Health inequalities persist and grow in the UK. Differences in morbidity and mortality add to rising public concerns about household poverty and children’s health and development. Current attempts to redefine and find new national lower measures for poverty in the UK when current measures show increases, talk endlessly about getting more information about poor people and their lives and involving them in defining the problems. This blog is about how the language used itself diverts attention from the real underlying issues, such as why, in the rich UK, are personal and public resources so badly distributed by government or the labour market that anyone is left without sufficient to choose an acceptable conventionally inclusive and healthy lifestyle. Whatever the role of freedom of choice in people’s lives, which is a basic premise of our marketised consumerist society, it follows that no one should have too few resources to exercise it as others do.

Today’s problems are constant reminders of what Sir Douglas Black brought to wider public and political awareness as long ago as 1977. His report concluded that “poverty remains the chief cause of disease, and it is a factor which is beyond the immediate control of medicine”. ‘Disease’ here means all forms of ill-health, and the poverty referred to is not only that of the individual household lacking adequate disposable resources (mainly cash incomes) to be free to make its own healthy choices of food and socially-inclusive lifestyle, but also the lack of the collective resources of decent housing, health and care, children’s services, education, public transport, opportunities for adequately paid work and other collective means of enabling and empowering people to take a recognised part in their society over time. These are matters that Sir Donald Acheson’s report on Inequalities in Health reiterated in 1998 and others repeatedly have since then.

Public expenditure on and availability of all of these collective as well as individual resources at the levels needed to prevent deprivations and health inequalities has been considerably reduced by deliberate government ‘austerity’ policy since 2010. It is just possible that the politicians who devised and maintained these anti-statist policies were unaware of the health consequences of their pursuit of austerity; at any rate, if not culpably ignorant and oblivious, they seem to disregard the reports which increasingly make the connections between their policies and the consequent growth in a wide range of social evils including health inequalities. Beyond a little fire-fighting in crisis situations the current political response is too often to focus on or even blame the victims, suggesting for instance that they wouldn’t be so unhealthy if they’d made the right lifestyle choices compatible with their resources. The current government does not acknowledge that the resources are inadequate for such choices.

The obvious problem of inadequate resources and incompatible objectives, such as eating or heating, can’t be answered as long as we focus only on people in poverty and their own reports. The language we use to talk about the problems (the discourse, to use the technical jargon) not only distorts our focus on underlying causes but actually closes off some options for policy action, and this is being deliberately promoted for ideological reasons by some of the people involved. It’s part of the bigger story of attitudinal manipulation widely discussed in political circles, but it’s relevant in many other fields as well, and it affects social scientists as well as other publics. That’s why the current discourse matters when we discuss health problems.

First, a note about the social science technical aspects. The discourse reflects the currently accepted explanatory paradigms, the self-consistent system of concepts and theories which any scientific system uses to structure its approaches in ways which make it seem like ‘common sense’ not needing to be questioned. That’s why to make sense of what’s happening now, we need to review,  brutally briefly, the succession of dominant poverty paradigms since the 19th century. The traditional paradigm was acceptance of class-based social stratification, given its authority by the dominant social order or even by religious beliefs, in which poverty was the way of life of the lowest layer of society, in terms of squalor and exclusion. Dividing poor people into the ‘roughs’ and the ‘respectables’, many well-off people assumed this was a matter of individual choice even if the system was immutable. But the earliest systematic attempts by such pioneers as Seebohm Rowntree showed the poorest people lacked adequate resources even for physical efficiency. He designed an artificially low ‘primary poverty’ budget to show it was inadequate for real life, but even so it was criticised for superfluity.

This generated the second dominant paradigm in this field, poverty defined as and measured by household incomes below artificial minimum subsistence budgets. In the 20th century this generated an academic industry of competing prescriptions for variants of what the lowest level of living for poor ‘othered’ people could be, some allowing for minimal social participation expenditure as well or targeted on ‘healthy living’. Against this, during the 1930s, Sir John Boyd Orr argued that instead of prescribing minimum budgets for the lowest level of living at which people didn’t show nutritional deficiency symptoms, researchers should study empirically at what minimum levels of income households actually achieved optimum levels of nutrition. This generated lively scientific and professional association arguments for years. In the post-war period, the sociologist Professor Peter Townsend argued that if households were to be studied for sufficient spending on adequate nutrition, this applied even more strongly to adequacy of their resources for social participation. He suggested that seriously lacking resources for participation in conventional lifestyles was the conceptual definition of the social phenomenon of poverty, identifying its cause in the structure of resource distribution and pointing to a more appropriate measure of poverty than normative budgets based on the natural science measures of nutrition and health alone.

