A recent issue of JAMA (Journal of the American Medical Association, March18, 2009) contains two commentaries by leading researchers on the social determinants of health, a broad catalog of factors shaping human health which:
“Include[s] the lifelong importance of health determinants in early childhood, and the effects of poverty, drugs, working conditions, unemployment, social support, good food and transport policy “(Wilkinson and Marmot 2007).
The authors present the fiscal/economic crash of 2008 as an opportunity for health professionals to educate governmental officials and other policy-makers about the far-reaching effects of these factors. Well and good; but isn’t it astounding that they DO NOT consider whether the socioeconomic meltdown is a threat to the social determinants of health -or, for that matter, to public health systems? Let’s try to give an answer to why this is so in light of my contention that the world faces the intertwined problems of Bad Money (Phillips 2008), the financial and economic unwind, and the Bottleneck (Wilson 2002), the connected set of ecological constraints -especially peak oil- humanity can no longer defer to the future.
In the first commentary Woolf tells his peers that:
“the health consequences of social policies warrant greater attention from the health policy community…the nation is being reconfigured to overcome unprecedented challenges. Sweeping decisions are being made that will affect living conditions, and resulting health outcomes, for many years. This is the wrong time for professions to keep their distance from these issues.” (Woolf 2009: 1168.)
The second commentary, authored by Marmot and Bell, is an overview of the World Health Organization’s (WHO) Commission on Social Determinants of Health:
“The international response to the current global financial crisis provides the opportunity for the international community to recommit to a more representative multilateral system with fairer participation by all countries and the opportunity to place health equity at the heart of multilateral policy development in areas including trade, finance, responses to climate change, and international security.” (Marmot and Bell 2009: 1171).
To explore how the social determinants of health might be deteriorating as a result of the crisis of 2008, I am conducting a series of interviews with local public health directors across the nation. All but a few are receiving budget reductions this year; many have been experiencing these cuts for several years; and a few –in rural areas- are approaching the point where they will cease operations if their funding again is reduced next year (Bednarz 2009). They are trying to be creative, proactive, and so on; but human ingenuity only takes them so far.
In the US public health is primarily funded by state and local tax dollars; and since all but four states this year are in fiscal distress, that is, their budgets are contracting, a further decline in states’ revenues next year portends a deep blow to the nation’s public health system, and by extension the social determinants of health. With tent cities popping up across the nation; food banks pleading for donations; unemployment growing; a 20% decline in household wealth since mid-2007; the World Trade Organization predicting global trade will shrink 9% this year; four governments recently toppling in Europe; Great Britain may ask the IMF for a bailout; national, personal and business debt in the USA of gargantuan proportions; China warning the US that its substantial dollar holdings must not be monetized away; and 90% of the (borrowed and printed into existence) funds the US federal government is pledging to “save the economy” going to what now appear to be “Zombie” financial institutions, -well, what more needs to happen to get these researchers to gaze beyond their time-lagged data sets to notice the real time threat to the social determinants of health? In other words, these two commentaries have little insight or advice for local public health directors across America.
Not probing the issue reflects (Kuhn 1970) how a paradigm directs inquiry –and how it enters into crisis when it allows anomalies to accumulate. Kuhn writes of paradigms as illustrative metaphors that guide scientific inquiry; and Foucault (1970) –whose concept is the episteme rather than the paradigm- proceeds at the cultural level. The dominant episteme regulates socially shared –and enforced- constructions of “reality.” It proscribes thought, knowledge, and notions of morality and judgment to conform to current arrangement of power, status and propriety. An episteme operates non-consciously as a “strategic apparatus” determining which statements and questions may be regarded as reasonable, obvious, true, etc. and which other statements and questions are considered absurd, illogical, irrelevant, trite, and unworthy of consideration. (It is noteworthy, and frequently misunderstood, that Foucault considers the emergence of a counter-episteme(s) sociologically inevitable, that is, normal even though it is regarded as deviant or subversive through the lens of the dominant episteme.)
St. Clair (ND) writes, “The most interesting kind of metaphor is the root or the cardinal metaphor. These represent metaphors that have become an intrinsic part of a culture. They represent [following Foucault] the tacit knowledge upon which a society is constructed. Western culture has an interesting profile of cardinal metaphors, viz., society seen as an organism (the growth metaphor)…” I would add to this the complementary metaphor of technological progress to claim that these two cardinal metaphors, particularly in the United States, synthesize into the dominant episteme that underlies virtually all public health theorizing and, more widely, civic discourse.
Accordingly, without exception business, governmental, cultural and political leaders invoke growth as the (self-evident) means -and intrinsically valued end- in combating the economic crisis. Technological progress, especially to “solve” the energy and climate change crises, is a complementary means of returning to growth; and rhetoric about “confidence” is a psychological derivative of this episteme. So it is no surprise that Woolf, and Marmot and Bell implicitly regard the fiscal/economic crisis as a temporary severe deviation from normalcy.
In contrast, I see the dominant episteme “rupturing” because it has produced fiscal and ecological dilemmas it cannot fix. Regarding the connection of Bad Money and the Bottleneck, even if some method were found to wipe away the trillions in debt in the financial system, say a worldwide debt jubilee (which itself presents formidable problems), there is an ecological limit now in place: energy, specifically peak oil. It is the first direct manifestation of the limits to growth (Meadows et al 1972, 2004). Oil prices crashed with the economy in the fall of 2008 and they will increase IF growth does restart because we appear to be at peak oil.
