The Impact of Social Conditions on Health

Why do they fight against the poor youth of today?
- Bob Marley

THERE IS SUCH A THING AS SOCIETY

Individualism

When Mrs Thatcher uttered the famous words "There is no such thing as society", she was not only betraying her ignorance of an entire domain of scientific knowledge, but also denying the existence of an important life support system which she herself used every waking moment of her day. In making that statement she was proclaiming her faith in the philosophical doctrine of individualism, the dogma of faith in the paramount importance of the freedom of the individual which can be traced back to the philosophy of Hobbes.

Socialism

In matters of philosophy, excesses in one direction are followed by excesses in the opposite direction as night follows day. The diametric opposite of individualism is socialism. Socialism has many forms and definitions, but all forms have a philosophical reference point that makes society itself the foundation of its view of reality, rather than one aspect of a many faceted reality. The existence of sectarian squabbles between a myriad different brands of "social-ism", all mutually exclusive, is evidence of "socialism" as a quasi-religious belief system, rather than a scientific or political construct.

Diverse forms of socialism - including the Conservatives at war

Individualist philosophers accuse socialists of valuing society above the individual, but in conditions of war, socialism is practised by devout individualists without devoting a second's thought to the matter. Sir Jerry Wiggin, the Conservative MP for Weston-Super Mare, lost his job as a junior Minister in Defence as a result of a fit of excessive zeal during the Falklands war, when he tried to commandeer a privately owned merchant ship pro bono publico. In peacetime, such an action would have been an unforgivable symptom of detestable socialism; but it seems that war makes socialists of us all. The necessity of a supreme effort overrides the interests of the individual, and a collectivism emerges even in civilian life. "Entrepreneurs" find themselves renamed "opportunists" unless they are very careful.

The armed forces can be seen as classical state-socialist organisations, with the wishes of the individual overridden by the dictates of the institution. Paradoxically, life in the services is often extolled by the political Right despite the anti-individualist tone of the Forces. The old socialist economies of Eastern Europe imported armed forces institutions into civilian life, with its "command" economy where economic life was the product of plans produced by quasi-military leaders. The National Socialism of the Nazis and the apartheid regime of South Africa mirrored the State Socialism of the USSR: both tried to crush the freedom of the individual, both were repressive, and both found in the other the enemy that it needed to justify its own excesses. Both tried to bind the loyalty of the individual to a gargantuan State which means nothing on a human scale, but which means fanatical devotion to an adherent of the System, and oppression to any dissident. Both systems can be seen as founded in the perception of a perpetual state of war.

On the positive side, people's memories of the war are often coloured by the feeling of social solidarity. People sometimes - not always - behaved to each other in the Second World War with a greater degree of decency and self sacrifice than is apparent during peacetime. Although the cause of increased social bonding may have been the possession of a common enemy and common hardships, the fact remains that the increased sense of society added quality to life.

At very least, the social aspect of existence reflects the benefit of pooled resources, when a small amount taken from many people becomes a large amount which can obtain for those people things which would be beyond their individual means. The whole is (sometimes at least) greater than the sum of its parts. Trade Unions begin as a pooling of individual resources for the common good, when faced with an exploitative employer. When their adversarial stance became institutionalised in the late 70's, they were rejected by the British people. Since their emasculation by Margaret Thatcher, exploitation of the worker has recurred.

If we are to avoid the fate of perpetually swinging between the thesis of Thatcherism and the antithesis of overbearing union power, we must find a synthesis in worker participation in the company, through share ownership, co-operatives, and involvement within the decision making processes of the company. In particular, the economic unit must be made smaller so that the workers at all levels feel themselves to be people among people, rather than inanimate cogs in a vast machine.

