Neoliberalism’s challenge to public health
I keep chewing over an article by George Monbiot, who asks if neoliberalism is the root of all of our problems. It’s a long piece, so jump to how Monbiot describes neoliberalism:
Neoliberalism sees competition as the defining characteristic of human relations. It redefines citizens as consumers, whose democratic choices are best exercised by buying and selling, a process that rewards merit and punishes inefficiency. It maintains that “the market” delivers benefits that could never be achieved by planning.
This ideology frames the individual person as the organizing unit of society — as opposed to, say, socialism, which sees social class as the organizing unit, and fascism, which sees the nation-state as the organizing unit of society.
This poses problems for the field of public health. Let’s take a look how:
The Washington Post reports that a study found out that people on food stamps have diets that are much less healthy than that of the average American. Understanding this issue through a framework of individual choices leads us to ask: Why don’t those people just eat healthier? Why are they choosing bad food? What’s wrong with them?
But, public health is most effective when we understand that problems and solutions are about more than what people choose to do — it’s about why we do it collectively. And to answer this, we have to look at people in groups, and the environments they’re in. We have to look at things that affect whole populations of people, instead of the factors that affect somebody’s individual choice.
The framework of seeing things like health outcomes as only the product of an individual’s person’s choices makes us ignore systemic, structural, and environmental causes that affect whole populations. Understanding these causes is crucial to good public health work. After all, John Snow didn’t try to educate people not to use the Broad Street Pump. He removed the damn handle.
The Fundamental Attribution Error
Neoliberalism encourages us to make the fundamental attribution error, by viewing things through a lens of individual behavior instead of collective behavior. The fundamental attribution error is the mistake of saying “I crashed my car and it was an accident — but you crashed it because you were driving recklessly.” It associated unknown, uncontrollable, or environmental factors to one’s own behavior, but individual factors with somebody else’s.
Take a look at this video of a staircase in a subway station in New York City. Now, you probably consider yourself to be pretty good at walking up stairs. Maybe you’re an expert. And then you trip. Oops — you just weren’t paying attention.
But one stair is larger than the others — people trip on it. A lot of people trip on it. So to say that somebody trips on this stair because they’re clumsy is an error.
Public health should observe: “A lot of people trip over this stair — there’s something wrong with the stair.” Unfortunately, too often, we take a bad shortcut and asks, “How do we teach people not to trip on stairs?” instead of asking, “How do we fix the stair?”
We want people to walk and take transit instead of driving; we want people to take the stairs instead of the elevator, and we want people to eat vegetables instead of “edible food-like substances.” But social, economic, and built environments make these choices harder — crappy options are easier. The things that affect behavior add up to a topographical map that we navigate, and too often, routes to healthy behavior are uphill journeys in this landscape — they’re stairs that people trip over.
Neoliberalism’s challenge to public health
A person’s individual actions matter — but accumulated among many people, they make up a population’s behavioral trends.
Neoliberalism is an ideology that doesn’t want us to see these trends. Monbiot says, “The rich persuade themselves that they acquired their wealth through merit, ignoring the advantages — such as education, inheritance, and class — that may have helped to secure it.” This point can be converted to the same observation about public health — that healthy persuade themselves that they acquired their health through merit, ignoring the advantages — such as environment, education, and wealth — that helped to secure it.
This piece on Vox reports that researchers spent 18 months with low- and middle-income parents, and found that these people had many barriers to preparing healthy, home-cooked meals.
[Researchers] found that, while many [low- and middle-income parents] enjoyed cooking, the time pressures … made home-cooked meals a tiring, stressful experience. Those who lacked reliable transportation only grocery shopped once each month, making perishable foods impractical. Roasting a chicken requires time between finishing work and serving dinner.
Telling people what to do has limited use when there are structural barriers that prevent people from doing it.
Getting suckered into buying into an ideology that says that every action is fundamentally the product of a person’s neutral choices and not moderated, determined, or coerced by the environment around them is dangerous. It can make us abandon the important population-level perspective that is central to public health. We must look at trends, and whole populations — and the systemic causes behind individual behavior. It’s hard — it’s certainly harder to measure and less direct than simply measuring what people do.
But it’s important. It’s vital to our field. When we see look at behaviors on a population level, we see factors that are changeable on a systematic level. We remove individual blame from the equation, and we put the onus on society as a whole to create conditions for health — individual and collective. We stop asking why people are drawing water from a poisoned well — and we remove the damn pump handle.
