by Cathy Campbell, Ellen Duff and Sally Zlotowitz
“The pandemic is a portal. We can walk through it with our dead ideas. Or we can walk lightly, ready to imagine another world.”
Psychologists for Social Change aim to develop new ways of being, seeing and doing in the field of ‘mental health’* and well-being. This includes moving beyond models that focus solely on the individual. We are committed to promoting understandings of psychological health and care for others in distress as a political act - one which involves not only psychological therapies, but also efforts to promote social conditions that enable and support the possibility of well-being for all through tackling the social inequalities that drive ill-health in many local, national and global contexts.
PSC have described the mechanisms through which social and economic policy can damage the population’s psychological health, notably the impact of austerity. We also describe how it is possible to do the opposite by generating more trust, connection, security, meaning and participation through social and economy policies. It is in this spirit of hope and solidarity that PSC added our name to the campaign calling for us to #BuildBackBetter from COVID-19. The five principles in the letter map out social conditions which would significantly increase opportunities for psychological health, not only in relation to COVID, but also in relation to future health threats, including those created by climate change - particularly amongst the socially disadvantaged who tend to suffer the poorest health and the least protection from adversity.
1. Put people’s health first, no exceptions.
There is much debate between those prioritising ‘the preservation of every life at all costs’ and those who suggest that the long-term damage the COVID-19 response (such as the lockdown that is keeping people away from work) is doing to the economy may be a worse consequence than the loss of life. It is our view that every single life matters. We find the notion of a trade-off between life and money abhorrent.
We are devastated by the deaths of health professionals, social care workers, bus drivers, supermarket employees and other key workers that are supporting the sick and enabling the survival of the rest of us. This has disproportionately affected BAME groups and women as they are over-represented in lower paid and caring roles. We regard the government’s failure to provide adequate protective equipment and testing to support this group in their vital work as a particular outrage.
2. Provide economic relief directly to the people.
Politicians are faced with choices about how to distribute financial relief - to industries, such as aviation, or to people, be that particular groups of people or to everybody. They have taken a reactive stance to protecting the income of particular sections of society - firstly contracted employees, then the self-employed, meanwhile failing to address existing issues of casualised labour in which people have no recourse to sick pay, and increased pressure on the already not-fit-for-purpose Universal Credit system. This stance reinforces the divisive austerity-era narratives of the striving workers vs the skiving workless. To date the government has rolled out £200bn of quantitative easing, which typically disproportionately benefits the richest in society. An alternative approach would have been to distribute this directly to people through, for example, a period of Universal Basic Income (UBI) - we have written about the potential psychological impact of UBI here. Within our current political and economic system, a large part of that money would still ‘trickle up’ through people’s rent, utilities and shopping into the pockets of the richest, but will have also directly benefited people and their communities in the process. An assessment of the impact of UBI would be important after this initial period to ensure it is working fairly for all citizens. For example, it's vital that the provision of UBI is not linked to a loss of income for people who claim benefits which are assessed on need, such as disability benefits.
3. Help workers and communities, not corporate executives.
COVID assistance directed at specific industries must be channelled to communities and workers, not shareholders or corporate executives, and never to corporations that don’t commit to tackling the climate crisis. Indeed, it is time to take seriously the government’s own position of advocating for localism. The importance of transferring power and resources directly to communities at this time cannot be overstated, especially, as the group #charitiessowhite has emphasised, to marginalised groups such as BAME communities, without whom we cannot truly collectively create a new future for the UK.
We know the positive impact of participation and active citizenship on people’s health and wellbeing but this can only be enabled through adequate resourcing. Austerity policies decimated these resources, as the government chose to bail out the banks and then slash funding of public services and the community and voluntary sector, contributing to thousands of preventable deaths and suicides in contexts of ever increasing psychological distress and health inequalities.
4. Create resilience for future crises.
There is an urgent need for our economic systems to address inequality and the climate crisis, to work towards the zero-carbon future we need, such as outlined in the Green New Deal. This unique moment in history gives us the opportunity to ‘build back better’. Community-led businesses and employee owned, democratically run cooperatives, social enterprises and businesses could form part of a more fair, resilient and sustainable future. Possibilities could equally lie beyond the labour market, in a system where access to the basics of living does not rely directly on labour. How might the current crisis look different if we all received universal basic income or universal basic services, for example?