Resolution within objective reality

No useful purpose is served in forming grand theories from inadequate absolute starting points, whether the foundation stone be the primacy of the individual or the primacy of society. The only way to balance the conflicting demands of individual and society is to place both into the matrix of objective reality. This reality is clearly the natural world in which we exist both as individuals and as societies. Our full existence has many aspects - time, space, energy, life, consciousness, language, reason, imagination, social, aesthetic, moral, ethical and spiritual - and our existence as individual egos and as component parts of society are each aspects of this many faceted reality. Both can be studied objectively and experienced subjectively, but in order to make sense they must be referred to the ecological systems which support life. Many thinkers - the majority if we look away from those that dominate our narrow sector of cultural time - would go further and refer the physical world to a spiritual framework of reality which is beyond the physical.

Interdependence

"No man is an island" wrote John Donne, "entire of itselfe; every man is a piece of the Continent, a part of the Maine; if a clod be washed away by the sea, Europe is the less...any man's death diminishes me, because I am involved in Mankind." This sentiment, written three hundred and fifty years ago by a metaphysical poet, is startlingly modern in its understanding. Our individual personal existence is not an absolute; we exist in a state of mutual interdependence with other beings in society, and as a species we exist in a state of mutual interdependence with the myriad forms of life on this planet. The tragedy of our age is that we are well into the process of destroying both the generality of life support systems and the social life support systems for the sake of financial profit in the short term. The hope is that in tackling these problems we will rediscover social cohesion in working together in pursuit of a common goal.

Communitarianism

In place of State socialism, where the means of production are owned by the State acting as proxy for the people, there is an emergent feeling for community based solidarity which is emerging spontaneously from all strands of politics. It is not new, and indeed can be traced back to village and tribal life. It has always formed one of the core values of the Green Party, which argues that if power is decentralised so that a community is given authority over its immediate environment, it will protect it conscientiously, since it goes against nature to foul one's own nest. The Liberals and Liberal Democrats have similar decentralist aspirations. Labour also in the last two years have been speaking increasingly of community values, while the Conservatives have encouraged neighbourhood watch and the idea of active citizenship. A conference in Birmingham in November 1994 titled "Rejuvenating Britain for the Third Millennium" brought representatives of all the political parties together in a rare show of agreement. When political parties show signs of agreement, something is clearly happening. The communitarian movement in the USA has reached the ultimate accolade of respectability, the cover of Time magazine.

SOCIAL SUPPORT AND HEALTH

An effective web of social support is an important contribution to the sense of well being of an individual. The Alameda County Survey in California found that individuals without social ties were more likely to die from various causes than those with more effective social contacts. The results were not affected by socio-economic status, self-reported health status at the beginning of the trial, or health practices. The most effective support for men was their wives, whereas the most effective support for women was their family, friends and community groups. This conclusion has been confirmed by other researchers. Rosebgren et.al.. concluded that stressful life events are associated with high mortality in middle aged men, but that men with adequate social support seem to be protected

SOCIAL HIERARCHY - CIVIL SERVANTS AND BABOONS

The effect of social position on health has been recorded in the "Whitehall Study" by Professor Michael Marmot in a classic work that has separated out confounding factors such as deprivation and environment. He has shown that better health is consistently associated with higher occupational rank.

He studied 17,500 male civil servants in Whitehall over 20 years, grouped according to their occupational grade, which is a well-defined index of status, and which he found to be more positively related to health than the rougher classification of social class. One important conclusion that is to be drawn from this work is that estimates of health which are based on social class are liable to underestimate the effects of deprivation on health. He found a greater than threefold difference of death rates between highest and lowest ranks that could not be explained by differences in smoking, cholesterol levels or lack of exercise. The workers in the lower grades smoked more, but this was not enough to account for the differences that he found. By definition, none of the subjects were unemployed nor were they suffering from deprivation. The health gradient affected many different diseases and causes of death, indicating a common underlying factor. Much effort has gone in to try to explain these findings. Possible candidates that have been put forward are:

· Better quality of medical care for higher ranks.
· The role of health selection, that is, the possibility that people with worse health end up in lower positions.
· Influences which persist from early life. Greater advantages in childhood may have helped the later good health of those in the higher ranks.
· Health-related habits. Higher ranks were more likely to be non-smokers, to have a healthier diet, and to exercise.
· Unequal access to material resources such as housing transport and environment.

