If a person died from tuberculosis in the eighteenth century, this might not only be expected but might also be considered unavoidable. But if a person dies from tuberculosis today, is that either expected or unavoidable? We have the means both to prevent and also, almost always, to cure tuberculosis.
Galtung saw violence, where the unequal distribution of power in society led to unequal life chances, as ‘structural violence’
Johan Galtung, a Norwegian sociologist, famously posed that very question, concluding that if a person does die today from tuberculosis ‘despite all the medical resources in the world’ that death is a violent death (Galtung, 1969: 168). Galtung widened the concept of violence to capture the intangible harms and injustices in society’s structure. He saw violence where the unequal distribution of power in society led to unequal life chances: he termed this ‘structural violence’.
We live in a society characterized by structural violence and sadly, there can be no greater signal of that fact than the experiences of the Covid-19 pandemic. The virus tore through society, but it was not indiscriminate. The burden of exposure and death was disproportionately shouldered by people at the bottom of the social ladder: people still reeling from a decade of government austerity. In illuminating the violent structures of society, Covid-19 also shone a light on deep chasms in the provision of welfare. It revealed a broken system of health and social care, a social security safety net no longer fit for purpose. But perhaps it can also catalyse change.
Beveridge’s characterization of the Five Giants mobilized public and political support for radical change
In November 1942 – a similarly turbulent time of war, fear and death – Sir William Beveridge delivered a report to a parliamentary committee placing the UK firmly on a path towards a universal healthcare service, free at the point of use. Beveridge’s provision for the health of the nation was the flagship of his welfare system that for a time became the envy of the world. His characterization of the Five Giants mobilized public and political support for radical change, the impacts of which still resonate today. But his assault both on disease and its brothers-in-arms has run its course.
Our current health and longevity undeniably owe much to the healthcare system he envisaged, but also to the improved living conditions through better housing, the expanded education system, and the full-scale attack on poverty which his proposals led to. Consider for example that babies born when Beveridge was writing his report might have expected to celebrate around 60 birthdays. By the time they reached 60 they were in fact looking to enjoy another 20 or so years of life.
Despite such successes, the health and social care systems established through, and in response to, Beveridge’s landmark report have not kept pace with the changes they heralded. We are a very different population from that of 1942. We are more diverse, and we are older. Even aside from our increasing longevity, what ails and kills us is today very different from what ailed and killed people in the 1940s. Though we live longer, we do so often with more complex and multiple health conditions, and our mental health is at least as complex as our physical health. This challenges the sustainability of a system that in the 1940s Beveridge and Bevan premised on treating illness and returning people to their ‘normal’ state ready either to resume work, if they were men, or motherhood, if they were women.
Not only has the nature of our ill-health changed, so too has our understanding of it. Health is socially determined. Where we sit in the social and economic hierarchy matters for our chances of good health, both physical and mental. Whether or not we live in a leafy suburb or a crowded inner-city tower block, for example, matters for our health. The 1980s saw growing concern about health inequalities between social groups, which had occurred despite a comprehensive, universal health service. This concern led to a report – the Black Report – that was suppressed during the Thatcher administration’s programme of rolling back, rather than shoring up, a struggling social security system.
Almost as soon as Aneurin Bevan realized Beveridge’s ‘Assumption B’ and created our National Health Service, the costs began to worry those responsible for delivering it. But instead of concerted and sustained effort to establish a new approach, better suited to the changing size, age, diversity and health of the population, successive governments seemed more ready to dismantle, weaken and erode the extent and value of welfare provision, whether in earnest or by accident. Beveridge, though perhaps unintentionally, had already offered the means to do this.
The health and wellbeing of the population were seen as a means to an end rather than as a goal
Framed in the liberal ideology that governed Beveridge’s politics, the health and wellbeing of the population were seen as a means to an end rather than as a goal. Providing for the health of the nation provided for the wealth, growth and prosperity of that nation. A healthy population was a happy by-product of a prosperous society. The maturing of liberal ideology in the UK and the growth of neoliberalism saw policy and political rhetoric increasingly centred on the individual. At the same time, economic debate elevated the market and competition principles as the key mechanism through which to organize society, allocate resources and measure success. The primacy of both the market and the individual carved out space in which responsibility for health and wellbeing has gradually been relinquished by the state and progressively transferred to the individual.
