I have repeatedly called for academics interested in the social determinants of disease, and most particularly sociologists, to go beyond: (1) merely re-affirming the existence of health inequalities; (2) emphasising the salience of structural factors like class, gender and race; and (3) commending social and health policy reform that is simply not going to happen given (2). Without claiming any great import for this blog, I thought I should put my money where my mouth is and venture a few arguments myself.
As it happens, Michael Marmot has today published his report on health ‘equity’ (equity refers to inequality that can be addressed and remedied) in Greater Manchester in the context of the pandemic (hereafter COVID). In a blog in the BMJ he rightly insists that ‘it is not fanciful to posit a link between failure to pursue policies on social determinants of health and England’s poor state of health before the pandemic. From 2010, the rate of increase in life expectancy slowed markedly; health inequalities increased, linked to deprivation and region; and life expectancy for the poorest people outside London declined. This worsening health picture, we suggest, is related to policies of austerity and regressive cuts to spending during that period.’ In short, as others have reported – and as Benny Goodman, Miranda Scambler and I insisted in a paper on ‘muckraking sociology, the NHS and COVID’ that we refused to tone down to satisfy the referees of a leading journal (reproduced with other relevant blogs at: www.grahamscambler.com) – the decade of austerity both contributed to increasing health inequalities and set up the response to COVID in England to fall well short of what was required.
In a nutshell, Marmot found the death rate in Greater Manchester to be 25% higher than the England average during the year to March. Life expectancy in North West England fell in 2020 by 1.6 years for men and 1.2 years for women (compared with 1.3 years and 0.9 years across England as a whole). Within the region, life expectancy dipped most sharply – and often dramatically so – in the poorer areas. Totally predictable, and indeed predicted by Marmot himself.
Marmot commends an initiative in 2019 to establish Greater Manchester as a ‘Marmot City Region’, made possible by increased local – Mayoral – powers consequent upon devolution. He reports limited progress since. But he also re-emphasises the priorities for policy change set out in his earlier report, ‘The Marmot Review 10 Years On’ (see my blog on ‘Marmot, COVID and Health Inequalities’). In summary form, these are:
- Give every child the best start in life
- Enable all children, young people and adults to maximise their capabilities and have control over their lives
- Create fair employment and good work for all
- Ensure a healthy standard of living for all
- Create and develop healthy and sustainable places and communities
- Strengthen the role and impact of ill health prevention
These are surely unobjectionable, indeed evidence-based. Moreover, Marmot’s contributions both as a researcher and increasingly active proponent of policy reform (as in Greater Manchester, with Andy Burnham) are positive and welcome. The qualification can be anticipated: nothing much of significance has or will change given the structural parameters and constraints associated with post-1970s rentier capitalism. So this is the true take-off point for this blog!
Clare Bambra, Julia Lynch and Kat Smith make some interesting observations in their ‘The Unequal Pandemic’, in which they define COVID as a ‘syndemic’ (ie a co-occurring, synergistic pandemic which interacts with and exacerbates existing chronic health and social conditions). In their concluding chapter they offer a list of salient factors for change:
- The pandemic might stimulate progressive economic reforms (after all;, COVID has exposed what I have called the ‘fractured society’)
- COVID might – in opposition to present tendencies towards a post-truth culture, usher in a new era or ‘golden age’ of scientific expertise (witness the success of the vaccine rollout)
- The governmental shift to an authoritarian style of leadership might stimulate democratic rejuvenation
- The pandemic might be an important ‘learning opportunity’ for efforts to tackle climate change (ie scientific expertise can be effective)
- COVID might make the case for greater inclusivity by highlighting the high costs of discrimination (Gottlieb et al: ‘societies can only be as healthy as their weakest members’)
These points edge us closer to a sociological, or macro-focus, on transformative social change.
