Mental Health and Inequality


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  • The growing influence of psychological explanations is evident in the fields of health, education, crime, employment, social cohesion etc., as well as in wider debates about economic growth, recession and market failure.Wider recognition of the profound importance of mental health and wellbeing to life chances and life outcomes - across many different domains
  • Recent years have seen a welcome recognition of the non-material dimensions of poverty – in the human development initiative and other efforts globally to capture the ‘missing dimensions of poverty’ – to draw on the testimony of people living in poverty. Issues of dignity, affiliation, meaning and autonomy – there’s a difference between starving and fasting – Sen/Zaveleta etc ‘ability to go about without shame’ This is part of a broader critique of materialism – an undue focus on income and wealth - wellbeing does not depend solely on economic assets, as Sen has observed. The market does not have a monopoly on meaning.What’s becoming clear is how understanding mhdeepens our understanding of the social determinants of health – richer picture – what Angie Hart has called ‘an inequalities imagination’ - understanding the non material dimensions of deprivation - Impact of Being made to feel of no account... on relationships, sense of meaning and purpose, opportunities to contribute and autonomy 
  • This interest in the social, emotional and spiritual impact of poverty and inequity has deepened understanding of the social determinants of health International comparative studies suggest that status – the respect we receive from others – control - influence over the things that affect our lives/ - and relatedness - affiliation, sense of belonging - are universal determinants of wellbeing and we need to pay more attention to the impact of injuries to these needsThe freedom to live a valued life depends on more than moneyWe need to pay much greater attention to the factors that injure these needs and to the impact of injuries to these needs – lack of status, lack of control, lack of affiliation – primary causes of stress - undermining what Sen has called ‘freedom to live a valued life’.But in these accounts – the distribution of economic assets is still of fundamental importance. There’s a link between living conditions and dignity. The idea of justice is paramount. What’s fair?And that’s my first problem with the assets agenda – what’s the analysis of injustice – who and what creates inequalities in Scotland? How we answer that question will determine where we focus our energies.What’s the relationship between economic policy and inequality?
  • We see from this very powerful meta analysis based on around 145 studies the importance of social support/social integration on mortality riskThe size of this effect (someone to turn to, sense of belonging) is comparable with quitting smoking and it exceeds many well-known risk factors for mortality (e.g., obesity, physical inactivity)Received support is less predictive of mortality than social integrationfacilitating patient use of naturally occurring social relations and community-based interventions may be more successful than providing social support through hired personnel
  • What’s come from epigenetics is a body of evidence on how :Social Processes can influence gene functionWhat Clyde Hertzman has described as experience that gets under the skin and alters human bio-developmentIn other words: systematic differences in social experience lead to different bio-developmental states the differences are stable and long-term; they influence health, well-being, learning, and/ or behaviour over the life courseWe know from International comparative studies that status – feeling respected – control - influence over the things that affect our lives/ - and relatedness - affiliation, sense of belonging - are universal determinants of wellbeingWhat’s emerging is the importance of paying much greater attention to the factors that injure these needs and to the impact of injuries to these needs – what epigenetics demonstrates is that social determinants stretch back in time
  • In a related development, this fascinating study shows how social risk factors outweigh clinical risk factors – raising important questions about the investment of resources – low birth weight and prematurity – vs support for single mothers for example.Population attributable riskrelative importance of early social and biologic risk factors in predicting poor health and education outcomes in a large birth cohort of children followed up for 19 years.Far more infants fall into high-risk social categories than fall into similarly high risk biomedical categoriesPredictors were 3 routinely assessed biologic risks (birth weight, gestational age, and Apgar score) and 3prominent social factors (mother’s age, parent marital status, andsocioeconomic status). Outcomes were childhood hospitalizationand passage of a required high school examination.extensive documentation of socioeconomic effects on adult and child health. Teen motherhood,4 parental marital status,5 and neighborhood of residence6 also strongly influence child health and well-being.Together these findings suggest that healthcare providers should assess social factors at birth as carefully and systematically as traditional biomedical measuresuse of biologic risk criteria alone misclassified as low risk 65% of the children with an increased likelihood ofsubsequent serious health or scholastic problems.
