Daniel Ridge: One of the most marked changes in the socio political landscape of European societies since the 1980s has been the rapid and widespread adoption of neoliberal policies across the continent.
In this episode, we're talking with the editors of a new book which examines health and healthcare in our neoliberal era. The book scrutinises three key characteristics of neoliberalism: self-responsiblisation, health inequality and organisational reform and discusses the impact of neoliberalism on public health and the social construction of health and illness in Europe.
We are joined by Jon Gabe, emeritus professor of Sociology, Royal Holloway University of London; Mario Cardano, full professor of Sociology of Health and Qualitative Methods for Social Research at the University of Turin and Angela Genova, Researcher in the Department of Economics and Society, Politics at the University of Urbino, Italy.
We’ll begin first with Job Gabe to set the scene and outline the key themes and discoveries of the book.
So thank you so much for joining me today Jon.
Jon Gabe: That's okay.
DR: You know, to begin with, can you give us an overview of the book that you co-authored with Angela Genova and Mario Cardano?
JG: Sure. So, the starting point for the book was a recognition that neoliberalism has had considerable impact on healthcare policy and practice, and on everyday experience of health and illness, all across Europe. So, we thought that this deserved serious attention. So we wanted to provide an overview of the impact of neoliberalism on health care across Europe highlighting the different aspects of a common policy discourse, both at the national level and that the local level, and we use case studies from different European countries to do this.
DR: Wow, okay so can you give us some of the key terms, you know, specifically what is the neoliberal era? What do you mean by that?
JG: Sure. Well in the social sciences, neoliberalism is a contested term. It's been defined as a political and economic philosophy and an ideology, and in some cases, it's seen as a transnational process. In other words, it crosses national boundaries. Some combine these elements simultaneously seeing it as an ideology, a set of policies and programs, a set of distinctive institutional forms, and a variety of conceptions of how people should behave, or act responsibly. So, given its varied application, we thought it was best to recognise this and avoid using it deterministically. Rather, we wanted to emphasise the importance of context, the context in which neoliberalism is applied. And, importantly, recognising that the application of neoliberalism is always partial. It's, in other words, an incomplete process. And it also has a rather uneven geographical spread, basically that we want it to be seen as a sensitising concept. In other words, a concept which guides our gaze to something which is complex, but something which we can make intelligible.
DR: Right, so if we're in the neoliberal era now, and in a sort of global sense, what came before it?
JG: Well, that's a good question. I suppose one would argue that it was influenced by a different form of economics, an economics which was, for example, behind Roosevelt's New Deal, an emphasis on greater public spending. From the point of view of Britain, the influence of Maynard Keynes, and the emphasis, therefore on public spending as a way of promoting economic growth.
DR: Right, so what have been the main findings of the book?
JG: So, we focus in the book on three things. The book in other words is divided into three sections: one on health inequalities. Secondly on self, what we call self-responsiblisation. And thirdly, on cost containment. So, I thought what I'd do is give you an example of each of these three areas from different chapters.
DR: Yeah, that sounds great.
JG: Yep. So, talking about health inequalities, what we tried to show in the book is how austerity policies, in other words, policies which involve a reduction in state spending, have exacerbated existing health inequalities. An example would be the huge increase in food banks in some countries, for example, in England. That is providing food to those in poverty, as a consequence of austerity policies, and these policies have resulted, have been based on cuts in welfare and of course these cuts in welfare have resulted in people being in ever greater poverty and therefore the need of calling on food banks. In terms of self-responsiblisation I suppose the question here is how do citizens and patients in countries influenced by neoliberalism respond to the imperatives of healthcare policies? To what extent do they accept the ideology of responsiblisation? Or do they resist it? An example which deals with this as a chapter focusing on neoliberal health policies in the Czech Republic and shows how citizens and patients in that country have, in part, come to accept that they should demonstrate self-responsibility as regards to their health and praise the possibility of choice, but may also question how healthcare is delivered, governed by neoliberal tenants. So, for example, some patients criticise the market logic dominating the character of healthcare services as well as the role played by private actorsin healthcare, and finally the third finding is relating to cost containment as a part of the drive to maximise productivity. What problems do neoliberal policies face when applied in actual historical context? One example is a chapter on the Italian national health service, which discusses how Italian healthcare has been decentralised in line with neoliberal principles. But the financial deficits in some of the regions in Italy, have in fact resulted in the central state intervening, but intervening at a cost. For example, reducing the number of hospital beds in a region, controlling the amount of money which can be spent on pharmaceuticals, freezing the number of people working in the healthcare system. So, choice of health policy has been limited in half of Italy, as a result of these financial reasons.