This third paradigm thus raised the question of whose standards of adequacy of resources and life choices were to be applied to distinguish normally inclusive lives from poverty. Should they be the experts’ prescriptive (normative) views about healthy diets and lives, or the population’s views about inclusive lifestyles (though research experts are needed to discover empirically what they are)? The question of whose and what standards were to be applied, and the levels of various resources needed to enable inclusive lifestyles, became a matter for the poverty research industry, but some policy-oriented researchers (and many politicians) found it hard to accept the shift from expert to ordinary people in defining what an inclusive lifestyle and adequate resources might be. Some of this was caused by manifest confusion between the social science question of what levels and standards of resources were needed for social inclusion, adequacy, as defined by the whole population, and the completely different political question of what governments asserted ‘the taxpayer’ could afford for social security claimants.

A larger problem, one which is rarely admitted openly but colours all such arguments, is the ancient class distinction between living standards Good Enough for Us, We the People, or sufficient for Them, the Poor. Evidence from social surveys and focus groups shows that when they ask about what levels of living are needed for poor people to escape poverty, participants offer more restrictive views than when they are asked about what all of ‘us’ need to live a minimally decent inclusive life in society. If the word ‘poverty’ is used in the question, responses often ‘other’ the victims as ‘them’. Thus although the currently dominant paradigms may succeed in dominating discourse to squeeze out previous ones, the older ones may leave persistent residues in common thought. Today’s focus on poor people’s lives which avoids the social and economic structures within which they occur harks back to the traditional paradigm of class divisions.

This is no accident. It shows that it’s not only traditional social distinctions but ideology, how power should be used politically, which influences the discourse. The chief distinction is between the traditional conservative view that different minimum standards are naturally hierarchical since in that ideology each class has its ranked position and unequal status and the decent minimum may vary accordingly. By contrast, the socialist egalitarians argue that the minimally adequate inclusive lifestyle standards should apply to everybody. This reflects the recognition that conventionally inclusive lifestyles may remain unequal in many respects but everyone within them has sufficient resources to make choices and still be recognised as included or healthy. Inequalities remain but are no longer caused by a serious lack of resources, and are therefore not a poverty problem even if they are some other. For instance, assessing the promotion of ‘go private and get better service’ in the NHS then depends on whether the standard quality of services in this essential collective resource demonstrably meets the ‘good enough for us all’ expectations or whether it reflects a ‘NHS good enough for those who don’t have resources to make choices’ conservative austerity perspective.

The focus of all the public argument right now against this background is the people in poverty as defined by the current paradigm, as people whose “resources are so seriously below those commanded by the average individual or family that they are, in effect, excluded from ordinary living patterns, customs and activities” (Townsend 1979). Why then do some anti-poverty organisations welcome more intensive study of people in poverty — “to fight poverty, we must first understand more about those in its grip” (The Guardian 17.9.18). This focus dominates much media framing of what to do about poverty. Even if the scope is broader, it’s the counterpart of studying malnutrition in terms of why don’t poor people eat greens instead of junk food. In terms of the old analogy of pulling drowning people out of the river downstream, it’s asking why don’t they swim, and planning to teach them better, instead of asking why did they fall in upstream — or even who keeps pushing them in. The article quoted calls on policy makers to use this focus “to help alleviate poverty in Britain”. But why not work to abolish it? The answer must lie on the political right where alleviating poverty is philanthropic and OK, while policy to abolish it is political and ‘lefty’.