  • There are important social values in assets based approaches – respect for people’s strengths, resourcefulness, creativity - the power of the human spirit, the power of collective action – these values have a long history in Scotland.  My problem is with what happens: when these values are separated from an analysis of social justice and human rightswhen assets approaches are used to suggest that Scotland’s problems are largely psychological and cultural when dependency and need are stigmatisedwhen assets approaches are used to attack public services - collectively owned assetswhen hard questions about competing interests, corporate power and redistribution – are avoided
  • A recurring assertion from the assets movement is that tackling inequalities in Scotland has failed – what we’ve tried, though well meaning, hasn’t worked.But what is it exactly, that’s been tried? It’s true that there’s been huge effort to address symptoms –- but material inequalities have increased. It’s surely no surprise then that health and other inequalities have got worse. And this is in spite of that OECD figures show that public services reduce inequalities in the UK more than almost anywhere else, and this impact has increased over 2000’s. Against all the odds, public services have improved their impact on reducing inequalities.In the past decade, richest have seen sharp increase in income. For the rest of us, distribution has changed little. This means the sharp inequalities of the Thatcher years remain - and the problems associated with them – exacerbated by what’s happening at the top.Income inequality has widened since devolution. It’s well above the OECD average. Of course income inequality isn’t the only driver of other inequalities – but isn’t it generally implicated? A deepening understanding or an alternative explanationLet’s look again at some of the indicators:and, up to 2004/5, notable reductions in poverty and child poverty, which have since stalled
  • UK as a whole - The gini co efficient is currently near to its highest point since 1961.The income inequality gap has widened since devolution due to an increase in the income of the top 30% - while the income of the bottom 30% has remained static. 1/5 of pop share 6% of Scotland’s income1/5 share 45%Urgent need to reflect on what this means.
  • It’s not inevitable – the UK had falling inequalities from 1945 until mid 1970’s.But In the eighties, UK inequality rose more than in the USOECD (Divided we Stand 2011) UK Transfers and taxes have become less redistributiveUK Benefits have become less redistributive – declining benefit amounts and more people working at low wage jobsBritain has some of the lowest social mobility in the developed world - the OECD figures show our earnings in the UK are more likely to reflect our fathers' than any other countryTackling Poverty Board – quote – too many people for too few jobs; too many skilled people for available skilled jobs – greater level of honesty about this??Scotland is doing marginally better than the UK as a whole – but only marginally
  • Britain has some of the lowest social mobility in the developed world - the OECD figures show our earnings in the UK are more likely to reflect our fathers' than any other countrySo what hasn’t worked is that millions have been poured into tackling the symptoms of inequality – not inequality itself.These figures are about assets – the distribution of assetsStill, while communities are reflecting on their ‘inner and innate resources’ and ‘starting from what they have, rather than what they lack’, they won’t be asking questions about the wealth gap in Scotland
  • What’s the cause of these inequalities? A culture of dependency – engendered by the public sector and the welfare state?The assets agenda stigmatises dependency and need.It implies that take up of welfare is driven not by market failure, but by certain character traits – dependency and coping styleBut isn’t dependency a feature of being human, rather than a moral failing? As the disability rights movement has argued, dependency is a gift, reminding us of our humanity. And isn’t the whole dependency discourse also a distraction? In material terms, it is the rich who are most dependent, not the poor – fiscal and economic legislation that support the privileges of the rich – tax, inheritance, property, capital gains, private schools. The rich are utterly dependent, hence the howls of outrage when there’s any attempt to reduce their benefits.... In Scotland, as elsewhere, the poor live much more lightly on the exemption on private education – enjoyed by the 7% of children who go on to become 70% of high court judges, 1/3 of MPs, 50% of medical consultants, 50% of FTSE Chief Executives...
  • Poor mental health often reinforces inequalities, because those who are most disadvantaged are most likely to experience both mental illness and poorer mental wellbeing. So, mental health is a consequence and a cause of inequalities and a crucial factor in understanding the limitations of focusing on ‘health behaviour’
  • Focus on psychological explanations abstracted from:Contested nature of understanding of mental distress and diagnostic categoriesStrong social gradient in mental illness and even stronger in recovery – i.e. Greatest inequalities are in duration not incidenceUsed to explain ‘health behaviours’ and reinforce behaviourist approaches, rather than deepen understanding of structural inequalitiesConnecting with history of struggle – SUMP – bringing together critique of psychiatric services and analysis of wider determinantsScotland pioneered user action in the United Kingdom. In 1971, SUMP, The Scottish Union of Mental Patients, was the first recorded mental patients' union. By 1974 there was a Federation of Mental Patients Unions. Now Glasgow mental patients lit the fire that became the Survivors Speak Out movement. Two of the service users, Tam Graham and Charlie Reid, became founding members of Survivors Speak Out in 1986. Source: The Survivors’ History Group Pageant of Survivor History
  • This also involves understanding the wider structural factors that influence individual mental illness journeys – individual and collective experiences of pain, anger, demoralisation, despairHow we explain inequalities is a mental health issue.... Fix the individual? Or fix society?