Those who depend on the welfare state are increasingly demonized and marginalized by political rhetoric
Prioritizing the global competitiveness of the economy and the labour market has come at the expense of a strong safety net of social protection – such as Beveridge had sought to weave – or regulated wages and progressive taxation. When people are framed as being solely responsible for their own health and wellbeing – while ignoring the harmful social structures that differently enable or prohibit good health – shared interests at either the political or even public level in maintaining a welfare state declines. Those who depend on that welfare state are increasingly demonized and marginalized by political rhetoric. The fleeting premiership of Liz Truss saw a resurfacing of her infamous quote that “the British are among the worst idlers in the world” – a rather apposite example of such demonization. And yet, it is ironic that the ideology, which enables this demonization and emphasis on individual responsibility, is the root cause of the growing numbers of people in urgent need of welfare support.
Recall Galtung’s concept of structural violence and his condemnation of the unequal life chances afforded by the unequal distribution of power in society. Where we agree with the primacy of the pound, of economic growth, and of competition, are we complicit in that violence? If we prioritize economic growth and those who can contribute to it, we simultaneously erode the health and wellbeing of society at large. We create far more problems than we solve, and we drive up the costs of a system we already fear is unsustainable. We are complicit. Without public and political recognition of this complicity in maintaining a system that harms and demonises those who need it most we are enabling if not actively wielding that violence.
Beveridge’s giant is now a behemoth
Beveridge’s giant is now a behemoth. Despite remarkable gains to life expectancy, those gains began to stall and reverse even before Covid-19 emerged alongside the nudging upwards of infant mortality. Through vaccines and antibiotics, tuberculosis and other respiratory complaints are no longer among the leading causes of death for our children and young adults, but suicide has taken over. Although we celebrate extending lifespans, we simultaneously dismiss, marginalize or stigmatize older people in our society. Our health and social care systems are both chronically underfunded, and the act of ‘caring’ is relegated to the margins of political interest and public merit. What is the alternative?
In revisiting Beveridge, I explore what gaps in provision have emerged as the needs, shape and size of the population has changed: the importance of ‘care’ cannot be overstated. A care or caring economy is not a new idea, but it is one that the experiences of Covid-19 should now give new urgency to. Primacy should no longer be given to economic growth but to “everything that we do to maintain, continue, and repair our ‘world’ so that we can live in it as well as possible”, to repeat Berenice Fisher and Joan Tronto’s (1990: 40) famed definition of care. Economic growth need not be the be all and end all, but it is both possible and equitable in an economic system which prioritizes all forms of care sustaining life and the planet.
Care economies focus investment in public services, allowing for sustained, targeted and substantial investment at all levels of the health and social care system. The benefits to overall levels of well-being and life satisfaction, as well as the health of the population more generally, would be sizeable. But so too would the economic benefits, with health and well-being framed as both the means and the goal, recognised to be worth more than their instrumental value. Afterall, think how much we are capable of when we have our health, the ability to manage and cope with ill-health, our wellbeing, and are content.
Care work, informal and formal, cannot be secondary to wider macroeconomic planning and policy
Beveridge underpinned his recovery and flourishing with an Assumption B, the creation of a National Health Service. For us, let us underpin a new recovery and a new flourishing with Assumption B.2, driving forward from a national health and social care service adequately resourced to tackle more than the immediate costs of morbidity. Care work, informal and formal, cannot be secondary to wider macroeconomic planning and policy. Build a system that is community-led, where care is valued and reciprocal. Build a system for a society committed to dismantling the violent structures through which unequal life chances are maintained and perpetuated. Beveridge proposed revolutionary, radical change, not simply ‘patchy reform’. It was needed in the aftermath of war, and it is needed now.