A discourse which focuses obsessively on the characteristics and experiences of people in poverty is a bit like first aid. Victims must of course be relieved, even if at that stage no account is taken of causes. But overall in the health field much more attention is rightly focused on prevention even while state funding is restricted. The danger of the discourse focusing only on victims is that it normalises acceptance of ill-health and alleviation (the conservative stance) instead of emphasising attention to its preventive ‘clean water’ of adequate resources. ‘Poverty porn’ attracts many television viewers and normalises ‘othered’ lifestyles whose deprivations and deviances are enforced. It’s a modern version of visiting Bedlam three hundred years ago. Of course ‘those who experience it are best able to describe it’, a perspective long emphasised by for instance community workers and mental health service patients (not forgetting victims of oppressive social security, as illustrated by ‘I, Daniel Blake’). But this is not the same as the shift to claiming that the ‘voices of the poor’ should be the principal source of valid evidence on how to abolish it. This would be like acknowledging that sick patients are the best guides to what their symptoms feel like, and then claiming their reports as scientific analysis of causes. Cholera patients report fever and diarrhoea, not polluted water supplies. A neglected factor in this well-meaning emphasis on victims’ accounts is the implication that people who aren’t suffering can’t understand it, or even that they lack empathy, which is used to discredit critics who look beyond symptoms to causes.

The more the current discourse emphasises focus on people in poverty, the more it distracts from discussion of preventive measures, especially when these are discussed in terms of government policy instead of the foundations of good health. But to avoid policy argument as “not our business” gives covert support to ideological opposition to structurally redistributive policies, not the foundations of social policy for health and social security of resources for everyone. Evasion of those issues is discourse closure on prevention. Preventing poverty and health inequalities sounds good, but when it means trying to change the behaviour of victims without increasing their access to relevant individual and collective resources to adequacy levels, it’s dishonest.

Poverty prevention is not the only subject closed off by discourse focusing primarily on the lives of people in poverty. In this world of inequalities, there doesn’t seem to have been interest in studying how far statistically normal individual variability in health experience overlaps with health inequalities which themselves correlate with variations in levels of individual or household power over resources and the availability of collective resources. No one expects the normal range to be dependent on resources alone, so we need research to establish what its contribution is. The ‘Money Matters’ research by Kerris Cooper and Kitty Stewart (JRF 2013; 2015) showed that (contrary to some conservative lobby groups’ claims) money indisputably does matter and others showed the causative networks by which it does. Regrettably the project failed to proceed to ask, ‘and if money matters, then how much money matters?’ If we are to have effective preventative policies to abolish poverty as well as alleviating it, then we need to know what the evidence suggests that bit of the anti-poverty target is.

There is no theoretical reason (except perhaps in some neo-liberal economic or politically reactionary fantasies) why anyone in UK society should have too little power over resources to be able to make healthy choices without detriment to their conventionally decent socially-inclusive lives. Discourse matters because when it focuses only on poor people’s health it closes off the bigger problem of those structural inequalities which also damage everyone’s social health.




John Veit-Wilson is Emeritus Professor of Social Policy of Northumbria University and guest member of Sociology at Newcastle University. He is author of Setting Adequacy Standards: How governments define minimum incomes (Policy Press 1998) and was poverty consultant to the Joseph Rowntree Foundation’s Money Matters research programme. He was a founding member of the Child Poverty Action Group in 1965.

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  1. mike.roberts says:

    The situation of health inequalities in the UK is shameful taking one, by deliberate Govt Policy, back to the dark ages.

    As someone who worked with the Marmot Team at UCL a few years ago I saw first hand how this whole set of issues was developing

    For example we have a Govt which does nothing about the offshoring of moneys from the 10 big tech companies now estimated at a staggering £2.5 trillion (FT)

    It even stopped the work that the ONS , in my view, was doing at a pace confirmed at a mtg in Sept 2017 at the Warwick Business School mtg at the Shard.

    It does nothing about the loss of revenue by such means which can be , for the UK alone, measured in many tens of billions per year billions using such British Protectorates as the Isle of Man to Virgin Isles to Gibraltar. No its not about the rock or apes but the former why Gibraltar is important.

    This Govt since 2010 has made its quest in economic terms the normalisation of austerity to inverse the normal law – one of malice.

    So its a typical deliberate choice and every attack on Local Govt and other needs is part of that strategy.