  • Mental health problems are of course correlated with parental incomeWhat more than parental incomematters for adult outcomes?
  • Consistent parenting in situations of extreme inconsistency and stress
  • Those who are well resourced are more likely to have better mental healthMarked socio-economic gradients in social and emotional adjustment across childhood, with no evidence that the gradients narrow as children get older. SES patterns anxiety, aggression, confidence, emotional and cognitive development, concentration and hence readiness for schoolFor those who are poor, the effects of material disadvantage are only partially offset by better emotional and cognitive skillsTake the impressive results of pre-school programmes e.g. Perry High Scope – among deprived children, those on the programme did very much better than those not on the programme – but better off children had better outcomes without any programme at all
  • Those who feel they are finding it difficult or very difficult to live on their present income are more likely to have significantly lower wellbeing than those who are comfortable or coping
  • Of course there are issues raised by the assets movement that need addressedThere’s an important debate to be had about transforming the relationship between public services and people who are disadvantaged The current welfare system is inadequate, demeaning and needs changed. But we should be clear that this is a debate about social justice and human rightsOne Scotland contains two entirely different worlds – one among the most privileged in Europe – the other experiencing outcomes that are shaming and shameful. Is this a result of public health focussing on deficit? Blaming the public sector – the public services that are both picking up the pieces and picking up the tab – is unfair and a dangerous strategy. It lets unregulated free market capitalism off the hook.And it reinforces the neo liberal attack on the values of collective responsibility, pooled risk and universal services
  • Deep seated problems persist not because communities have unacknowledged assets but because material assets are so unequally shared – and everything that flows from thatBottom quintile have 6% of Scotland’s income; top quintile have 45%. This pattern of distribution isn’t accidental. And it’s not inevitable.Talking about redistribution is unavoidable unless we abandon the idea of a fairer ScotlandUS story: when liberals turned their backs on unions — when they put “identity politics over economic justice” Richard Freeman, a Harvard economist, has estimated that the decline of unions explains about 20 percent of the income gap the majority of increased corporate profits between 2000 and 2007 were the result of “reductions in wages and benefits.”. At the same time labor has been in decline, the power of shareholders has been on the rise.
  • There are some urgent and difficult conversations about inequalities in wealth in Scotland, and the policies and practice that support this. Questions about the legacy of an unfettered free market. About who benefitted in the boom years, at whose expense, and why? The levels of regulation needed to ensure that corporate interests don’t take precedence over social goals – health, justice, environment, welfare of children. The levels of regulation needed to achieve the Scottish Government’s solidarity target.As it stands, the focus is on ‘radical change in the design and delivery of public services’, rather than on a radical change in economic and fiscal policies that in Scotland, as elsewhere, ‘sanction gross inequalities and obscene greed’As Colin Mair and colleagues have shown, the greatest challenge facing public services is to combat the negative outcomes for individuals and communities arising from deep-rooted inequalities, outcomes that absorb around 40%+ of local public service spendingThey are used to account for ‘health damaging behaviours’, not to deepen understanding of structural inequities
  • The language of assets includes some themes with a long history in ScotlandIn the past, these have been linked to an analysis of power and the struggle for social justice – we need to renew those links, that solidarity – where are unions in the assets movement for example?Never been better time, growing public distaste for the scale of inequalities, we’re seeing new routes to resistance and new forms of expressing solidarity – from campaigns against the cuts to organising for community ownership – new activism bubbling up - Firmly linked to the current distribution of wealth in Scotland and the policies and practice that support this.Solidarity with wider struggles for social justice – There’s no single model or solution – but there are some non negotiable values
  • These themes have led to calls for a return to the social – Which raises questions about what protects the social – the role of Equity and Social Justice – but also the nature of the relationship between professionals and disadvantaged communities1.Social justice 2. Opportunities for advancement 3. Financial resources 4. Access to and quality of work (Christian Kroll – four priorities for social democratic priorities)
  • Community renewal bill – what’s it for?Should include measures of success related to equity/fairness – economic and political justiceLinked to, not separate from, measures to revive local democratic structures and faith in them – danger of assets movement rubbishing local democracy and supporting public disillusion and apathyGenerating more resources – side bar – land tax, minimum incomes, campaign for living wage/ issues of income are inseparable from addressing paid/unpaid work Much talk of how bill will re-dress balance between public sector/local government and communities – but what about balancing the voice of communities and the power of big business – transfer of assets to private sectorHow will we know bill has been a success – something about distribution of assets of wealth and power?
