UWS-Oxfam Policy Forum : 'What do local communities know and ...
Whoneedstobeeducated? Working-classdiscoursesofpolitics,policyandhealth:Idon'tsmoke;Idon'tdrink.Theonlythingwrongwithmeismyhealth UWS-Oxfam Partnership Policy Forum, June 2015 Overview Learning from a qualitative study of working-class communities aimed at understanding how health outcomes emerge from the impact of politics and policies in participants lives. Reflect on the perspectives of health researchers, working class communities and the understandings of policy-makers and practitioners: Who needs educated? The project
A collaborative research project involving UWS, University of Glasgow and NHS Health Scotland (research team: Prof Mhairi Mackenzie, Prof Chik Collins, Dr John Connolly, Mick Doyle, Prof Gerry McCartney) This study is part of a research agenda in relation to understanding the drivers and implications of health inequalities in Scotland - a qualitative study of two postindustrial working communities in East Ayrshire (Cumnock and Kilmarnock). We explore how health outcomes emerge from the experience of macro-level determinants impacting in their lives. Key health inequalities literatures (contd) Scotlands excess mortality and a synthesis of the Social Determinants of Health -There is research consensus that health is socially and politically determined (e.g. Black,
1980; Marmot et al., 2008). -McCartney et al (2011) proposed that Scotlands particular experience of the post-1979 UK Conservative Governments neoliberal political attack on social democracy has had implications for Scotlands excess mortality. This was an attack to which Scotland was particularly vulnerable, given its social, economic and political-cultural characteristics something that has largely been ignored by researchers (see Collins and McCartney, 2011). -Indeed, this hypothesis had not been tested against the lived experience of communities likely to have been most adversely affected. There is also little in the way of qualitative research on how social and political determinants connect to health outcomes in real lives (e.g. Roberts, 2009, Peacock et al, 2014). The geographical areas Multi-generational in-depth interviews in two comparable towns in West Central Scotland adversely affected across two periods of government-imposed austerity, the 1980s and the period since the launch in 2010 of the UK Conservative-Liberal Democratic coalitions austerity programme (20
participants in total). Kilmarnock: A private sector manufacturing town in the post-war period with a range of major employers, including BMK (carpets) and Johnny Walker (whisky bottling). The town suffered from the sharp deindustrialisation and related unemployment arising from UK-level macro-economic policy in the years immediately after 1979. Cumnock: The town was dominated by the nationalised deep coal mining industry until it was shut down by UK Conservative administrations in the years following the bitter miners strike of 1984-85. Mining communities experienced the full coercive power of the state during their attempt, as they saw it, to save their industry and their communities from politically-driven destruction. Key health inequalities literatures Causes and Pathways: Discourses of the Social Determinants of Health
Raphaels continuum of discourses within policy networks: Level 1: Social determinants as identifying and treating individuals in need of health and social services. Level 2: The need for health services to focus on modifiable risk factors is recognised. Level 3: That life circumstances such as unemployment actively shape health is recognised. Level 4: That life circumstances are seen to be patterned by group membership (e.g., by class or gender). This is more sophisticated than preceding levels, but rests with mitigating impacts of health-compromising circumstances. Level 5: That the social determinants and their distribution are the results of public policy decisions, and modifiable by policy action. Level 6: That macro-level perspectives i.e. policy decisions as shaped by economic and political structures Level 7: Builds on level 6 and emphasises that that those benefitting from decisions causing inequalities - leading to questions about the wider dynamics of neoliberalism as a political force in contributing to health inequalities.
Alignment with discourses (levels 6-7). There was no shortage of discourse about how life circumstances shape health (Raphaels level 3/midrange discourse). BUT what determines such circumstances? Almost all participants told of austerity and labour markets shaped to benefit the affluent. Neoliberal political attack was rendered almost viscerally in some accounts; as Marion said, I think theyre trying to kill folk aff For both periods of austerity, material circumstances were described as having direct health effects. Regarding current austerity, material deficits were described and demonstrated e.g. in Cumnock, interviews with John and Cathy were held simultaneously because only one room in the home was heated; Nancy in Kilmarnock opened her cupboard showing that it was almost bare: the only things my mum told me when I got married was always make sure there was tins of meat in the cupboard, so if you run short youve got something to fall back on, which I always did... right up until recently [but now] you cannae afford to eat healthy. The good times (prior to the 1980s) were over. This was signified in Cumnock by the pride of doing a hard job well and of knowing relative stability. In Kilmarnock they were represented by abundant employment; as Claire said, if you didnae like a job one day, you could walk intae a job the next day.
