Chris Yuill says the solutions to the health inequalities that still stalk Scotland lie in economic and social change.
Walk across the Wellington Suspension Bridge over the River Dee in Aberdeen from Torry to Ferryhill and something worrying happens. Average life expectancy drops by about ten years for men and just under six for women. In the east of Torry, average male life expectancy is 70.7 years and average female expectancy is 76 years, while in the south of Ferryhill it is, respectively, 81.1 and 81.4 years. The difference is not due to higher levels of pollution – the areas are very close to each other – or access to public health care, both areas have easy and quick access to GP practices and the city hospital, but due to the relationship between class and health.
Torry, on the southside of Aberdeen, built upon the now declining fish industry, exhibits high levels of deprivation, particularly among the social housing on its edges. Ferryhill, on the other hand, is reasonably affluent but not the most affluent part of the city. If you were to continue your walk for a further twenty minutes, then you would reach Mannofield. Average life expectancies there are 83.5 years for men and 86.9 for women. Echoing Michael Marmot in his two reports, that is a waste of life, a waste of people’s potential and a loss to the economic functioning of society.
Similar journeys could be made in other parts of Scotland. Walk through, for example, Colquhoun Park in Glasgow, a nice enough urban park with play areas and green space, that lies between Drumchapel and Bearsden. Stark differences in life expectancy emerge once more. In the part of Drumchapel that overlooks the park, life expectancy is 68.3 years for men and 71.3 for women, while in directly opposite Bearsden, it is 82.8 years for men and 87.2 for women.
These differences in life expectancies should come as no surprise to Scottish Left Review readers. In addition to these, inequalities in emotional wellbeing can be added alongside health inequalities by gender and ethnicity. The existence of persistent and enduring health inequalities has been a known and well researched feature of our society for some time.
Engels in his ethnographic tour in the 1840s of the rapid capitalist urbanisations of England witnessed what he famously described as social murder, the ‘early and unnatural deaths’ of poor people due to the structures and relations of capitalist society. Forty years later Booth, in his empirical mapping of London, observed a relation between poverty and health in the poorer streets and lanes of the capital city.
In Scotland, classic work in the early 1990s, such as that by Carstairs and Morris, also drew attention to the relationships of class and health. A whole slew of other research has consistently pointed in the same direction each and every time: class – often expressed as social inequalities in the mainstream academic literature – influences, shapes or determines health and wellbeing. Wilkinson and Pickett’s research, presented in their best-selling, The Spirit Level, found a correlation between health inequality and income inequality. The higher the income inequality – the gap between the highest and lowest earners in a society – then the higher the health inequality. Societies exhibiting high income inequality create corrosive and toxic social relations that distort how other people are seen and valued. We also witnessed during the pandemic that both class and race inequalities contributed to higher morbidity and mortality rates for working-class people and people of colour.
Running through all this research is the theme that health and wellbeing is much, much more than the taken-for-granted so-called ‘lifestyle’ or risk factors. What the research reveals is that diet, smoking and other so-called lifestyle factors do exert an influence on health, but they are far from a complete account. Sociologists who study health and wellbeing, such as Bambra, Scambler and Yuill, have demonstrated the need to turn attention to the deeper machinations of capitalism, and how its logics of accumulation and exploitation are the causal mechanisms of health inequalities.
Health and wellbeing are not solely reducible to individuals and what they do and do not do. People exist in an assemblage of biological, physiological, psychological, social, cultural, economic, symbolic, cultural, power, class, and other material relations. Their health emerges out of these relations with some relations such as class and power exerting considerable influence on the other parts of that assemblage. In terms of improving health and wellbeing, it is therefore more effective to address issues of power, control and meaning in people lives rather than fixate on what choices they make.
Approaches that emphasise improving health and wellbeing at an individual level may make some difference – encouraging anyone to stop smoking is inherently a good move – but they will not lead to the reduction in class and health inequalities that is required to fully meet everyone’s capacity, and the right to live a long, fulfilled life. Individuated approaches stem from the flawed perspective that health and wellbeing is the outcome of individual choice manifest in what people choose to drink or eat. These perspectives emerge from two different sources. One is behavioural psychology which holds that all behaviours are anchored in individuals’ decisions. The other is neo-liberalism which seeks to deflect and project the causes of social maladies onto the individual.
One common response to health problems is to call for increased funding for the NHS. Putting more and more resources into the NHS will not in itself prevent health inequalities developing in the first place. As with all health services, the NHS treats people once they become ill. We require more radical action that begins to make deeper and more fundamental changes to create a society of good wellbeing.