  • Mental Health and Inequality

    1. 1. Mental health and inequalities: what’s happening to thesoci(et)al determinants of health? Lynne Friedli Socialist Health Association Health Inequality in England and Scotland Edinburgh 9th June 2012
    2. 2. The paradox.... As material inequalities grow, the pursuit of non material explanations proliferatesPicture source: Sleeping with spirit #2 Bradley Guiboche courtesy determinants?whats happening to social
    3. 3. I own, therefore I am.... Source: Banksie – grafitti, London, Englandwhats happening to social determinants?
    4. 4. Nussbaum’s capabilities Life Bodily health Bodily integrity Sense, imagination, thought Emotions Practical reason Affiliation Other species Play Control over environment: a) Political b) Material Source: NussbaumWhat can capabilities contribute?
    5. 5. Commission on the Social Determinants of Health Some living conditions deliver to people a life that is worthy of the human dignity that they possess, and others do not. Dignity can be like a cheque that has come back marked „insufficient funds‟ Martha Nussbaum Freedom to • material requisites live a valued life • psycho-social (control over lives) Amartya Sen • political voice (participation in decision making) Status Control Relatednesswhats happening to social determinants?
    6. 6. Meta analysis: comparative oddsof decreased mortality The relative value of social support/ social integration whats happening to social determinants? Source: Holt-Lundstad et al 2010
    7. 7. Social Epigenesis: biological embedding * In 2012 there‟s no talk of getting out. It‟s more important to be somebody where they live, than to be nobody outside. Status and respect are valued above everything Lisa McKenzie 2012 Status Control Relatedness “The most effective interventions will require a deeper understanding of how common social risks “get under the skin” to affect human biology and influence the causal pathways to disease”whats happening to social determinants?
    8. 8. Relative importance of early social and biological risk factors (PAR %) ag Social risk factors e Clinical risk factorswhats happening to social determinants? Source: Jutte, Brownell, Roos, Schippers, Boyce, Syme, 2010
    9. 9. Reasons to be concerned? I knew about inequality, how unfair life could be. But I thought it was something to do with me, with my family, what we‟d done..... Lisa McKenzie ‘Thinking • allowed’ An analysis of injustice? Who/what creates inequalities? • Are Scotland’s problems psychological & cultural? • Stigmatising dependency and need? • Avoiding the hard questions?whats happening to social determinants?
    10. 10. Myth No 1: „What we‟ve tried, though wellmeaning, hasn‟t worked....‟ Nearly a third of workers in Scotland - 4% of public sector 28% of private sector - earn less than a living wage (£7.20 perwhats happening to social determinants? hour) (ASHE 2010)
    11. 11. Trends by political leader or ‘30 years of brutal global capitalism’Source: Brewer M, Goodman A, Muriel A, Sibieta L. Poverty and Inequality in the UK:2007. Institute of Fiscal Studies, London.whats happening to social determinants?
    12. 12. UK Inequalities well above OECD average„If the rich could hire others to die for them, we, the poor, would allmake a nice living‟ 0.42 Fiddler onTrends in inequality of disposable income the Roof 0.40 Gini coefficient of income 0.38 0.36 inequality 0.34 0.32 0.30 0.28 0.26 0.24 0.22 1975 1980 1985 1990 1995 2000 2005 2010 Source: OECD 2011 Divided We Stand whats happening to social determinants?
    13. 13. Persistence of intergenerational earningswhats happening to social determinants?
    14. 14. Ideas that massacre the welfare state: Myth No 2: ‘dependency’ „an assets rather than a deficits approach to tackling poverty and inequality..... moving from welfare to wellbeing and from dependency to self determination.‟ Scottish Government 2011 • Deficit approach of public services A man goes to work full time and still has to get the social • Culture of dependency because wages is so low; folks haven‟t a clue how the he needed that money to rest of us are having to keep his kids make ends meetwhats happening to social determinants? Source: Dundee Equally Well/ONS Fairness & Wellbeing
    15. 15. Holding on to an inequalities analysisImage: Banksy; whats happening to social determinants?
