of services that can make a ‘healthy’ contribution to their bottom line.
So… it is pretty clear that the way in which we think about health has been affected by neoliberal governmentality. We are increasingly encouraged to think of health as our own individual responsibility, and something to be protected and strengthened through the consumption of a variety of products and services which are, in turn, increasingly provided by the private sector as it carves out new markets to be exploited for profit.
Doesn’t health inequality start to seem just a bit more, well, understandable? Just as there has been a growing demonisation of the poor, is the same not happening with the ill too?
Well they did bring it on themselves… I mean if they didn’t insist on eating takeaways every night…If they smoked less or didn’t drink so much, if they weren’t so lazy, and actually got off their fat arses once in a while… if only they thought about their own wobbling bottom lines a bit more and did some exercise.
Excluding the terrible joke (which was unfortunately inevitable) at the end of the passage, how many of us can honestly say that we haven’t had thoughts like this at one time or another when contemplating the plight of somebody whose health – and quite possibly, socio-economic status – is in someway less advantaged than our own? If we start to feel more and more responsible for our own health, and feel more and more justified in revelling in our own hard earned successes at maintaining it, doesn’t it also become easier for us to start judging those in ill-health for failing to match our own exemplary levels of dedication and effort?
At a time when our own public health service, having not so very long ago been ranked as the best in the world, is being dismantled and sold off piece by piece, at a point when the Employment Support Allowances (ESA) for disabled people has just been slashed by £30 a week and yet the able-bodied largely remain absent from the streets in protest, at a time when the poorest citizens in the UK die 25 years earlier than the richest and yet health inequality continues resolutely to grow, shouldn’t we be thinking of health as a collective human right rather than as an individual responsibility?