Dying for work?

The English have an expression when they are desperate for something, which is “I’m dying for…” as in “I’m dying for a cup of tea”. Health educators have used the double entendre and coined slogans such as “I’m dying for a cigarette”.  With so many people out of work, especially young people, they might be forgiven for saying that they are “dying for a job”. Discussing the determinants of health, as we have been these last few weeks, there’s been general agreement that productive employment is possibly the single most important determinant, as it brings income, purpose, esteem, structure, identity – in short, a package of economic and psycho-social benefits that mean it’s no surprise that the suicide rate for the long term unemployed is many times that of the employed in the global North.   

Two utterly shocking news events of the last couple of weeks have shown that ‘dying for a job’ all too often becomes a reality – firstly the scandal of the situation facing Nepali workers building the football stadia in Qatar, and secondly the plight of migrants escaping from lack of opportunities in Africa, through Libya, and drowning in the Mediterranean.

If the International Labour Organization’s definition of modern-day slavery is used, the Nepalese workers can be described as such. They are reported to have said things like, “ We were compelled to come just to make a living; we’d like to leave, but the company won’t let us”. The Guardian newspaper has stated that almost one worker died every day during this summer (44 workers between 4 June and 8 August), usually from heart attacks or accidents at work. These are largely fit young men but they were reportedly denied water, food, pay, and lived in appallingly squalid conditions. The Nepalese government put the figure of dead at 70 this year and warned that 4,000 deaths could occur before the kick off in 2022. More than a million workers are building the nine new stadia plus the entire infrastructure required to hold the football World Cup. The International Trade Union Confederation has also waded in to defend migrant workers from the Indian subcontinent, warning that 600 deaths could occur annually.

It remains to be seen what will occur as a result of the exposure of the scandal, including the criticism of FiFa, who arguably, in this world where football is so powerful, have the strongest voice. That workers are ‘dying’ to get into the job opportunities perceived as existing in Europe was even more starkly shown by the sinking of a ship carrying migrants earlier this month. That it’s unknown exactly how many people the boat was carrying (500?) is telling in itself, as is the fact that those still unaccounted for originated from one of Africa’s poorest countries, Eritrea. With bad weather and the winter coming on, the boat was joined by about another 350 people who decided to risk the crossing. More women than men are among those who did not survive, with many simply crammed into the boat’s hold, now 47 metres down on the seabed. Cecile Kyenge, Italy’s first and only black minister, commented that it was absurd that survivors of shipwrecks are immediately put under criminal investigation, given that underground immigration is a crime. Kyenge, originally of Congolese nationality, has herself been subjected to all sorts of racist abuse. Take a look at the Open Democracy website for a truly shocking account of what the Minister of Integration has had to endure: http://www.opendemocracy.net/can-europe-make-it/susi-meret-elisabetta-della-corte-maria-sangiuliano/racist-attacks-against-cécile

The writer evokes Franz Fanon’s Black Skin, White Masks to demonstrate the white-gaze that is turned on those without white skins. If a government Minister can face this kind of abuse, there’s little sympathy in many quarters for those drowning in the seas off Italy.

These two incidents, shocking as they are, make the news for a short time. What’s happening in the background however is an ongoing scandal. There have been two more sinkings (and many more fatalities) since the major one hit the headlines last week near Lampedusa, one off Malta and one off the Egyptian shore. There’s been an estimated 19,000 migrant deaths from drowning since 1988 and tens of thousands attempt the crossing each year. The prime minister of Malta, Joseph Muscat, has said that Malta, which picks up many of the struggling migrants, feels abandoned by the EU, which, he says, has talked but taken no action.