    16. 16. Declaration of Intent of the Mental Patients Union•We proclaim the dignity of societys so-called mental patients•We challenge repressive psychiatric practice and its ill-definedconcepts of Mental illness•We state that the present appalling situation in Mental healthprimarily arises from the acute problems inhousing, unemployment and social inequality•Mental patients in determinants? are treated as people with no whats happening to social our society lynne.friedli@btopenworld.comhuman The Survivors’ History Group Pageant of Survivor History Source: rights
    17. 17. Mental health and deprivation Not ‘every family in the land’ Findings from 9 large scale population based studies: • Material and relative deprivation • Childhood socio-economic position • Low educational attainment • Unemployment • Environment: poor housing, poor resources, violence • Adverse life events • Poor support networks (Melzer et al 2004; Rogers & Pilgrim 2003; Stansfeld et al 2008; APMS 2007) Cycle of invisible barriers:whats happening to social determinants? • Poverty of hope, self-worth, aspirations
    18. 18. Explaining the social gradient: mental illness journeys... Most of the experiences that cause mental distress are directly linked to a lack of money....... powerlessness linked to poverty Peter Campbell Beyond the Water Tower • Adverse childhood experiences/stressful life 2005 events • Racism and other forms of discrimination • Contact with criminal justice system • Socio economic status – parental income, tenure, education, occupation • Institutional care inwhats happening to social determinants? childhood
    19. 19. Mental health of children by parentalincome 25% Percentage of children with a mental disorder 20% 15% 10% 5% 0% under £100-£199 £200-£299 £300-£399 £400-£499 £500-£599 £600-£770 Over £770 £100 Gross weekly household income Source: Meltzer et al 2000 Mental health of children and adolescents in Great Britainwhats happening to social determinants?
    20. 20. Mental health and the social gradient “Infants develop the attachment behaviours that optimally enhance their survival in their own characteristic environments.” Crittenden, 2000 Source: Fair Society, Healthy Lives: Marmot Review 2010whats happening to social determinants?
    21. 21. Rates of poor social/emotional adjustment by father’s social class at birthwhats happening to social determinants?
    22. 22. Low levels of (adult) mental wellbeing by concerns about income 45% Source: NW Wellbeing Survey Percentage with a low level of wellbeing 40% 35% 30% 25% 20% 15% 10% 5% 0% Living comfortably on Coping on present Finding it difficult on Finding it very difficult present income income present income on present incomewhats happening to social determinants?
    23. 23. Austerity rhetoricwhats happening to social determinants?
    24. 24. Austerity solutions....whats happening to social determinants?
    25. 25. Big fish/little fish: questions of power are unavoidable Source: happening to social determinants?
    26. 26. whats happening to social determinants?
    27. 27. Return to the social.... And what I shall endure, you shall endure For every atom belonging to me as good belongs to you...... Walt Whitman Solidarity Equity and Freedom and the Social to live a core Justice valued life economy I am, because we are...whats happening to social determinants?
    28. 28. Select bibliography Beckfield J and Krieger N (2009) Epi + demos + cracy: A Critical Review of Empirical Research Epidemiologic Reviews 31(1):152-177 Birn Anne-Emanuelle (2009) Making it politic(al): Closing the Gap in a Generation: health equity through action on the social determinants of health Social Medicine 4:3 p166-182 Christie C (2011) Report on the Future Delivery of Public Services by the Commission chaired by Dr Campbell Christie CSDH (2008) Closing the gap in a generation: health equity through action on the social determinants of health Final Report of Commission on Social Determinants of Health Geneva: World Health Organization. Friedli L (2009) Mental health, resilience and inequalities WHO Europe London/ Copenhagen Nussbaum M (2011) Creating capabilities: the human development approach Belknap Harvardwhats happening to social determinants?
    29. 29. Select bibliography Mair C, Zdeb K and Markie K (2011) Making better places: making places better the distribution of positive and negative outcomes in Scotland Improvement Service making-places-better-distribution-of-positive-and-negative-outcomes- in-scotland/ McKendrick et al 2011 Poverty in Scotland Child Poverty Action Group People First Scotland report.pdf OECD 2011 Divided we stand: why inequality keeps rising,3746,en_2649_33933_49147827 _1_1_1_1,00.html Stuckler D, Basu S, Suhrcke M et al (2011) Effects of the 2008 recession on health: a first look at European data The Lancet Vol. 378, Issue 9786, Pages 124-125 happening to social Board: A Summary of the Evidence Tackling Poverty determinants?
    30. 30. whats happening to social determinants?
    31. 31. Variation of growth of genetically identical marbled crayfish in an aquarium: how well would epidemiologists be able to predict outcomes? Source: Davey Smith G (2012) picture: Journal of Experimental Biologywhats happening to social determinants?