Athough each of these candidates are factors, the effect is not large enough either singly or together to explain the observed differences. Marmot found that the "big three" illness agents - smoking, blood pressure and cholesterol - could account for only two thirds of his observed differences. He looked more closely at cholesterol, which is divided into "good" (HDL) and "bad" (LDL) types, and found that the good type was more prevalent among the higher ranks. He also found that lower rankers were more likely to show resistance to insulin - a condition that predisposes to diabetes, which is itself a cause of heart disease. Fibrinogen levels, which are a measure of blood stickiness, were also higher in the more stressed workers. Finally, he found also that antioxidant vitamins - A,C and E - were consumed less by lower ranks.

The current opinion of most researchers is that psychosocial factors determine the differences in the Whitehall Study. It is thought that a sense of lack of self esteem and lack of control over their circumstances may damage the health of the lower ranks. Lower rankers also have a less supportive social environment with family and friends when compared to higher ranks. To expand this line of thinking it is helpful to look at animal studies. Even civil servants are, when it comes right down to it, animals, members of the primate order. Studies of the physiological responses of another kind of primate, in this case free ranging baboons, have shown that dominant animals in the social order are able to switch off their stress responses quite rapidly, while subordinate baboons continue to display low levels of anxiety and stress long after the immediate confrontation is over. In another study, female macaque monkeys were fed high cholesterol diets. Both high and low rank animals developed cholesterol deposits in their coronary arteries, but interestingly, the low rank monkeys laid down four times as much as high rankers.

Transferring these insights back to civil servants, we find that blood pressure levels, which are an index of stress, while similar in high and low grades during the working day, are quite different when away from work. High rankers show a much greater fall in blood pressure than those in lower ranks. This is consistent with the hypothesis that social animals in lower ranks continue to suffer the effects of stress for a longer time than dominant animals. It would be reasonable to infer from this that in order optimise health for all, we must try to set up work social conditions so that we distance ourselves as far possible from the rigid hierarchical pecking orders that characterise societies such as baboons and the civil service, and encourage a sense of participation in a common enterprise. This kind of workplace democracy is found in co-operatives and in various schemes of workers participation, including the practice of workers holding shares in the company for which they work. Out of the workplace, the notion of active citizenship, which recently found favour with all political parties is promising prescription. Confirmation for this idea comes from another quarter.

INEQUALITIES OF WEALTH AND HEALTH

There is a good deal of evidence showing that mortality rates are lower in countries with a more egalitarian distribution of income. Wilkinson has followed up these findings by showing that as time passed, the average change in percentage share of the total income of a country was positively related to changes in life expectancy. In other words, countries that distributed wealth more equally tended to have better levels of health. In particular, Japan, which has the most egalitarian tendencies in distribution of wealth, obtained the best increase in mortality, while the UK, with the greatest changes towards inequality, gained least in mortality. The other four comparable countries were strung in between these two extremes, confirming that the relationship was proportional. It is reasonable to conclude from this data that an effort to produce more income equality should lead to an increase in the health of the nation.

THREATS TO THE SENSE OF COMMUNITY

Urbanisation

The sense of community first began to fail in the Industrial Revolution, when agricultural labourers left their villages for the large towns. Relocation not only broke up the physical sense of community, but also the delicate web of kinship, neighbourliness and friendship which bound the rural community together. Villages have a common space, the village green, for which the shared street can become a substitute, but towns cannot supply the other subtle commonality, the sense of living-place which is offered by the countryside terrain. A child develops an intense, almost mystical sense of attachment to a point in space, a tree or river, and as successive generations grow up with that locale imprinted on their subconscious mind, it is reasonable to suppose that this shared love will contribute something to a sense of community.