Once migrants do make it to a country where there is work they are likely to be in unskilled manual work. Over 900,000 of Qatar’s 1.2 million migrant workers are in the ‘unskilled manual’ category and nearly a quarter of them are from India, with another quarter from Pakistan. These are all countries where work is hard to find, countries which have traditionally exported their labour. What’s unusual about Qatar is that migrant workers make up 70% of its total population, and a staggering 94% of its total workforce. Where labour is plentiful and replaceable, it has not been in the interest of the employing classes to look after that labour particularly well. Industries such as mining, construction, forestry and heavy engineering account for a disproportionate number of deaths. Yesterday marked the centenary (1913) of the biggest mining disasters ever in the UK , where 440 workers were killed in Senghenydd, Wales, after an explosion.  However, behind these major incidents is a steady drip drip of deaths at the workplace that are often unreported. The USA, possibly the country that can most afford a good safety record, still sees deaths in mining of about 35 per year (2012 figures); about 12,000 miners are killed globally each year, much of that figure being made up by China, which although it only accounts for 40% of global coal production, accounts for 80% of global mining deaths. Mining unions in middle-income countries such as South Africa and Chile have urged governments to do more, as the technology is there, but the political will is lacking. Meanwhile, in an interesting and brave move, Ghana has recently expelled illegal Chinese miners.

So work for many is highly injurious to health, as is the search for it, which takes many literally into dangerous waters. We’ve said that work that is decent work, properly paid and safe, can be the biggest factor affecting a person’ health. Where that work is not safe, not decent, or is exploitative, then clearly it has a commensurate effect on health and contravenes basic human rights.

Thinking and teaching about inequalities

We have just welcomed our new cohort of students to our MSc Public Health – Health Promotion. It’s always an exciting time of year, not only seeing how many students we have, but welcoming new faces, new backgrounds and beginning to form a new group of interested minds with interesting experience to bring.

It’s important that we outline, at the beginning, our philosophy of what we think health promotion is all about. Of course it’s a bit too late for students to change their minds at this stage and decide it’s not for them! But we presume too that they have read our websites and have some idea of what we’re about. It’s important for us that students know that they will not emerge as experts on epidemiology, or having detailed knowledge of particular diseases, or knowing about health care systems. What they will come out with is an in-depth understanding of the social determinants of health, of how to tackle health inequalities, and an understanding of the politics of health. In short, they will be clear that there is a great deal of health injustice in the world. A global dimension inevitably emerges from the composition of the class – this year we have students from the UK, Pakistan, Kenya, Uganda, Ghana, Cameron, Nigeria, Sudan. There will be those who know first hand the effects of conflict, and the destruction of primary health care as a result; about the progress towards the Millennium Development Goals; about rural-urban inequalities. Those who have practiced principally in the UK will be able to share their experiences of the changing fortunes and structures of public health in England.

One of the first things we do is to discuss inequalities in health, with a session on the facts – the empirical data on inequalities, together with their possible causes, and then next week, a session on the ethical dimensions of inequalities – the normative aspects, which asks how the world could and should be different. Students from overseas might be surprised to find glaring inequalities in the UK, such as a ten-year difference in life expectancy between certain groups depending on social class and neighbourhood. There are also groups about which detailed data is missing (an interesting fact in its own right), such as travellers and gypsies, who are reputed to have a life expectancy for men of only about 48 years.  And of course some of the ‘developed’ countries have huge levels of inequality - the USA for example, ranks as the fourth least equal society in the world in terms of wealth. (Russia, Ukraine, and Lebanon are above it).

The Millennium Development Goals aimed to decrease inequalities in poorer countries. Failure to meet all the MDGs has led to some analysis of those policies put in place to achieve them and also to what is becoming known as the Post-2015 framework. The Post-2015 Framework emphasizes the importance of decreasing inequality, which is known to have an independent effect on a range of other social variables (see Wilkinson and Pickett 2009 The Spirit Level). More unequal societies appear to experience more health problems, social unrest and economics ills, irrespective of their level of development. Apart from the moral imperatives to tackle inequity, the strategy of improving life chances and wellbeing through addressing inequality is an important plank of policy alongside the other main approaches to development, viz. addressing the situation of only the poorest, and of using a whole population approach.