Examples of insights from Cumnock Alex, an ex-miner, speaks of the Thatcher governments attack on the miners and of the roots of current austerity. Alex: It was planned. We got a sense in probably 81 or 82 prior to the miners strike of what was coming, and there was a sorta lightning reaction and the pits all walked oot . But Thatcher backed doon at that time because she wasnae ready, looking back you can see the preparation got made. And they really backed the union into a corner But it was all planned, they wanted to take the mining union and communities on. Interviewer: What was peoples kinda sense of the reasoning for that? Alex: Well at that time I thought it was to diminish the power of the unions and fragment communities Interviewer: And the cause of current austerity? Alex: You saw the sudden influx of banks going bust, liquid assets going, dispersing all over the place. And, I think it was probably the Blair government that encouraged it. . Theyd built up the financial services to such a strength that it outweighed manufacturing, it outweighed any other service in the UK. But they were the kings and everybody else was the minions. financial services I would say were the main cause of what happened, the greed. And what gets up oor noses is that we still see bankers bonuses being paid, we still see
the very rich getting tax breaks and were looking at people living in our community getting hit wi sixteen pound, or fourteen pound a week [benefit reductions]... theres no a God, at this moment in time. Examples of insights from Kilmarnock In Kilmarnock, with its different economic base and different experience of austerity, the analysis of the causes of poor life circumstances was less that of a targeted attack on a particular group of workers (although this was clearly identified in relation to mining communities); instead there was a focus on policy shaped by definite minority economic interests. Alison reflected on the failure of inward investment policies in Scotland: The government brought a lot of firms up into Scotland, I think, with lots of promises you wont have to pay this, you wont have to pay that, you know? And then, when everything went belly-up, all the firms pulled out because they were either Americanbased or European-based, and the promises ran out and they went, oh well, thats it, were going.. For Sharon, corporations used globalisation to find a less confident workforce: People were changing, people were starting to speak oot a wee bit more and say no,
thats no right. People realised their ability to say I might work here but Im a person and Ive got rights. And again, the big employers I think thought well, we can make carpets cheaper wherever, so.... Individual and community-level stress Interviewees from both communities spoke of mental ill-health and low self-esteem resulting from unemployment. Mary, wife of a miner, speaks of gendered roles and of how men lost their identity when the pits closed: Mary: A man no working was a bad thing in those days, it was the men that kept the women and their families afloat. Interviewer: Although a lot of women here wouldve worked as well? Mary: thats right, thats right, but the men got depressed because that was their job tae [provide] for their family. In Kilmarnock the experience was linked to prior causes affecting employment and role status. Psycho-social processes were identified in both areas at community level. For example, Marion, a middle-aged woman from Cumnock describes:
everybody kinda looked oot for each other. If somebody was short [of money], like the neighbours next door, there was a, still a long running joke, the floating fiver [5 note] because this fiver, you dinnae ken who it belonged to it, it just went between the two hooses There was mair a kinda sense o community. Theres no the same kinda feeling noo, doors are shut and naebody says nothing. Health behaviours and practices Some participants spoke of health behaviours as responsible for poor health whilst some referenced cultural practices as generating poor health (such as poor parenting or work ethic) . More commonly, discourses about lifestyle behaviours and health related to prior causes. For example, Alex, an ex-miner, provides a broader account of unemployment including links to problematic behaviours: about a year later you started to see things dwindling. You seen the disjointed community because what was happening, the younger people werenae having places to go and work, and probably about two, three year after the Barony [local deep coalmine] shut the textile
industry was going belly-up at the same time. So where, where people maybe got redundancy fae the deep mining, their wives were still working in the factories. It was like a double-whammy for us because it was only probably two years at the very maist when the textile industry went belly-up and a lot of people started losing their job in the factories. The factories started slimmin doon, cutting workforces. The ability for young people to get into work was becoming limited. We started to see probably drugs in our community for the first time. And probably the excessive drinking was starting to take a hold as well If youre working and in a steady environment you have a much more controlled life. Where you dont have that central plan where youre working you tend to do chaotic things and probably self-harm although you dont even know it yourself. And do things that affect your health, maybe no at that particular time but in the longer time it affects your health. Othering Although many participants across areas demonstrated implicit reference to othering, a number of participants expressed a very clear understanding of othering as a fragmenting device deployed in
communities but also by government (rhetorically and through specific policies) and other powerful interests. This othering is best conveyed by Marion, who grew up in Cumnock: They are using the media, tae bombard folk wi this image and the good old divide and conquer. Cause you can see the divide and conquer all around you. You just need tae fire on Jeremy [Jeremy Kyle the reality TV programme that specialises in televising turbulent lives] at half nine every morning I think thats Tory sponsored TV to be quite honest wi you. its like stigmatising full groups at a time. It comes in waves. I mean, the immigrantsll be due a shot its a their fault. Its like theyre trying to deliberately create this, everybody thats on incapacitys a scrounger. Who are the ones that need educated, then? Raphaels (2011) recommendation for closing the gap involves educating the public to raise understanding towards the upper levels of his continuum of
discourses. The conclusion from the research conducted with our participants with few claiming to be highly educated and many of whom have lived through terribly difficult times and are continuing to do so is that they are there already. Mackenzie et al (2015) highlight that the majority of policy-makers and practitioners interviewed offered varied theories of inequalities which contained both material and behavioural explanations. A lack of synthesised discourses of the social determinants of health (unlike working class communities). So, if there research consensus that health is socially and politically determined and work class communities are far more tuned into this than policy-makers and practitioners then who are the ones that really need to be educated? Questions Who really needs educated about the relationship between politics, policy and health? Possible next steps with this work?
Forthcoming publications Mackenzie, M., Collins, C., Connolly, J., Doyle, M., McCartney, G. (forthcoming), 'Working-class discourses of politics, policy and health: "I don't smoke; don't drink. The only thing wrong with me is my health", Policy and Politics MacKenzie, M., Babbel, B., Hastings, A., Simpson, S., & Watt, G. (2015). Tackling and mitigating health inequalitiespolicymakers and practitioners' talk and draw their theories. Social Policy and Administration.
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