5. Build solidarity and community across borders – don’t empower authoritarians.
The current global crisis opens opportunities for social change: towards increased division and inequality, national isolationism and xenophobia; or to turn the tide on neo-liberal individualism, to recognise the power of cooperation and increase our agency as communities. There are already numerous examples of the former approach, but have also likely seen many cases of increased cooperation in our communities in the form of mutual aid groups, for example. We want to see this amplified to an international scale, in which money and technology are shared with lower-income countries and communities to allow us to share solutions across borders. We commit to fighting any use of this crisis as an excuse to trample on human rights, civil liberties, and democracy.
The UK has a long history of health and mental health inequalities, with socially advantaged people living much healthier and longer lives than any other group. These health inequalities mirror the unequal distribution of economic wealth, political power, oppression and social status. COVID is drawing new attention to the social fault-lines that sustain these social injustices – potentially opening up new opportunities for the fight for more societies characterised by greater solidarity and equality. The pandemic throws a new spotlight on the long-standing failure of neo-liberalism to create social systems and conditions that protect the health and well-being of citizens. It has revealed the weakness of the social and political status quo that many took for granted until only weeks ago. It has undermined the worrying escalation of anti-science and anti-expertise narratives. It has forced governments to acknowledge that they need active citizens whose actions go beyond self-interest and the profit motive and can be mobilised to participate in collective efforts to promote social well-being. Horizontal networks have sprung up all over the country in the form of mutual aid groups, volunteers to support the NHS and people who are increasing their caring responsibilities. All these activities are reviving the hope that the world could be a better place: A psychologically healthier society in which participation, community, trust and connection might be valued over status, individualism, and competition.
We are supporting the call to #BuildBackBetter after Covid-19 and we are working out PSC’s place and role in this ambition. We would welcome your people’s ideas and comments. Please email us: email@example.com or tweet at us @PsychSocChange
*We use the term ‘mental health’ cautiously as it may prompt people to think of the biomedical framework and diagnostic terms such as ‘depression’. At PSC, we are explicitly advocating for a social and contextual model of people’s psychological experiences which moves us away from biomedical understandings and terminology.
Photo by Aniket Bhattacharya on Unsplash
by Karim Mitha
A decade ago, Professor Sir Michael Marmot published his landmark review highlighting the stark inequalities in our society. Along with Wilkinson and Pickett’s “The Spirit Level”, the report helped to outline the impact inequalities and other socio-economic factors have on population health, known as the “social determinants of health”. Despite the number of recommendations made, particularly in relation to good and fair employment, healthy places, and improving standard of living, the subsequent decade of austerity did little to make any improvements in tackling these issues. In many cases there has instead been a regression, particularly in relation to housing and employment. The current COVID-19 pandemic has made existing social inequalities in our society achingly visible, and seems likely to compound these divisions further. We already know that certain groups are disproportionately affected by the virus, with BME communities experiencing particular structural and health inequalities including barriers to self-isolation, and the spike in domestic violence in lockdown. As we try to weather this crisis, it seems particularly timely to reflect on the findings of the “The Marmot Review – 10 years on” recently published by the Institute for Health Equity.
“England is faltering”
The report is stark. It portrays a bleak picture of the impact of sustained cuts to social services and how this has exacerbated existing inequalities. The very first words of the report, “England is faltering”, are a call to action – asking how is it that in a high-income country social policies have been implemented to further disadvantage the working class, vulnerable, and marginalised, who experience greater years of life living with disability than those in less deprived backgrounds.
The report acknowledges the debate in the age of austerity regarding prioritising social or economic progress. The Coalition government, from 2010 onwards, used rhetoric of national identity and social solidarity, invoking a nostalgic idea hearkening back to the Second World War of “we are all in this together”, to push through reforms and cuts. This was done under the premise that Britons would band together and accept cuts which were portrayed as necessary to get the economy back on track. Marmot is careful to note it is difficult to establish a direct causal link between these austerity policies and the increase in inequalities over the same period. He does, however, suggest that sustained cuts in health and social care have combined with wider socio-economic factors to jointly reduce individual stability and security, which are important for psychosocial wellbeing. Marmot particularly highlights changes in the employment and housing sectors.
The myth of “we’re all in this together”
Marmot outlines how multiple political and economic factors have combined to contribute to areas, particularly in the North of England, feeling “left-behind” and has helped to compound the experiences within “ignored communities”, where there is little hope for alleviation of poverty or social mobility. The housing crisis, cuts to child and youth centres, and continued disinvestment in particular geographic areas have all played off each other in a negative spiral of disadvantage, further exacerbating and entrenching existing inequalities. The health impacts are severe. Life expectancy overall has stalled and has actually fallen amongst the most deprived. The social gradient of health – where those at the top have the least need – has also worsened. Men living in the 10% most deprived areas will spend 30% of their lives in ill health compared to 15% amongst men living in the 10% least deprived areas. Amongst women, those living in the 10% most deprived areas will spend 34% of their lives in ill health compared to 18% for women living in the 10% least deprived area.
