The New Victorians, and the Public Health Dichotomy

31 March 2014 by Tania Browne, posted in policy and politics

A family living in poverty, from the Salvation Army archive SlumXpoverty.jpg

We've talked about this before, and it's not going to go away any time soon. Epidemiology seems to be falling further and further from its public health remit, and it's time for us to claw our way back. A news report I saw today convinced me that we need this now more than ever.

Lord Warner, a former Health minister under the Blair government, has co-written a report for the centre right think tank Reform saying that the NHS is unable to cope with the workload placed on it, that there is no money from the tax system to give it more and that we should introduce a flat user's fee of £10 per month. He also pointed out, in a slot on the BBC's Breakfast news programme, that it may make people who smoke, drink and eat unhealthy diets take responsibility for themselves and mend their ways. He didn't waggle his finger at the camera like a disappointed headmaster, but he might as well have.

Now, I am a left leaning woman who strongly believes in the responsibility of governments to promote equality and give a helping hand to the poorest in society, so as an idea this offends me anyway. A tenner from the single mum of three struggling on benefits and a tenner from a banker who drops that on a commute coffee every couple of days are two different things. But this is a blog about epidemiology and health, so as such I'll leave that aside and focus on the Victorians. As you do.

For British people, learning about the Victorians in particular is a right of passage. We like to dwell on our past glories, but at the same time feel guilty that it was all a bit imperialist.

As a child I learned about the great Victorian inventors, engineers and thinkers. The Isambard Kingdom Brunels, the Charles Babbages and the Florence Nightingales - though sadly with the latter, the focus was always on the "caring nurse" rather than the brilliant campaigner and statistician whose infographics did so much to improve hospital hygiene. We also didn't skimp on the terrible poverty of the Victorian age - the slums, and the child labour. What was made less clear to us as schoolchildren was the direct link of industrialisation, which lead to the rich getting richer and the poor living in increasingly desperate circumstances. Benjamin Disraeli's 1845 novel Sybil put it this way...

"Two nations between whom there is no intercourse and no sympathy; who are ignorant of each other's habits, thoughts and feelings, as if they were dwellers in different zones or inhabitants of different planets; who are formed by different breeding, are fed by different food, are ordered by different manners, and are not governed by the same laws ... THE RICH AND THE POOR."

Did the Victorian middle classes feel guilty that they were getting rich by doing a disservice to the poor? Like heck they did. Although there were some brilliant social campaigners and reformers in the later Victorian age, theirs was an uphill battle. The prevailing attitude of this most "Christian" of all societies was that if the poor were poor, they had only themselves and their indolence to blame. Poverty was reinvented as a moral failing so that the wealthy could continue to feel OK about themselves and the huge inequalities in Victorian society.Thus, we had the dreaded workhouse where the poor would be forced to do pointless hard labour for a daily crust, we had factory owners who gave their workers decent housing and a way out of the slums - but often only on condition that they submitted to strict rules that looked out for their "moral values" and treated them like children who knew no better.

In short, if the Victorian poor were poor, it was their fault. Nothing to do with the towns they lived in, the factories they worked in or the lack of regulation for the gin palaces they frequented to "escape" from just how awful their lives were. It was their own fault for not being clean enough, not working hard enough, not having the "moral fibre" to live a good life - not pulling themselves up by their boot straps.

How times have changed.

Because we all know that if you get lung cancer, you're stupid and should never have smoked despite the ubiquitous advertising that told you how cool it was for a good 30 years. If you're obese, it's your own lack of control and nothing to do with the advertising of processed snack foods, for your "convenience" in your hectic life, everywhere you go. And nothing whatever to do with the fact that you live in a city full of traffic and the nearest green space is a bus ride away, you fear being hit by a lorry on your bike, and your local council had to close the leisure centre. If you drink then it's your own fault you're getting a liver condition, not the supermarket deals on cheap booze and the idealisation of alcohol as something to turn you into a social superstar.

So yes, Lord Warner. We deserve to be made to pay for our bad lifestyle choices, and maybe that will help us to gain some moral fibre and pull ourselves up by our boot straps.

But wouldn't it be so much better to fund our struggling NHS by closing down the tax loopholes that make international chocolate peddlars such vast profits? The corporate avoidance schemes that allow breweries to sell those cans of lager so cheaply in the first place? Wouldn't it be better, not only to tell people what to do to lead a healthier lifestyle, but also to, you know, do something to actually make that the easiest choice  for them?

We need a modern day Bazalgette, with the audacity to rip cities apart. Not to make sewers, but to make traffic free areas, open spaces, cycleways and places to walk without fear of being run over. We need the deduction work of John Snow to figure out what's actually stopping people, then taking the proverbial handle off the pump. We need modern Joseph Rowntrees to step forward and provide some cash to help people escape from their poverty traps - whether individuals or corporations.

But it's so much easier to blame people's poor health on some kind of individual moral failing, to say "if only they tried harder."


Isn't it?

One Response to “The New Victorians, and the Public Health Dichotomy”

  1. Merkin O'Grady Reply | Permalink

    Hmmmm. Afraid I shall have to respectfully disagree with much of this.

    Not all of it though. I quite agree that the Victorians treated the poor like dirt. And I'm all for encouraging public transport, keeping nice green spaces and not closing leisure centres.

    I also quite agree that a tenner a month fee for using the NHS is an unfair flat tax.

    Though I must say that in the (sadly various) English cities I have lived in over the past few years I wasn't aware of any leisure centres having been closed - and I think I would have noticed, having always been involved with a local political party.

    A poor sample and a minor point perhaps. But again, in none of the places I lived, including a couple of big grimy ones, it wasn't particularly difficult to pull my trainers on and go for a jog. In fact, on reflection, it wasn't at all difficult for a person to go out and get a bit of exercise if they so chose. Plenty of opportunities. So not really a minor point after all - I don't accept that we are all in need of some courageous lefty government to come and change everything for us here: it's already there. It could always be better, but what we have is largely pretty good.

    Here's another one. Probably every day I went in my local Tesco, past the stacks of naughty cheap lager, and packs of Bensons. Now, (and I know this will make me sound like the ubiquitous demonic heartless privileged white male etc etc), I chose not to indulge in either. I don't accept that we are helpless slaves to advertising. We do have a choice.

    Furthermore, I’m afraid it’s a strong word, but there’s no other word for it, I have encountered a somewhat patronising attitude amongst the left when it comes to the question of choice and awareness. My own experience of politics has shown me that many people across all social classes are well aware of the trade offs to do with lifestyle choices, enjoyment, and longevity. Put simply, I’ve met enough working class people who well know that cigs will shorten their life by a few years, but go ahead and smoke them anyway.

    In other words, the lefty image of the working classes as helpless slaves to advertising is a very simplistic one. By all means, dislike and disagree with those choices if you wish, but be cautious in a liberal democracy before forbidding things, and avoid euphemising punitive taxes and other legal compulsions as ‘nudges’ or ‘decision architecture’ or some such.

    Finally, I noted I don’t like a flat fee at the point of use for the NHS. But: life assurance policies have a pricing structure which punishes poor lifestyle choices. There is an (imperfect) verification system. This is largely accepted. Driving insurance policies pricing punishes poor driving behaviours. In both cases, the suggestion that we should move to a flat pricing scheme would be treated as absolute madness.

    Similarly the NHS is an insurance pricing scheme which differs not at all depending on how risky your behaviour is. Eat salad and exercise every day? Flat price. Smoke a pack a day on the sofa? Flat price. You’re fond of state actions to ‘help’ people make the right decisions? How about a small premium for heavy smokers?

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