One of the influential thinkers about development and inequality whose work we admire, is that of the Indian economist and Nobel Laureate Amartya Sen. His book published in 1981, Poverty and Famines: An Essay on Entitlement and Deprivation showed that hunger was not simply because there isn’t enough food. Rather, hunger is caused by inequities in the mechanisms that distribute food. Later, in an article titled ‘Equality of What?’ he developed the ‘capability approach’ which emphasizes the importance of understanding how people in different groups are able to mobilize resources to improve their lives, and of how governments and other policy players can mobilize resources on their behalf. Sen has always declined to specify exactly which capabilities are important, preferring instead to leave this to the exact context of the country in question, in contrast to Nussbaum’s “ten central capabilities”. (These are easily found on Google – see especially her book “Women and Human Development”).  Sen’s stance mirrors the fact that we do not have adequate knowledge of which policies and actions enable people to develop capabilities to control their environments, just as we do not have robust enough evidence of which policies and actions decrease inequalities.

This is the first year that we have our own textbook available, which of course, we have recommended students to buy, as we structured it to follow the modules that make up our Masters’ course. See Dixey, R. (2012) Health Promotion: Global Principles and Practice http://bookshop.cabi.org/default.aspx?site=191&page=2633&pid=2454

Any comments on the book or feedback will be gratefully received – you can email me on r.dixey@leedsmet.ac.uk

Here’s a short quiz that we will be using as a little group exercise. Answers below!

The Quiz: Inequalities - 12 entirely arbitrary questions on inequality compiled by Rachael Dixey, September 2013

1.How many people live below the poverty line globally? 

2. Which African country is at the bottom of the Human Development Index?

3.What’s the average life expectancy in Chelsea and Kensington (England)?

4.What’s the average life expectancy in Glasgow city (Scotland)?

5.Which group in the UK is widely agreed as being the most ‘at risk’ of health problems and dying younger than any other group?

6.In the USA black people make up 12% of the population. What proportion of new HIV cases are black people?

7.How many people globally live in slums?

8.What proportion (percentage) of total wealth do the poorest 50% of the American population have?

9.Out of 141 countries, the U.S. has the 4th-highest degree of wealth inequality in the world. Which three countries have more wealth inequality?

10.Malnutrition (measured by stunting) affects what proportion of children in developing countries?

11.How much does Wayne Rooney make per day?

12.What’s the average wage in the UK?

Answers:

1.How many people live below the poverty line globally?  1300 million

2. Which African country is at the bottom of the Human Development Index? Niger

3.What’s the average life expectancy in Chelsea and Kensington? 82.4 years

4.What’s the average life expectancy in Glasgow city? 72.9 years

5.Which group in the UK is widely agreed as being the most ‘at risk’ of health problems and dying younger than any other group? Gypsies and travellers

6.In the USA black people make up 12% of the population. What proportion of new HIV cases are black people? 50%

7.How many people globally live in slums? 800 million

8.What proportion (percentage) of total wealth do the poorest 50% of the American population have? 2.5%

9.Out of 141 countries, the U.S. has the 4th-highest degree of wealth inequality in the world. Which three countries have more wealth inequality? Russia, Ukraine, and Lebanon.

10.Malnutrition (measured by stunting) affects what proportion of children in developing countries? 32.5%

11.How much does Wayne Rooney make per day? £28,571

12.What’s the average wage in the UK? £26,000

Social determinants or social determination of health?

The Commission on the Social Determinants of Health quite rightly turned the focus on the ‘causes of the causes’ and gave a boost to those of us in health promotion who had always called for a sociological analysis of poor health. I have been wondering recently whether the radical intent of the CSDH has been diluted - a tendency affecting any radical initiative.  The Commission was headed by Sir Michael Marmot, a medical doctor, and some have argued that the reason the report was taken so seriously was because it had the legitimacy afforded by its provenance within those medically trained. (Fran Baum, as one of the Commissioners, was the most notable health promoter. ) Following this line of thought, it could be argued – and it has been suggested by some -  that the CSDH shows continuity with the biomedical approach to disease and ill-health, showing the continued battle between the social and medical models of diseases, and the dominance of the latter in the discourse. Certainly reading various national government reports and those from the UN there is a real emphasis on the proximate causes of ill health, those related to individual lifestyles, ‘choices’ and ‘risk factors’. Mainstream epidemiology can often, perhaps unwittingly, reinforce the dominant discourse, and also, of course, the further upstream, to more distal factors, the harder it is to show the precise relationship between causes. Thus the ‘causes of the causes’ discourse has perhaps become rhetoric.

