Wiser people than me have discussed our failure to act on what we now about the social determinants of health (Baum et al 2009, Katikireddi et al 2013). Poor health is located in social disadvantage and would need to be addressed through education, housing, transport and health. As a consequence of this knowledge the UK  and EU have looked at a Health in all Policies approach.

Problems that arise are that these areas are; big and expensive, complex and interacting, based in social structures, and do not fit within election cycles. Those of us who are left leaning philosophically  would be happy to commit as a society to reducing disadvantage because we understand the impact of social structures on individuals. For the left failure to deal with  disadvantage may exacerbate binge drinking, poor health, or crime  and so will be expensive to those individuals but also our society as a whole. Dealing with disadvantage will be expensive but we will all benefit. We won’t have to live in fear, or behind razor wire and thus have our own lives constrained.

For those who are right leaning this is more difficult. They see the society as the product of the agency or actions of individuals and privilege the protection of individualism. The emergence and achievement of a Roger Bannister or Stephen Hawking draws our society forward so that we all benefit. The significance of the commitment required at a social level to address disadvantage inherently requires a shift in investment, at least to some extent, away from economic growth, and into social well being. More funds for housing education and transport require more taxes and less middle class welfare. This is not attractive to the right and they are unlikely to believe it to be fair or a plausible route. Because of their faith in individualism, and their influence on policy, we continue to spend on ineffective health campaigns to influence individual behaviours.

Inherent in the right left divide is the positing of agency as against structure. People who are well off have more control over their lives. This has been identified as one of the social determinants. But people who have never not had control over their lives tend not to understand what it is like not to. The behaviours that disadvantaged people have that harm their health are also behaviours that are stress related; alcohol and tobacco use, gambling, poor eating habits, poor exercise habits and risk taking behaviours.

It is our social structures that reduces the agency of our disadvantaged. I am fortunate not to have to deal with Centrelink. If I did I would know that I cannot call them from my mobile phone ( I gave up my landline)  because there is a wait of 45 minutes or more which exceeds my credit. I can go to the Service Centre but these are being closed and increasingly made self service. I don’t have a car or at least not a reliable one and the one I have is expensive to run because it is old. I’ll need to use public transport to get there. This is time consuming. The reporting requirements can be onerous for me, eating into the time I have for parenting, training and education, and job seeking. It is stressful and I’m broke and depressed. I lose motivation and stop exercising. I buy cheap, accessible (unhealthy) food for the family. Etcetera.

My question is, how do we as a society re-adjust the relative privileging of individualism as against communitarianism? This is a question being faced in all western countries who have moved to greater inequality. How can a case be made for those with power and influence to grasp the long term consequences for us all, if not the unfair suffering of the many, if we do not move to adjust this balance?