Health Inequalities and Community Empowerment …….. ……….Connecting the dots. Jennie Popay Professor of Sociology and Public Health, School of Health and Medicine Lancaster University

The dotted line I’m going to try to draw……..  Health Inequalities are a matter of social justice  Social justice requires policies and actions that release the capabilities of people and communities  Universalism and community empowerment have done this and can do it again (with a digression into knowledge and power)  Do contemporary public health policies do this?  The latest guidance from PHE and NHS England - are the dots finally being joined up?????

Putting right these huge and remediable differences in health between and within countries is a matter of social justice. Reducing health inequities....is an ethical imperative. Social injustice is killing people on a grand scale. (CSDH) In the UK between 1.3 and 2.6 million lives would be saved if inequalities in premature mortality between socio- economic groups were significantly reduced. (Marmot review 2009). Health Inequalities and the pursuit of social justice WHO Commission on the Social Determinants of Health

 Behavioural and health outcomes do not provide an ethical or sustainable basis for policies aiming to enhance social justice  We need an Aristotelian framework which prioritises human flourishing as the aim & capability development as the means.  In this framework social justice demands policies that:  support the development of individual/collective capabilities (agency)  Remove barriers to people’s ability to exercise reasoned agency “The challenge is to work out the precise demands of justice that is....practically useful. Amartya Sen 2010

After the WWII Beveridge identified 5 giants on the post-war “road to reconstruction” : want, disease, ignorance, squalor, and idleness. The response then - universal systems free at point of use for social security, health care, education and action to sustain full employment, increase public housing, and renew neighbourhoods – release extraordinary collective capabilities Delivered unprecedented improvements in living standards and health and could do again. 1945: a brave experiment in capability release

1. Enhance capabilities via renewed universalism “ The task is to re-shape a historical model to meet new problems as well as problems that have been familiar for generations. The strength of a universalistic approach is in building coalitions between groups in society across generations and social groups Shrewdly interpreted, universalism can encompass rights by gender, race, ethnicity, age and disability and give nationalism a stronger edge both in negotiating with outside powers and withstanding international shocks”. (Townsend, 2007, pp1 He was looking at design of a global tax system before he died

2. Enhance capabilities through community empowerment Empowerment is much more than the involvement, participation or engagement of communities in other organisations’ agendas. It is a process through which people bearing the brunt of social and health inequalities forge a shared identity, recognise common interests and use experiential and other forms of knowledge to act collectively to demand greater social justice This process involves the re-distribution of power – for some people to gain more power others have to share or give up the power they have From this perspective processes of empowerment involve struggles over power in all its forms– not something readily commissioned by LAs & CCGs!

Knowledge is one key element of power The historian E. P. Thomson argued that we need to “rescue the wisdom of experience from the crushing condescension of history” Aristotle called this ‘practical wisdom’ “the complex responsiveness of ordinary people to the concrete situations they experience in their everyday lives ”

But ‘practical wisdom’ is still being crushed in the health field. The argument for truth [science/evidence] as a hierarchical quality of knowledge is an act of domination that tries to sustain superiority of one set of beliefs over others based on idea that these beliefs were achieved through reliable procedures J Castiel, 2003

Health Inequalities –numbers not peop le individuals dominate but as accumulations of risks, vulnerabilities and resiliencies or sets of freely chosen behaviours Absence of people as ‘knowing subjects’ using practical wisdom to make decisions that are logical in context of their lives

Give two of the multiple ways in which the practical wisdom released when communities are empowered could contribute evidence for greater health equity

Experiential knowledge reframes problems and solutions Whilst Roma parents are taught about the value of education Roma children get lessons in personal hygiene 4 5

Practical wisdom about health inequalities between neighbourhoods 1.Stress seen as a major cause of health inequalities 2.Strength of character presented as the main protection If you let it get you down, you are going to have the health problems 3.But they had no control over material determinants of health everybody has a bit of worry but outside worries has a bigger effect like not having a job or money Cos you haven’t the power to change it These theories aren’t right or wrong – they serve a purpose 1.Re-assert individual control 2.Reconcile need for control with recognition of wider determinants 3.Perhaps most importantly they reconstructs moral worth “To acknowledge inequality would be to admit an inferior moral status for oneself and one’s peers: hence perhaps the emphasis on ‘not giving in’ to illness. This can be seen to be a claim to moral equality even in the face of clear economic” inequality Mildred Blaxter, 1997, 754 Understand the moral significance of practical wisdom

And community empowerment can have dramatic health impacts …. Study of Indigenous suicide in British Columbia – Significantly elevated suicide rates (5 time across the province, ) – But not uniformly distributed across 1 st Nation groups: – Aboriginality per se is not a risk factor. ‘Cultural continuity’ explained different risks But measures reflect degree of ‘control’ – history and success of land claims; – self government; – control of services; – Dedicated cultural facilities Later looked at adult suicide and extended the indicator – Proportion of women in political positions Personal persistence, identity development and suicide, Chandler, Lalonde, Sokol, Hallett, Monogr.Soc.Res.Child.Dev. 2003:68(2)

Decreasing suicide rates with increasing community ‘control’

Do contemporary public health policies/action release individual and collective capabilities?

