Over a decade ago, in a calculated bid to rile and provoke engagement with other sociologists, I formulated the ‘greedy bastards hypothesis’ (GBH). This asserted that health inequalities in Britain were first and foremost an unintended consequence of the ‘strategic’ behaviours at the core of the country’s capitalist-executive and power elite. It is a hypothesis even more plausible in 2012 than it was in the late 1990s.
The term ‘capitalist-executive’, borrowed from Clement and Myles, contained what I subsequently called a core ‘cabal’ of financiers, CEOs and Directors of large and largely transnational companies, and rentiers. These individuals were perfectly capable of ‘conspiring’ but despite being involved in fierce competition rarely had a need to do so in the post-1970s neo-liberal era of financial capitalism. This cabal, I intimated, has come to exercise a dominating influence over the state’s political elite (that is, the upper echelons of government together with its multifold ‘new middle class’ tacticians). US historian David Landes’ once asserted that ‘men (sic) of wealth buy men of power’; and my contention was that they got more for their money post-1970s than in the postwar welfare-statist era. So the GBH charged leading capitalists and politicians with what the likes of Engels and Virschow in the nineteenth century called homicide. As Michael Marmot has more recently averred, policies can kill, and when these are reflexively enacted their architects shouldn’t be surprised to find themselves liable to prosecution in the event of a regime change.
If the GBH indicted individuals – and in a 2009 paper I cited a list of names from a column in the Guardian – this was not its primary aim. Notwithstanding allowances for charisma and the like, the stand-out wealthy and powerful are more replaceable than they would have us believe (and doubtless than they believe). As a sociologist my interest was in the social structures these individuals were able to surf while many others were not waving but drowning: the sheer heritability of wealth and power is better researched than it is grasped by the public (hence the need for ‘action sociology’). Core members of Britain’s rapidly globalising capitalist-executive are the beneficiaries of enduring relations of class. Those comprising the more slowly globalising power elite at the pinnacle of our multi-layered state reflect relations of command. My contention was and is that financial capitalist Britain is characterized by a revised ‘class/command dynamic’ whereby class interests exercise greater sway over state policy and practice than hitherto. This strikes me as blindingly obvious.
Let anyone who doubts the thrust of this argument venture a more telling macro-analysis of the journey of the (English) Health and Social Care Bill into law in March of 2012. This Act is re-commodifying health care. Without mandate, and in defiance of unusually unambiguous comparative research, the ConDem coalition is turning the NHS over to predatory US-style for-profit companies. What better case could be made for the new class/command dynamic?
It would be convenient if type of health care organization and delivery was decisive for health inequalities, but it isn’t. Morbidity and mortality rates do not simply reflect differential access to good quality health care. Although GP Julian Tudor Hart’s ‘inverse care law’ still applies 40 years after its formulation (that is, the provision of health care is inversely related to the demand for it), it is in amongst the basic building blocks of people’s everyday lives that the explanation of health inequalities rests. I have suggested that the notion of (initially) capital and (more recently) asset flows is helpful here. These asset flows, I contend, are the media through which the class/command dynamic, via the GBH, decisively impacts on people’s health and longevity. The noun ‘flows’ is significant here. People do not either have or not have assets positive for health and longevity, rather the strength of flow of these assets varies through the life-course.
So what are these assets? I so far have listed biological, psychological, social, cultural, spatial, symbolic and material assetsl. This is not the place to discuss each in turn, but it is important to stress that a strong flow of one asset can and frequently does compensate for the weak flow of another. Examples: a strong psychological asset flow (i.e. high personal resilience) can cancel out the negative propensities of a weak flow of social assets (i.e. an absence of close-knit social networks); and a strong flow of symbolic assets (i.e. high social status) can mitigate the damage liable from a weak flow of spatial assets (i.e. living in a deprived neighbourhood). There are five points to add:
- the strength of flow of material assets (i.e. standard of living via personal and household income) is paramount;
- flows of assets tend to vary together (i.e. mostly strong or weak ‘across the board’);
- weak asset flows across the board tend at critical junctures of the life-course (e.g. during infancy and childhood) to have especially deleterious effects on life-time health and longevity;
- weak asset flows across the board, and I daresay strong asset flows across the board, tend to exercise a cumulative effect over the life-course (negatively and positively respectively);
- the ‘subjective’ evaluation of the strength of an asset flow can exert an effect over and above any ‘objective’ measure of that flow (e.g. a symbolic asset flow perceived as weak relative to that enjoyed by an individual’s reference group can be injurious in its own right).
Ok, it’s complex. But I want to stress (1) here. I regard the material asset flow as vital or prepotent. To assert that it underpins all other asset flows is not to diminish the latter’s salience for health inequalities; but it is to put on record, surely the key lesson of Wilkinson and Pickett’s The Spirit Level, that a purposeful reduction in income inequality is a precondition for taking health inequalities seriously?
This last point takes us back to the GBH and the revised class/command dynamic that underwrites it. Our society, one in which income and health inequalities are rapidly rising, and in which policy-based evidence has allowed a Health and Social Care Act to deliver a proven cost-effective publicly-owned NHS into the hands of transnational profiteers, is slipping into a post-welfare-statist, neo-liberal abyss. And even my fellow sociologists are reluctant use the ‘class’ word.