Urban redevelopment
Despite all the disadvantages of urban living, it is unquestionable that a sense of community does exist in towns, even in the most uncongenial physical surroundings. It is as if the lack of interesting features in the physical environment is compensated for by an increased interest in the human environment, with the result that a network of longstanding characters are known and recognised in a locality. This network should be preserved and fostered at all costs, and urban regeneration programmes should be at pains not to destroy them. In the 1960's a slum in Liverpool was threatened with clearance and rebuilding. Local people rejected the official clearance plan and responded to architects and builders who redesigned and refurbished their houses piecemeal, to the immense satisfaction of the residents. The sense of community was preserved, while the housing was upgraded at the same time.

Severance of communities by roads

Trunk roads violate communities. As the main street through a locality becomes more and more busy with traffic, the place which was once the focus of community activity turns into a river of hostile, dangerous, evil-smelling metal. Crossing from one side of the street becomes first time-consuming, then frustrating, and finally downright dangerous. Friendships wither and acquaintances become strangers, cut off on the other side of a divide.

Lack of Common Space

Community needs common space. Warm weather supplies a ready-made common space in the great outdoors. In Bedminster, Bristol, it was noticeable that on warm summer evenings people would greet each other and chat for long periods, while in the winter those same neighbours would hurry from car to house with scarcely a glance at each other. Warm common space is therefore a prerequisite for community relations to develop. In the past, this was supplied by the public house, church and to some extent by theatre and public transport. All four of these facilities are relatively diminished with time, with the pub giving the best account of itself. However, the pub is not available to those without money, and is facing competition from the trend in takeaway alcohol to be consumed at home in front of the TV or video.

Entertainment

Entertainment has become passive and professionalised. Singing is not now something which just anybody may do in company with others. We spend our days immersed in popular song, but most people know only a phrase here or there, and it is a rare group of friends who between them know all the words of more than one song. In times when community singing is given a chance to happen, inhibitions die away, and the sense of individual ego is dissolved into a sense of song. Physically, it seems to be concerned with a resonance established in the chest of the individual person; linguistically, the Welsh simply describe it as hwl, akin to communal joy. To a great extent, this is now diminished, and replaced by an all-pervasive mechanised music produced by a few professionals, and brought to the people by an immense industry. We are surrounded by music, yet we cannot sing.

Youth Culture

The painful rite of passage into adult society that is found in most simpler cultures has disappeared from our culture. A prestigious report by Sir Michael Rutter and Professor David Smith ascribed part of the increase in crime after the war to the increased freedom and independence of youth culture, together with increasing expectations of material well-being that cannot easily be met. Many young people now feel they have no stake in society, and pass sideways into a parallel universe of sex, drugs, and rock 'n' roll. As a culture generally, and as youth culture in particular we seek instant gratification and reject long-term plans for progress. In the end, the drug reverie is another expression of the philosophy of individualism.

Single Parent Families

The numbers of single parent families are increasing exponentially in the UK. It is a contentious political issue, with extreme right-wingers blaming lax morals and the desire on the part of the mothers to jump the housing queue, and left-wingers blaming unemployment. Certainly there is an emergent perception that the father, once he has inseminated the mother, is of no further use if he does not bring home a wage. If the queue for housing is indeed a motive, then this adds another reason for society to solve the housing shortage with an intensive programme of house building and renovation. Meanwhile, the question for society is, what effect will being reared in single-parent families have on the coming generation? Will it mean a cohort of anarchic little monsters lacking a masculine role-model and firm fatherly discipline? Or will it perhaps lead to a generation of boys who are more influenced by feminine values of nurturing than masculine values of violence? This is clearly an area that needs much research, and in all probability an intensive programme of therapy and education to bring about a beneficial outcome.

In conclusion, many forces are working against the vital sense of society. Can these forces be opposed?

