Elsevier

Social Science & Medicine

Volume 118, October 2014, Pages 173-180
Social Science & Medicine

Dependency denied: Health inequalities in the neo-liberal era

https://doi.org/10.1016/j.socscimed.2014.08.006Get rights and content

Highlights

  • Debates in epidemiology stress income inequality as a cause of health inequality.

  • This emphasis underplays the impact of neoliberal discourses on health inequality.

  • This study of women's lives exposed a discourse called no legitimate dependency.

  • This is both painful and damaging, where dependency is disavowed or othered.

  • Including neoliberal discourses is central to understanding contemporary inequality.

Abstract

The ways in which inequality generates particular population health outcomes remains a major source of dispute within social epidemiology and medical sociology. Wilkinson and Pickett's The Spirit Level (2009), undoubtedly galvanised thinking across the disciplines, with its emphasis on how income inequality shapes the distribution of health and social problems. In this paper, we argue that their focus on income inequality, whilst important, understates the role of neoliberal discourses and practises in making sense of contemporary inequality and its health-related consequences. Many quantitative studies have demonstrated that more neoliberal countries have poorer health compared to less neoliberal countries, but there are few qualitative studies which explore how neoliberal discourses shape accounts and experiences and what protections and resources might be available to people. This article uses findings from a qualitative psycho-social study employing biographical-narrative interviews with women in Salford (England) to understand experiences of inequality as posited in The Spirit Level. We found evidence for the sorts of damages resulting from inequality as proposed in The Spirit Level. However, in addition to these, the most striking finding was the repeated articulation of a discourse which we have termed “no legitimate dependency”. This was something both painful and damaging, where dependency of almost any sort was disavowed and responsibility was assumed by the self or “othered” in various ways. No legitimate dependency, we propose, is a partial (and problematic) internalisation of neoliberal discourses which becomes naturalised and unquestioned at the individual level. We speculate that these sorts of discourses in conjunction with a destruction of protective resources (both material and discursive), lead to an increase in strain and account in part for well-known damages consequent on life in an unequal society. We conclude that integrating understandings of neoliberalism into theorising about inequality enriches sociological perspectives in this area.

Introduction

Since its publication in 2009, Wilkinson and Pickett's (from here-on W&P) “The Spirit Level” (from here-on TSL) has stimulated popular and academic debate on the subject of inequality in a way that is probably without precedent, at least in the UK. TSL's central argument – that unequal societies have an excess of ill-health (and social problems) and that it is income inequality per se that is the underlying cause – was reinforced by the findings from the Strategic Review of Health Inequalities in England (widely known as the Marmot Review) in 2010. In the years following publication of TSL, subsequent work by others provided robust support for the relationship between inequality and health that W&P describe (De Vogli, 2011, New Economics Foundation, 2011, OECD, 2011, Rowlingson, 2011).

One of the novel features of TSL was that it looked beyond the empiricism of much social epidemiology and entered the more epistemologically challenging domains of medical sociology and health psychology. It sought to extend the authors “psychosocial” explanatory framework linking population health with income inequality, as well as proposing a set of mechanisms which (they believe) mediated this relationship. These mechanisms, they argue, include “low social status, lack of friends and stress in early life. All have been shown … to be seriously detrimental to health and longevity” (TSL p39). The study we report on here explored one aspect of this explanatory framework – the experience of shame and social comparison which they believe flows from being of ‘low social status’ and which forms a backdrop to life in an unequal society (with consequences, of course, for health and well-being). A key finding from our study, set in Salford (in north-west England), highlighted a linked, but rather different finding from W&P's hypothesis – the extent to which neoliberal discourses concerning individual responsibility appeared to have been internalised in women's accounts of life in an unequal society. Furthermore, it was also apparent that neoliberal discourses seemed to shape agency and resistance in the face of inequality and the associated strains of everyday life – and it is these aspects that we discuss in this paper.

We recognise that incorporating wider political projects and their attendant discourses in the area of health inequalities is epistemologically demanding, but there is a growing body of quantitative evidence exploring the negative impacts of neoliberalism on health which we argue require qualitative exploration. Coburn (2000), for example, in a well-known debate with Wilkinson (2000) made the case for, “go[ing] beyond the income inequality hypothesis towards a consideration of a broader set of the social determinants of health” (p41). This entailed evaluating how more unequal societies get to be more unequal, and in particular, how to integrate class and the neoliberal project into explanations for health inequalities. Coburn argued that political decisions and attendant discourses legitimised high levels of inequality, demonstrating empirically that neoliberal societies had more invidious consequences for health and well-being than more social democratic ones. These issues merit qualitative exploration given the historical expansion of the neoliberal project and in the context of the increasing evidence for the toxic nature of neoliberalism for health (De Vogli, 2011; Hall & Taylor in, Hall and Lamont, 2009, Collins and MacCartney, 2011).

Indeed, there have been relatively few sociologically informed qualitative studies exploring the processes which TSL authors' argue are the ways that inequality gets “under the skin”, (Dolan, 2007, Gibson, 2007, Davidson et al., 2008). There are even fewer studies that begin to explore the close-grained detail of what might underpin the finding from epidemiological studies which show that population health trends are different in more (and less) neoliberal societies (De Vogli, 2011, Collins and MacCartney, 2011). Similarly, there has been little exploration of what resources might be drawn upon to resist health damaging discourses in neo-liberal societies (Hall and Lamont, 2009, Peacock, 2012, Scambler, 2013).