We are talking about a fundamental transformation of a society. Whilst revolution may be the ultimate answer there is little indication it will occur anytime soon. So, what to do instead? There are steps that can be put in place that will begin to make a manifest difference to the lives and wellbeing of working-class people across Scotland but it will involve thinking differently, in ways that are not usually associated with health policy.
There are three suggestions that come to mind. None are perfect. All can be critiqued, but they represent a start and – at very worst- a better way of living than we currently do. Some are nudges while others are more of shoulder charges.
The right to the city – reverse the privatisation of mobility: Research analysing issues of deprivation and health always produces one interesting finding: the need for cheap – if not free- public transport that is frequent and well connected. Decades of transport privatisation across Scotland has greatly restricted movement within and without urban and rural areas.
In one study of food insecurity in Aberdeen, for example, researchers found that life for people living in working class communities was made harder by not being able to easily access cheaper supermarkets, health facilities (such as their GP), and job interviews. Many of the people spoken to in the research also experienced long-term poor physical and mental health and wellbeing, while additionally caring for family members with disabilities or chronic illnesses. Trying to reach either places or the people for whom they provided care was very hard. Buses were expensive and did not connect different housing estates or were non-existent. The lack of transport limited what they could achieve and, in turn, negatively affected wellbeing while adding to the hard work of living in poverty.
As Marxist urbanist, Lefebvre, argued everyone has the right to the city in terms of mobility to move around in the city and to influence its wider development. By providing the resource of movement, wellbeing would be improved allowing people to easily maintain supportive caring relationships, and access facilities plus also make them feel part of the city, that their needs are recognised and that they are not marginalised and forgotten. Providing cheap transport may not seem that radical but it constitutes area that could easily be returned to public ownership with obvious benefits.
Reducing health inequalities by reducing power inequalities in the workplace: Giving people control over their lives while working provides another improvement in health and wellbeing. The findings of the Whitehall I and II studies indicate that issues of power, status and reward in the workplace affect health. My own research focussing upon workplace alienation also found that a lack of meaning and purpose can lead to poor wellbeing unless modulated by the support of other workers. The direction of travel in many companies is towards a hyper-managerialism built on deepening control, surveillance and disempowerment of workers.
Tipping the balance of class power towards workers is a further route to better health and wellbeing. Multiple models exist for how this arrangement could be organised. Economic democracy is one option as it seeks the diffusion of power across the workplace. It can be achieved though share options, more team working and so on. But those approaches do not reach far enough. The Mondragon Cooperative system in the Basque country offers a more radial version. In these organisations, workers exert considerable control as the policy of the sovereignty of labour as one of its foundational principles is practiced. More strikingly pay ratios of managers are fixed at six or nine times the lowest wage paid in the organisation, reining excessive income inequality (in Britain and America senior executives can be paid up to 250 times the lowest wage in their organisation). Mondragon is not a socialist project – in fact is a large company working across finance, retail and manufacturing. It is a version of capitalism where waged labour competes in the market-place. But it provides an alternative to the dominant shareholder version of capitalism in Britain where the mission of a company focuses on enrichment of a few rather than the wellbeing of the workforce. We also need to reverse the decades of anti- union legislation and enable working-class people to exert control over all aspects of work and employment.
Bring back social security by introducing universal basic income: Let us return to thinking of supporting people financially as social security rather than benefits or welfare, terms loaded with stigma and part of disciplinary armoury of neo-liberalism. We are moving to a post-work society. Automation and new technologies will drive that future. Unfortunately, this future will not be the post-work society envisioned by Keynes, let alone Marx, where people will be freed from alienating toil to actualise their desires and capabilities. It will be a post-work society of further surveillance and disciplining of the unemployed as being the architects of their misfortune. We need to move towards mechanism for supporting people centred on empowering them to live a life of meaning and above basic subsistence, and one that dispenses with the cruel bureaucracy of the current system.
Universal Basic Income (UBI) provides one way forward. The premise is that everyone in a society receives an income that makes it possible to do more than survive. Recent trials of UBI in Finland have found it does improve health and wellbeing across a number of indicators such as life satisfaction, stress reduction, and physical and mental health. The SNP has indicated that it could be adopted in an independent Scotland. That would be welcome but why wait?
Scotland’s health and wellbeing has been poor for some time – much poorer than it should be. The causes of Scotland’s health inequalities are not down to the inadequacies of individuals. We need to focus on how it is the workings of neo-liberal capitalism like privatised public transport services or increased workplace exploitation that creates these conditions. It is in areas like those, and generally making life tolerable for everyone, that change is needed to bring about lasting change. Fixing health is ultimately about fixing social, economic and power relations.
Dr Chris Yuill is a senior lecturer in Applied Sociology at Robert Gordon University in Aberdeen.