STIMULATING THE SENSE OF COMMUNITY

The health-promoting effect of a sense of community offers an interesting and extremely cost-effective way of improving health by stimulating community initiatives. Across the country there are a huge number of community initiatives often started by groups of people who identify a need in a locality and get together to do something about it, using local skills and resources. Rita Miller, a community worker from Somerset writes of Pre-school Playgroups, "Where parents, volunteers and paid work together in partnership all benefit, all learn, success is likely, and the feel-good factor blossoms, infecting others. Schemes are usually flexible and can adapt changes of need and produce spin-offs as relevant. People grow, and when they move on they take new skills with them". Many examples of successful community initiatives are by Rita Miller. The Neighbourhood Centre, Lawrence Weston, Bristol was set up in 1985 in a deprived area with appalling health statistics. It was built on reclaimed land near to a large chemical works. Each time Rita visited she found least one family in acute crisis of cancer, stillbirth suicide or domestic violence. The Centre had a flat, with all of the 50 user-volunteers having access to the key. About 150 families used the Centre. Decisions were made the families, with support from a volunteer paid by the local Health Authority. The effect of this is to produce a degree of mutual co-operation and support on the local estate.

The St Paul's Drop-in Centre, again in Bristol, consists of a community-owned flat and caters for people in a poor ethnic inner city area. A co-ordinator and sessional are paid a tiny salary which is supported by Bristol City Council. The main users are Pakistani Muslim women who to sew with their children at their feet. The sessional workers are trying to interest the group in providing a play group.

The Springboard special needs playgroup in Clevedon, Avon, was formed spontaneously between parents who met and formed relationships while waiting to be seen at out patients departments. They now have two playleaders, and children are referred to them by health visitors. Professionals come in occasionally on request to give advice, and the value of the group to children and carers is recognised by official bodies. It is seen as a cheap and highly effective form of care, but sadly, it is chronically short of funds.

The Pre-School Playgroups Opportunities for Volunteering Panel received £150,000 in 1991-2 from the Department of Health. (More than this amount of money is spent every hour on the Trident nuclear submarine fleet). The money is allocated by the PPA to Family Centres, Hospital Playschemes, projects to help children in need, and projects for cultural minorities. Other voluntary organisations may apply for funding for community schemes. Community workers are also funded by County and City councils, and sometimes by Health Authorities.

Training for community work consists generally of two year courses, although some areas will give accreditation based on assessment of work experience. This is probably a wise course, since the chief qualification for community work is a certain kind of resilient, active and engaging personality. If this ingredient is lacking, no amount of training is going to make a community worker out of a student. The other ingredient of success is being able to achieve something tangible for the community in a short period of time in order to attract people's attention and interest. The positive impact of these schemes is incalculable. They provide social support, a cost free opportunity to from imprisonment in drab flats, an opportunity to ventilate fears and anxieties, and an opportunity to gain a sense of power over circumstances. Community groups like this cost peanuts in terms of Government and even local authority budgets, but the returns on the investment to the health services, social services, police, law courts, courts and even industrial productivity are immediate and carry a payback of which a City financier could only dream. Yet all too often community groups are held back by lack of resources.

For instance the Windmill Hill City Farm, a project in Bedminster, Bristol which turned a derelict site into a flourishing community farm, took years of unpaid voluntary work to persuade the authorities that the scheme was viable and immense voluntary efforts to construct. Ultimately it was so successful that school children from the country are now bussed in to the city to look at a classic working farm, as rural farms are given over to intensive, battery-style farming. Funding came from local and health authorities, but with every round of local authority budget cuts, the leaders again had to fight to defend their funds. Energy that should have been devoted to the Farm is lost in this process.

The conclusion is that social links are a vital input to health, that they can be fostered in those poor areas who are most in need of it by community groups, that investment in these groups is extremely cost-effective, and that the community groups need regular supplies of adequate funding.

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