Similar inequalities exist in mental health need. Vulnerable and disadvantaged groups, often concentrated in more deprived areas , tend to be disproportionately represented in mental health service use. The report notes the worrying trend of increased mortality rates amongst middle aged-adults due to “deaths of despair”, deaths due to suicide, alcohol, and/or substance misuse. These can be understood as coping behaviours in response to socio-environmental strain and pressures. Marmot explores ‘avoidable mortality’, defined as deaths which could have been avoided through timely and effective health interventions. Amongst the poorest 10% of English people, deaths of despair are three times higher than amongst those in the richest 10%. This is where examining the influence of wider factors is important as it is often those experiencing the most socio-economic disadvantaged who are particularly susceptible to job insecurity, unemployment, debt, and lack of social support, which are linked with increased suicides.
Overall, the report portrays a bleak picture. Marmot notes that those living in more disadvantaged circumstances have been besieged with substantial changes in many social determinants of health. When people experiencing the greatest socio-economic adversity are socially “written off” and lose a sense of attachment and trust to their local areas , the boundaries of social cohesion are frayed. It is difficult to believe messaging such as “we’re all in this together” when social mobility is increasingly unlikely and already disadvantaged communities feel increasingly marginalised, vulnerable, and forgotten. Given this, it is difficult to not see how these factors have, along with cuts to community and social services, have contributed to higher levels of suffering and despair we can see manifesting as a 'mental health crisis'. It is quite concerning when we see the blanket of the social welfare state fraying – with successive governments failing to understand the long-term and societal implications of policies under austerity.
The politics of poverty and wellbeing
The report critiques the “individualist” agenda - that people’s poor health is a consequence of the choices they make. Marmot notes that being in poverty limits the available choices people can make and thus poor health actually reflects the limited range of choice available, along with the psychological strain and pressures that disadvantage brings (ie: poor quality housing, debt and financial strain, etc). Marmot also notes the impact of cuts to social care and the concomitant increase in youth violence and child and adolescent mental health disorders. Given these factors, it is unsurprising that his recommendations centre on improving children and young people’s environmental living conditions, fairer employment for all, increasing living standards, and creating healthy and sustainable communities.
Marmot also argues that in an era of localisation, it is important for local authorities to embed a social determinants of health perspective into their health and wellbeing strategies, as tackling deprivation can improve health and wellbeing outcomes for all residents. Marmot highlights the “Wellbeing budget and strategy” in New Zealand which looks at wellbeing as an investment for a happier, healthier population.
Marmot views the various social prescribing programmes in England as beneficial. He notes that this approach may help to build those connections and networks, as well as help people to gain confidence and a sense of agency, through being able to be seen as an active citizen. However, he also notes that this may not be able to address some of the underlying and challenging experiences and threats to mental health that those who are the most disadvantaged may be experiencing, and thus social prescribing efforts must be made in conjunction with movement on wider determinants.
Faced with the evidence of what the past decade has dealt onto the most marginalised in society - having the social welfare system and the promise of social mobility pulled away, feeling "left behind", stigmatised, and blamed - it is easy to see the futility of trying to address psychological concerns divorced from socioeconomic context.. Understanding a “whole-systems” approach is essential in being able to address the impacts of heightened neoliberalism and increased inequalities on mental health and wellbeing, particularly for those experiencing multiple forms of disadvantage.
Ultimately, it is clear that a decade under austerity has been detrimental with those most at risk and most vulnerable most affected. If we were to take the approach of countries like New Zealand, and embed wellness into our planning, strategy, and it being an overall aspiring target to achieve, we might be able to overcome these structural factors and facilitate improved physical and mental health and wellbeing of our fellow citizens.
The BMJ has astutely noted that the experience of the COVID-19 pandemic demonstrates the imperative of tackling inequalities and how systemic factors such as structural racism and class inequalities can facilitate susceptibility to disease, which can have global consequences. The pandemic climate has shown us how uniting to tackle inequalities and helping our most vulnerable will actually help improve health outcomes for all. The Marmot review has shown the consequences of failing to do so. In order to address the health of the whole population, it is important to pay particular attention to the most vulnerable and address inequalities. After all, as the proverb goes, “a chain is only as strong as its weakest link”.
Author note: Karim Mitha is a public health professional and a member of PSC. He is completing his part-time PhD in the sociology of mental health at the University of Glasgow.
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