The dominance of the neo-liberal agenda and the collapse of some of promising challenges to it do not lead to great optimism for a real change to the power structures that create health inequalities. There seems to be a great disjuncture between the ideas embedded within emancipatory health promotion, with its emphasis on empowerment and people taking control of the factors determining their health, and the reality on the ground facing those experiencing health inequalities. Emancipatory health promotion has citizenship and personal agency at its heart, as it is all about individuals and communities being able to change the material circumstances in which they live. Emancipatory health promotion thinks about the social determination of health, not simply the social determinants of health. How can health be socially determined by ‘ordinary’ people, those that professionals tend to call ‘lay’ people? The social determination of health requires citizens to have a voice, power, skills and to be able to operate within the kind of state that welcomes such involvement. This is clearly not the case in so many countries today and certainly not in some of the worse cases, such as Syria, and (having just returned from Eastern Europe) not in the case of minorities such as gypsies and Roma people. Despite the focus on ‘assets’ within the health promotion discourse, many groups have neither a voice or the ability to take collective action.

Our Centre for Health Promotion Research has always followed its principles by focusing on inequalities in health, enabling ‘lay’ voices, and involving lay people as fellow researchers. My colleague Professor Jane South has recently edited a special edition the Perspectives in Public Health journal, on health trainers. The Centre for Health Promotion Research has been involved in the evaluation of health trainers since the inception of this new public health service in 2005.

The special edition carries a paper by Jane and Leeds Met colleagues Judy White and Jenny Woodward, on how health trainers can tackle health inequalities. Jane South and Dr. Shelina Vishram provide an editorial on the whole concept and evidence base for health trainers. This journal edition is unique in also including opinion pieces from a health trainer and a service user, bringing a truly bottom-up perspective to academic publications. Although the idea can appear to mimic the use of individualistic, ‘lifestyle’ trainers, the reality is that the Health trainers programme is a fascinating example of community empowerment and is a refreshing approach to tackling health in communities facing damaging social conditions.

See:

http://rsh.sagepub.com/content/133/4.toc

Health inequalities mean that people bear the scars of social conditions in their bodies and minds. ‘Embodiment’ is an outward show of power differentials, though those scars are often carried internally, in the form of depression, despair and low expectations. To be active citizens means that people have the chance to develop their own meanings of health, and also not only to respond to public health policies, but also help to create them. The health trainers programme provides one framework by which such active citizenship can be fostered. There are other examples from around the world, and they need to be heard about. Moving towards the social determination of health has to be high up in our debate within the health promotion community. Perhaps it could be the focus of the next symposium, conference, web discussion, journal edition, so that the ‘causes of the causes’ discourse does not become tamed, that the momentum of the CSDH is not lost, and that the principles, methods, and practice of socially determined health can be shared.

Health promotion, statistics, politics

As health promotion is inextricably linked with tackling inequalities in health, the role of statistics in describing inequalities is vitally important in enabling us to see those patterns of health injustice that we are so concerned to eradicate. Clearly, our work depends on having reliable data. Equally clearly, many governments and agencies have a vested interest in not providing that data, or in presenting statistics in the best light. Statistics are thus political. One of the books from my own undergraduate days was called something like ‘How to lie with statistics’ and I suspect it’s still in print. Statistics provide the bedrock of understanding,  enabling us to see what’s happening now and what direction we want to go in for the future. For example, the Radical Statistics group has as their slogan, “Using statistics to support progressive social change”  See: http://www.radstats.org.uk/journal/issue108/

