We need urgently to rethink our concept of what it is for a society to be healthy. This is not to say that the distribution of health in populations contained within the boundaries of a nation state is no longer important. Quite the contrary.
Data on population health, like life expectancy at birth, perinatal, infant and child mortality, health-care access and years free of poor and declining health, are vital for national policy formation, public health and health-care systems. It is beyond time that we adopted a more global perspective. Beyond national health statistics, how can we see a society as healthy if it prospers economically, socially and in health terms on the back of exploitative relations with other societies? No society can be regarded as healthy if the price to be paid for an improvement in the health and health equity of its population is the export of distress, suffering and premature death elsewhere. Notoriously, Britain and other countries in the nominally post-imperialist Global North continue to exploit countries in the Global South.
In Healthy Societies, I argue against the neglect of social structures, especially relations of class, by sociologists as well as epidemiologists in research on population health. Proxy measures of class like the National Statistics Socio-Economic Classification (NS-SEC) have the unintended effect of ‘absenting’ consideration of the causal power of class relations. Much of the global economy, I contend, is under the influence of a hard core of globalised or ‘nomadic’ major shareholders, corporate bosses, asset managers and financiers emanating largely from the Global North who act transnationally. I call them ‘capital monopolists’. In fact, it is this less than one per cent that holds many national governments to ransom: capital buys power to make policy in its interests. It is not unreasonable to say that, aided and abetted by what has been called a ‘concierge class’, they comprise today’s ruling class. And yet they remain essentially invisible in research on the health domain. If this contention has substance, it helps explain the post-Thatcher emphasis on anti-unionism, benefit cuts and privatisation, and, post-2010, the calculated introduction of political policies around austerity that have unambiguously increased health inequalities and contributed to a pronounced decline in longevity.
But there is more to the concept of a healthy society than population health. Addressing health inequalities and declining life expectancy in the UK is just a part of the equation. Consider, first, climate change. No society deserves to be called ‘healthy’ if, like the UK in recent years, it: (i) makes light of the serious threat of planetary overheating; (ii) ignores the continuing clandestine commitment of members of UK-based capital monopolists to fossil fuels; or (iii) confines its concern and interests to the effective seduction of domestic voters via promises of economic growth rather than degrowth. A similar case can be made in relation to warfare. Any society warranting the description ‘healthy’ cannot sell arms to any willing purchaser. As I write this, to take a single dramatic instance, it is unambiguously clear that the continuing sale of arms to the Netanyahu regime in Israel, which is engaged in what the International Court of Justice sees as war crimes against the Palestinians in Gaza, offends any notion that UK society deserves to be labelled as healthy.
It is encouraging that there are public health practitioners who are calling for a new and wider definition of what constitutes a public health intervention. But acceptance of something like my concept of a healthy society would have serious consequences. The evidence from the post-Thatcher years is that rhetorical commitments to improving the nation’s health have been, to borrow a term from Hegel, ‘unserious’. While I applaud the research and governmental lobbying by Michael Marmot and colleagues, I suggest that this has yet to show a substantive return. In fact, life expectancy at birth is at present in decline and health inequalities are growing. I term the Marmot approach to ‘making a difference’ Realism 1. I call for Realism 2. Realism 2 draws a different set of conclusions from the research of Marmot and others. In a nutshell, it argues that a parliamentary route to a healthy society (in all its dimensions) is exceptionally unlikely and looks for viable alternatives.
Ralph Miliband argued that in the UK we inhabit a capitalist democracy which will always and effectively resist ‘transformative change’. Healthy Societies sets out multiple proposals for substantive change ranging from the ‘attainable’ to the ‘aspirational’ and suggests an overall political perspective rooted in ‘permanent reform’. It draws on a broad sociological literature on social structures and agency to suggest that significant social change is most likely: to occur in the event of a crisis of state legitimacy arising out of an extended cost-of-living crisis and widespread public anger; to take on a class character, importantly involving working-class leadership; and to be triggered by an unpredictable event and ever more severe state oppression. Although this is not a scenario that is currently on the cards, it is currently the ‘most likely’ route to transformative change. To neglect Realism 2 is in effect, if not in aspiration, to opt for the status quo. Starmer, like Blair and Brown before him, will surely just hold the fort while the Tories regroup. Sociologists of health and health care have a logical and moral responsibility to engage with and not sidestep or shirk these issues.
Graham Scambler is Emeritus Professor of Sociology at UCL and founding co-editor of the journal Social Theory & Health. He is also a Fellow of the Academy of Social Sciences, UK. His career has been committed to teaching and researching on health and healthcare and he has written many books, chapters and journal articles on these issues.
Healthy Societies by Graham Scambler is available to pre-order on the Bristol University Press website. Find it here for £16.99.
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