Here we encounter what Kuhn calls the problem of incommensurability. The relationship of the Bottleneck to the economic crisis is incomprehensible –or arrant nonsense- for someone under the sway of the growth/progress episteme. Pointing out that economic activity takes place inside the earth’s ecology is reminiscent of Foucault’s (1970: Preface The Order of Things) famous reflection about “the wonderment of this taxonomy” from:
“A certain Chinese encyclopedia called the Heavenly Emporium of Benevolent Knowledge. In its distant pages it is written that animals are divided into (a) those that belong to the emperor; (b) embalmed ones; (c) those that are trained; (d) suckling pigs; (e) mermaids; (f) fabulous ones; (g) stray dogs; (h) those that are included in this classification; (i) those that tremble as if they were mad; (j) innumerable ones; (k) those drawn with a very fine camel’s-hair brush; (l) etcetera; (m) those that have just broken the flower vase; (n) those that at a distance resemble flies.”*
Upon reading this definition Foucault commented:
“As I read the passage, all the familiar landmarks of thought—our thought, the thought that bears the stamp of our age and our geography—breaking up all the ordered surfaces and all the planes with which we are accustomed to tame the wild profusion of existing things and continuing long afterwards to disturb and threaten with collapse our age-old definitions between the Same and the Other.”
Kuhn claims that paradigms enter into crisis, Foucault that an episteme “ruptures” because they automatically perpetuate conventional rationality and resist the explanations of an alternative paradigm or episteme. Without digressing into the sociology of knowledge, suffice it to say that “business as usual” does not change as a result of the accumulation of evidence or rational public discourse. The established system is impervious until it enters extreme crisis -or collapses- and recycles explanations for its failure to deal with vexing anomalies, in our case the fiscal and economic crisis of 2008: “We’ve got a consumption and debt problem? We’ll solve it by taking on more debt and reigniting consumption because growth and consumption is the natural order of things.”
In summary, I suggest that Robert Costanza (2009), along with other ecological economists, offers an integrated understanding of the way out of the Bad Money and the Bottleneck dilemma.
“The current financial meltdown is the result of under-regulated markets built on an ideology of free market capitalism and unlimited economic growth. The fundamental problem is that the underlying assumptions of this ideology are not consistent with what we now know about the real state of the world.”**
Where does this leave public health?
Academic public health is ensconced in an institutional matrix of growth. It owes much of its existence to the socioeconomic expansion petroleum facilitated during the 20th century. Schools of public health are supported by government and foundation grants. That is to say, faculty members, even those with tenure, have anywhere from 50% to upwards of 80% of their salaries provided by “soft money” support –translation: no grants, no jobs. Obviously, most of these scholars must do research on topics for which there is funding; this system works when an economy is expanding. However, with many universities now imposing hiring and salary freezes, and the federal government and foundations facing extraordinary fiscal decline, it is likely that schools of public health will contract -lay off faculty and staff- or even close in coming years.
At the local level, where the rubber meets the road, a different dynamic is at play. There are indications from my interviews that health department directors will organize and exercise their “Voice” option (Hirschman 1970) as a response to the decline of the public health system. It is possible they will contribute to creating a low-energy, sustainable, and community-integrated public health system. This will not be easy, but it is a milieu where human ingenuity can blossom.
Finally, the best option I see for academic public health is to reorganize itself around a question that will join it to the existential reality of the practice community it was founded to serve: “If growth and economic development as they have been understood are no longer possible, then what kind of public health system is sustainable?”
*Some of Foucault’s legion of opponents claim this passage is fictitious: See: Keith Windschuttle, “Absolutely Relative,” National Review Online. http://www.nationalreview.com/15sept97/windschuttle091597.html.
** For Foucault aficionados an interesting question is what he would make of peak oil. I think he’d find it the epitome of irony.
Bednarz, Dan. “The Economic Crisis Impacts on Public Health.” Delivered at the “After Peak Oil” Conference. Johns-Hopkins University. March 12, 2009. Available online at: http://healthafteroil.wordpress.com/2009/03/18/the-economic-crisis-impacts-on-public-health/.
Costanza, Robert. “Toward a new sustainable economy.” Real-world Economics Review, No. 49. March 2009. http://www.paecon.net/PAEReview/issue49/Costanza49.pdf.
Foucault, Michael. The Order of Things: An Archaeology of the Human Sciences. New York: Pantheon. 1970.
Hirschman, Albert O. Exit, Voice and Loyalty: Responses to Decline in Firms, Organizations, and States. Cambridge, Mass: Harvard University Press. 1970.
Kuhn, Thomas. The Structure of Scientific Revolutions. Chicago: University of Chicago Press. 1970.
Marmot, Michael G. and Ruth Bell. “Action of Health Disparities in the United States: Commission on Social Determinants of Health.” JAMA Vol. 301, No. 11, March 18, 209: 1169-1171.
Meadows, Donella H. et al. Limits to Growth. New York: Universe Books. 1972.
Meadows, Donella H. et al. Limits to Growth: The 30-Year Update. White River Junction, Vt: Chelsea Green Pub. 2004.
Phillips, Kevin. Bad Money: Reckless Finance, Failed Politics, and the Global Crisis of American Capitalism. New York: Viking. 2008.
St. Clair, Robert N. Cultural Wisdom, Communication Theory and the Metaphor of Resonance. ND. http://epistemic-forms.com/The%20Metaphor%20of%20Resonance-1.html.
Wilkinson, Richard, and Michael Marmot. “Social Determinants of Health: The Solid Facts.” WHO, Europe. 2007. http://www.euro.who.int/document/E81384.pdf.
Wilson, E.O. “The Bottleneck.” Scientific American February, 2002. http://www.sciam.com/article.cfm?id=the-bottleneck.
Woolf, Steven H. “Social Policy as Health Policy.” JAMA Vol. 301, No. 11, March 18, 2009: 1166-1169.