National Audit Office Tackling in areas with the worst Health and deprivation Holyrood website Scottish Government's health inequalities pilot nears end PHARMAFILE website NHS Slow to tackle inequalities FUSE Newcastle University understanding and tackling health inequalities Not when they obsess about behavior and “Name and Shame” Sustainable Development Commission the key to tackling health inequalities The Guardian Close call on health inequalities

And not when they bribe and cajole Incentives: a lively and heated debate in the BMJ in 2008

Conditional welfare 1997

Conditional welfare programmes 2008 New York Northern territory Washington DC Many places in UK

Breastfeeding mothers offered £200 in shop vouchers (Guardian 2013) Paying pregnant smokers to quit in Glasgow (Guardian 2015 Get Paid to Exercise and Live a Healthier Lifestyle – private sector initiative Paying children to read books – Pay4Performance 2010 Obesity crisis: get paid to lose weight 2008 Pay kids to eat fruits, vegetables 2013 Just a few examples of increasing number of exciting opportunities to make extra cash!

A complex picture of impacts....  Evidence of reductions in child poverty and behaviour change in short term but largest impact on use of services and least on complex behaviours e.g. smoking  Mixed evidence of impact on ‘final’ outcomes e.g. more years of school but attainment not improved and wages not increased  Differential social impact e.g rates of smoking cessation smaller in low income groups And the conditions may not be necessary  Universal child benefits in UK are associated with:  Reduced child poverty & women spent money on food, children’s clothes & school fees  Universal free Primary education in Botswana resulted in :  attendance rates increasing to 84% and g ender parity at primary school level  Rural Ecuador experimental unconditional cash  positive outcomes for physical, cognitive, and emotional development of children  poorest children had outcomes significantly higher than the control group

And economic incentives breach ethical demands of social justice “Whilst functioning should be held in view by governments capability is the political goal – policies must respect humans’ ability for practical reasoning and choice...once capabilities are assured people must be free to make choices” (Nussbaum)

But are the dots finally being jointed? “There is extensive evidence that connected and empowered communities are healthy communities. Communities that are involved in decision-making about their area and the services within it, that are well networked and supportive and where neighbours look out for each other, all have a positive impact on people’s health and wellbeing. Three million volunteers already make a critical contribution to the provision of health and social care in England. This is a huge asset to our nation’s health”. A Guide to Community Centred Approaches to Health and Wellbeing Foreward: Duncan Selbie and Simon Steven’s Public Health England & NHS England

Presents a “family of Community Centered Approaches……”

Core concepts said to underpin the shift to community-centered approaches in the NHS and local government

Forgive my cynicism but where are these particular dots leading us….. A world of DIY health improvement and inequality reduction

A flavour of the text…. “Building resilience of local [poor] communities” “[Poor] Communities providing renewable energy” “Creating conditions for [poor] community assets to thrive” “LA & NHS important role in building confident and connected [poor] communities” “Celebrate, support and develop volunteering as the bedrock of community action”

Empowerment – to enable self care? Self-efficacy, self-esteem, confidence to change and problem solving skills are all factors in the adoption of positive health behaviours and self care. As well as promoting uptake and widening access to services, community-centred approaches may increase health literacy and give individuals the confidence to engage in their health care. Engaged communities can provide supportive environments and positive social norms that help individuals gain motivation, confidence and skills to self care.213

Empowerment – for local people to solve structural inequalities Communities enabled to identify health and social issues and then devise and implement appropriate solutions The emphasis is on community organising and capacity building, mutual aid based on strong social networks and independent community-led activities. This can result in sustainable social action, tackling the root causes of health and ill-health.

Meanwhile locally……….

Meanwhile nationally and internally……. ‘ Austerity’ is killing people and blighting lives (10,000 additional suicides between In the Europe and the U.S) and decimating public services and spaces (David Stuckler and Sanjay Basu, CNN September 9, 2013) Welfare reform and poverty wages impoverish thousands of people in these same communities and universal health care is under attack Educational reforms creating an instrument to integrate disadvantaged young people into our unequal society and foster conformity rather than 'practice of freedom’ supporting people to ‘deal critically with reality and discover how to participate in the transformation of their world.” And whilst community centred approaches are to increase ‘health literacy’ amongst the disadvantaged, there is nothing here about the need for the professionals who systematically disempower people to “re-examine themselves constantly”

Photography courtesy of Helen Roberts Health is not only the absence of ills But the fight for the fullness of life P iet Hein