    The middle classes, far from what some suggest, have had an equal income effect since that time but of course those at the top end a massive increase in incomes and assets.

    So who has paid.

    The rest of us directly, indirectly which is no wonder those inequalities are rising dramatically so is mortality going into reverse, issues of the delivery of social housing and much else.

    You can all make the list.

    The IFS in a recent report confirmed those trends demonstrating that it was the vast majority of people in bottom strata’s whose incomes were being deliberately squeezed.

    So when May says austerity is over she is not talking to the many by the few.

    She is not talking to the left behind areas, towns but her people only.

    They have done well out to the strategy and we, in Labour, need to make sure we nail them for it.

  2. i am one of those othered these days, I have degenerative disc disease and a prolapsed disc (only took me 8 years of arguing and being labelled as an exaggerator and paranoid personality who was erm selfish) before they actually scanned my spine and found the problem where by I was not exaggerating,
    however none of them 4 lots of GPs ever apologised, not to mention that they wrote to DWP how i was horrible and nasty and they hadn’t seen behaviour as bad as mine thus I was undeserving, because for that 8 years i was totally enraged and disgusted by those GPS. ( i was a former TA combat medic and auxilliary nurse before stress got the better of me).I did try to seek legal advice and was told ‘oh that’s hard to prove sorry go away’
    recently i found all this out because i re-applied for pip where upon yet again no points even though i use a raised loo seat, also had impingement injury in my shoulder due to struggling with shopping in a trolley on the bus ( trying at this point to save paying £7,50 bus-fare as i’m semi rural. in my notes names of illnesses to me altered, depression =stress low moods as it has now been relabelled. Advanced wear n tear which I notice nhs have relabelled osteo arthritis so that the othered me types cant claim correct benefits. I also observed when I was at my previous address the dreaded capita was doing medical records and in Newcastle be for they relabelled themselves orchard tree or something similar, capita was doing talking therapies, and in Newcastle we appear to get the choice of cbt or erm cbt or even more cbt, or go and join a group of mothers with drink drug issues none of which I had and no children to discuss, when I spoke about politics the group leaders accused me of being too clever. ,thus my trauma based needs never got met. badly let down, I did work heavy for 21 years hence back problem. let me explain this reason we give up caring about diet is this simple, our mh needs are ignored and I don’t fit in in work places as I like to work on my own now, can’t abide racism, the bullying of benefit claimants with hidden illnesses. and the cliquey gossip that bullies people whose mind works different from the follow sheep mentality. thus I end up in trouble at work. So here-in lies the problem, DWP constantly gives me 0 points for pip 12 years of this because drs made it clear I was undeserving. even though I have a degenerating S1 L4 L5, they refuse to operate on cos they left it 8 years. and now im under constant stress trapped in fight or flight mentality surviving dwp and atos kangaroo medicals, I then go to cab, last time room I was in was full of about 12 people n kids and im meant to present my case in front of those people and feel rushed, so I get angry walk out and couldn’t mentally cope, dwp wins again no reliable people to help me fore pip appeal. the assessor recommended no wca for 2 years re my shoulder but of course no mention of my on going degenerating discs, or mh. so here is where im at, if we don’t get the tories out the next WCA is a death sentence to me or homelessness because I wont tolerate after my life experiences some middle class office worker lecturing an ex 100 mile marcher and full kit uk wide competitioneer, of a shoddy work ethic, so my future is either jail ie I lose my temper, or its homelessness as I have no support network, im near 50, and have campaigned against racists for a lot of years. so im pretty much guaranteed to be left for dead a victim of crime. that is my othered human future. thus re diet I just eat what I want, food now is literally my only pleasure, I was robbed of my normal interests because of depression and isolation , when I moved from a horrible private flat where I got burgled and had to pay rent, then moving twice in 4 years and losing my long time pets. so yes my mh was impacted by this. this my friends is the reality of one life of the othered, once an ex service person written about in bosnia by obes ect now a benefit scrounger the tories will leave for dead along with their 120.000 others , not to mention often feeling suicidal. we are you, any one of you could be me. and mark my words it is not a nice place to be. So of course im helping the fight for socialism, it is life or death to us. . we are human, anyone can get ill

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