It’s therefore alarming to see that the UK government is considering, as part of its cuts programme drawn up by the Office of National Statistics, to halt the publication of politically sensitive official statistics on areas such as smoking, drinking, teenage pregnancy and infant mortality. The ONS is considering cuts to the ‘wellbeing programme’ which includes data on inequalities. It’s also considering the scale of the official crime survey. At the moment, these cuts are merely being talked about, but faced with the demands for savings being made across government departments, it would not be surprising if they were enacted. It’s proposed to stop all statistics on smoking and drinking and also under threat are data on cancer survival rates, analysis of healthy life expectancy figures, and reducing the causes of death data to the legally required minimum. Many of the issues under threat are those where the UK fares badly in comparison with other European countries.

It’s only when good quality quantitative research is carried out that the scale of certain health issues can be fully outlined and explained. Thus the first comprehensive report of its kind, on violence against women, recently published by the WHO, shows comparative data from 81 countries. The director–general of the WHO, Dr. Margaret Chan commented, “These findings send a powerful message that violence against women is a global health problem of epidemic proportions. We also see that the world’s health systems can and must do more for women who experience violence”. Although we already know this, the fact that we have the data means that we have a foundation, a line in the sand, from which to advance argument and action.

The data from this work, Global and regional estimates of violence against women: Prevalence and health effects of intimate partner violence and non-partner sexual violence – see http://www.who.int/mediacentre/news/releases/2013/violence_against_women_20130620/en/index.html

by Dr. Claudia Garcia-Moreno and Professor Charlotte Watts, show that 45.6% of women in Africa, 40.2% in South-East Asia, 36.4% in the Eastern Mediterranean, 36.1% in the Americas, 27.9% in the Western Pacific and 27.2% in Europe will suffer physical or sexual violence at some point in their lives. That’s a third of all women worldwide – 35.6%. Of all those who experience violence, 42% sustain injuries that bring them to the attention of healthcare staff. Most of this violence comes from women’s partners/husbands – 11.9% of African women are sexually attacked by a non-intimate partner, 12.6% in wealthy countries.

The authors call for the numbers to be a wake up call. It makes the point that it’s only when numbers are collected that we can see progress in the rights of particular groups. For example, the Labour Force Survey in the UK has reported recently that more disabled people are likely to be employed today than they were ten years ago. Of course we have to be suspicious of how ‘disability’ is defined and whether there are changes in that definition, but it seems to be the case that the gap between non-disabled and disabled people in employment has shrink by 10% in the last 14 years. Universities are required to collect data on the characteristics of graduates and their ‘first destination employment’ and these show that around 40,000 ‘disabled’ people graduate each year from UK universities and of these 60% find work within six months, which is about the same proportion as their non-disabled peers.

The Radical Statistics Group’s journal is a useful source for critical discussion of why and how certain statistics are collected, and of debate about how to measure key concepts such as wellbeing.  See for example, Carr-Hill’s paper on ‘Measuring Wellbeing’:

http://www.radstats.org.uk/no107/Carr-Hill107.pdf

Another recent paper unpicks the fallacy that schizophrenia rates are constant across societies, and relates them to the political structures of various countries: 

http://www.radstats.org.uk/no107/Saunders107.pdf

Of course, statistics are a starting point and it’s then necessary for social science to make sense of those statistics and come up with explanatory frameworks. Amongst my PhD students for example, I have one looking at male sexuality in Zambia, particularly in relation to the use of microbicides to prevent HIV (with Professor Alan White, an expert in men’s health) and another looking at sexual abuse of orphans and vulnerable children in Botswana (with Professor Nick Frost, an expert in child protection).  Both will emerge with theory to explain the statistics behind the practice and attitudes that can lead to gender-based violence.

In summary, statistics and epidemiology make a key contribution to the practice of health promotion and we have to be vigilant about how such data is collected, constructed and used. Construction of statistics, what is collected and how, are political acts, just as health promotion activity to tackle inequalities, is a political act.