I have over time and in a number of publications and blogs begun to address the issue of how to effect structural change in society. I have explored the following propositions:
- Social structures or relations like class, gender and race, understood as enduring generative (beneath-the-surface) mechanisms, have long historical tap roots and are exceptionally resistant to (on-the-surface) agential efforts to revise, deconstruct or disassemble them
- Within the UK’s existing system of capitalist democracy, a parliamentary route to transformatory structural change is all but inconceivable, as was evidenced recently by the rapid and effective undermining of the Corbyn challenge
- Principal among the mechanisms causally responsible for health inequalities is a class/command dynamic, reinvigorated in the period of rentier capitalism, which asserts that these inequalities derive above all else from transnational sway of a tiny minority of owners of capital who buy power from the nation state to implement policies to their advantage (ie capital buys power to make policy): these policies are in direct opposition – even exclude – the policies advocated by Marmot and others
- Given the ongoing ‘contamination’ of the state’s power elite and the impotence of parliament, the only way to effect transformatory or structural change is by mobilising the populace
- A precondition of the effectiveness of a social movement is that it is class-based, in other words underwritten by the working class, which, as Erik Olin Wright maintained, unites the bulk of those who ‘work to live’
- Although the likelihood of this kind of working-class unity – and hence of an effective people’s movement – remains slight, it can (perhaps only) occur in the event of a ‘trigger event’ occasioning a crisis of state legitimation
- Such a people’s movement will necessarily involve a series of alliances across overlapping campaigns and group interests
- As Bambra and colleagues maintain, COVID might carry the potential to precipitate a legitimation crisis (and tranformatory change typically only succeeds a major social upheaval, as occurred in the UK following WW2)
- The optimal political strategy in present circumstances could be one of ‘permanent reform’, that is, a continuous and coordinated push for reform along a spectrum from attainable (eg Marmot’s initiative in Greater Manchester) to aspirational (ie those that expose and call into question enduring social structures)
- Lenin’s challenge remains, namely, how to organise a people’s movement to secure institutional change, because an un- or under-organised movement is unlikely to survive what in the UK is becoming an increasingly (class-based) authoritarian or oppressive state apparatus
All this is merely to scratch the surface, but it is interesting that very few of these issues and challenges are mentioned, let alone discussed, in the sociological literature on health inequalities, which is resolutely professional, policy and occasionally public sociology oriented (and rarely critical, foresight or active sociology oriented). I have tried!
I have started reading Mike Savage’s monumental ‘The Return of Inequality’, which I am sure I will enjoy. But I was struck by a comment he makes on page 4. He cites a Joe Stiglitz article in ‘Vanity Fair’, which he describes as pulling no punches and ‘sensationalist’. ‘Americans’, Stiglitz writes, ‘have been watching protests against oppressive regimes that concentrate massive wealth in the hands of an elite few. Yet in our own democracy, 1 per cent of the people take nearly a quarter of the nation’s income – an inequality even the wealthy will come to regret.’ Savage picks up on this: ‘his article was short, sensationalist. In directing his ire against top earners he continued a long and distinguished American muckraking tradition of castigating robber barons and selfish plutocrats. Yet the article also unsettled conventional wisdom about the nature of contemporary social problems.’ Stiglitz was writing in 2011. Savage announces that since Stiglitz, ‘elite bashing’ has become ‘a major current of both academic and more popular discourses.’ We have ‘begun to’ reverse the telescope to look at the rich rather than the poor, hence a renewed professional sociological interest in ‘elite studies’. I have a few observations.
First, and I can’t resist saying this (although maybe I should try harder), I have been arguing via my class/command dynamic and ‘greedy bastards hypothesis’ that it is the rich we should focus on if we want: (i) to explain, and (ii) to alleviate health inequalities for a quarter of a century! So not entirely new. The fact that I have only very rarely, exceptionally, been cited by sociologists of health inequalities – even to challenge or reject my theorising – is interesting in and of itself (as I’ve often noted, some will agree with me in the bar but say they cannot risk citing me for fear of a crisis in institutional funding): I have elsewhere rehearsed my views on the taming of sociology.
Second, I think a focus on elite studies is limiting. It is of course perfectly justified if one’s interest is in how who emerges and ascends in particular elites, including major shareholders, financiers and politicians: horses for courses. But it necessarily precludes grasping and explaining phenomena in terms of class, and I continue to claim – as articulated in the class/command dynamic – that health inequalities are prepotently a product of class relations.
Third, I should once again record my rejection of the conflation of class and culture, as manifested for example in the Great British Class Survey (which as Mills and others have pointed out, has other major flaws). While I accept entirely that class relations have become ‘overlaid by’, or disguised by, changes in cultural relations, I contend that it is a mistake to blend the two because it then rules out consideration of the dialectic between them. I have preferred to suggest that while ‘objective’ relations of class, via the class/command dynamic, have gained in salience in rentier capitalism, ‘subjective’ class relations – that is, class as an input into identity formation, have lost their purchase. I think we need to retain theoretical clarity here (Andrew Sayer is excellent on all this).
This blog has become more extended than I intended, and I confess I have broken little new ground. But I’m a work in progress.