We argue that empirically examining the ideas Wilkinson and Pickett (2009) propose in TSL (in this case, shame and social comparison), can shed light on the discourses, practices and processes by which inequality, shaped by neoliberalism, is manifesting itself in England. In particular, we focus on a particularly prominent and damaging discourse that we identified in the accounts of our participants and which we termed “no legitimate dependency”. This was unanticipated in that we did not set out to explore this, but it emerged as a core finding and can be described as a discourse where (virtually) all forms of dependency were disavowed and disproportionate amounts of personal responsibility were assumed for aspects of life that we would argue are not reducible to the personal agency of an individual. In addition, “othering” was used by many participants as a response to protect the self from some of the stigmatised identities that have become a feature of contemporary neoliberalism (Jones, 2011). In the discussion, we go on to speculate how the no legitimate dependency discourse might figure in the spectrum of our understandings of neoliberalism and population health and link this with similar findings from other areas of social policy (Hoggett et al., 2013). Before describing the methods used, we expand on key debates in the literature.

Section snippets

Perspectives on neoliberalism, inequality and health

The central contention of TSL is that it is inequality (the size of the income gap) that is the key to determining population health. One of the consequences of this widening gap is an increase in stressors due to what they describe as shaming or invidious social comparisons:

Greater inequality seems to heighten people's social evaluation anxieties by increasing the importance of social status. Instead of accepting each other as equals on the basis of our common humanity as we might in more

The study

The study we use to illustrate the contention that there are aspects of neoliberal discourses which have been partially internalised and which impact on health and well-being, is a qualitative “psycho-social” study of women living in Salford, England. There are two uses (and two spellings) of “psychosocial” in this paper; psychosocial is used to in the context of social epidemiology and the theories of W&P (in TSL), and others. Psycho-social describes the set of methodologies which draw

Findings – the no legitimate dependency discourse

Although the primary aim of the study was to explore shame and social comparison (and these were present if not in quite the ways TSL would anticipate), we report on these findings briefly elsewhere (Peacock, 2012). Here we focus on what we termed “no legitimate dependency”. We used this term from early on in the process of interviewing to describe what occurred, in some guise, with every woman in the study (the quotes selected are those that best illustrate this discourse, but there were

No legitimate dependency and the therapy discourse

The ways that the women talked about their lives and sense of responsibility drew heavily on therapy discourses. Walkerdine has commented how, “psychological discourses and services (counselling, as in chat shows, popular psychology books … women's magazines and popular newspapers) combine with people's desire to make something of their lives … to transform oneself into the right kind of … subject” (2000, p3). These colloquial therapeutic discourses comprised a significant amount of the women's

Self-blame & self-criticism

One of the key ways in which the no legitimate dependency discourse manifested itself in women's accounts was through self-blame and self-criticism and this was a marked and pervasive theme.

I kind of push myself quite a lot and then when I can't do things I feel guilty feel like I'm letting people down and I think that's compounded from being a mother” (Annie, 52, part-time teacher, single mother, one teenage son).

In maintaining these standards, it was both the imagined judgements of others,

Othering

The second aspect of no legitimate dependency we encountered in the study was othering. Othering arguably, had a protective function as it enabled stigmatised identities to be managed and to be pushed away from the self. This was most forcibly demonstrated in Elsie's thoughts about disabled people.

I hate people that are disabled wanting everything. They want all the buildings altered so that wheelchairs can get in. Now for me, all the new buildings from the last ten years should be wheelchair

Protest

The third response to the no legitimate dependency discourse (and expressed by fewer women in the study), was protest, unease, ambivalence or resistance.

why do I get paid four times as much as the person who stacks shelves in Tesco's? … okay I've worked and my education and all the rest of it, but is my value to society … really four times as much?” (Kate, 39, accountant, mother of three).

There was often a shift in what was expressed between the first and second interviews. It seemed as though

Strains and tensions in the discourse

Despite its pervasiveness, there was widespread discomfort with the no legitimate dependency discourse and many places where it was incongruent or jarring in women's lives. Participants were often less critical of other women than they were of themselves, although they were critical both of particular aspects of other women's behaviour and of the broader “something for nothing” culture which they believed was increasing. Importantly most of the women experienced a tension in using such

Discussion

The aims of this study were to explore whether shame and social comparison were salient in the ways proposed in TSL, to look at what resources and strategies might be used to protect from such invidious comparisons and to consider if there were aspects of the women's lives which might worsen or sharpen the damages consequent on inequality. However the psycho-social method that we employed uncovered the no legitimate dependency discourse which we propose sheds light on how neoliberalism may be

Conclusion

We have argued here that neoliberal discourses are likely to be highly salient to the health and social outcomes of life in an unequal society. Such discourses are, arguably highly toxic across several domains of life. At the heart of the no legitimate dependency discourse there is an irresolvable tension: to occupy a morally and socially defensible position involves a disavowal of the social and the losses, demands and isolation that result, whilst at the same time, most do not want others

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