DR: Wow, so, can you tell me a little bit more about how health care fits into this neoliberal period and maybe why there's this, there was this push to put health care into that?
JG: Well I suppose we need to understand the context, really, because we can't separate out healthcare from the wider, economic and political policies of the time. So, we need to go back, really, to the late 1970s early 1980s when economists like Hayek and Friedman were very influential and importantly influenced political leaders like Ronald Reagan the in United States and Margaret Thatcher in the United Kingdom. And they saw neoliberalism as the answer to the economic crisis of inflation, of the time. What they wanted to do was to coin the phrase “roll back the influence of the state,” and reduce regulation. And importantly, this has since become common sense. In other words, seen as the only way to do things. There's no other way than the way that things are currently done. And this has been taken up in Europe, not just by England but also by countries like Germany, Italy, France. And all of this is being based on three different tenants. First of all, an emphasis on markets. Secondly, on individualism and thirdly, on decentralisation, and we can see that, then being taken up in health care with an emphasis for example, on creating a market in healthcare competition between providers, that's been important. Secondly, in terms of individualism, an emphasis on self-responsibility and choice with patients making choices about their healthcare reflecting their own knowledge so in a sense taking control of their health. And thirdly, in terms of decentralisation, the way in which policies, how both decentralisation and I was talking a little bit earlier about how that panned out in healthcare.
DR: I think it's interesting that in this neoliberal era we think that everything should be part of the free market, but at the same time, you said that this is partial, and so you know you look at other systems that we have in different countries, looking specifically the United States, for example, education for young people, prisons, those are paid for by the state even the prisons and education is also still partial, I guess, you know I'm just kind of wondering about health care why is it that we just automatically think that that should also be part of, of the free market?
JG: Well, I don't think we do in, I mean we, I think would be that would be true in the United States but it's not the case in a country like the United Kingdom and particularly England, or for that matter in Italy where we have a national health service. So, in England and in Italy, what we see is an attempt to introduce ideas about the market into a publicly funded healthcare system. So, we have in a sense a hybrid system. And what's interesting if we take England as a case in point, is the extent to which we still have a sensibly in attachment to a universal healthcare system funded by the state out of taxation. But at the same time, evidence of increasing privatisation, and we can see that most starkly in the current period of COVID. So, what we have for example, with the introduction of testing and tracing, we have something called NHS test and trace. In other words, we're trying to check the people who've got COVID by testing, and then tracing their contacts to warn them if people have got COVID. They might have been in contact with these other people. And now the point about this is it's called NHS test and trace, but it's actually being run privately. And this is not acknowledged. So this is an example of what some would describe as creeping privatisation.
DR: Well that's creeping privatisation, is it inevitable, are we heading further and further into privatisation the way it exists in the United States for example?
JG: It's not inevitable. It depends on the policies of the government in that time that the problem that the current government has in England is that there's a strong allegiance to the National Health Service. And indeed, that has been enhanced further, a result of the way in which the health service has tried to deal with the COVID pandemic, and indeed the Prime Minister himself had COVID and was treated in an NHS hospital. So, it's very difficult for this particular government to attack or confront the publicly funded healthcare system and turn it into a private healthcare system so they are therefore forced to do so if they want to do that in more subtle ways. Now what we're facing currently with Brexit, in other words, with Britain leaving the European Union is that new trade deals have to be struck. And we're currently looking at a potential trade deal with the United States. And one of the issues there is the extent to which that trade deal covers health care, and if it does cover health care that would leave the door open to private providers from the United States, increasing provision of private health services in the United Kingdom to a considerable extent. So, there's a lot at play for politically, in the future.
DR: There was a term in the book that really struck me which was neoliberal epidemics, and Ted Schrecker talks about that. Can you tell us a little bit more about that and what he means by this term?
JG: When Ted Schrecker talks about neoliberal epidemics, he's talking about a relationship between different things. He's talking about the relationship between austerity policies, on the one hand, the way in such policies have increased class-based health inequalities. And further, the speed of the spread of such inequalities across time and place. In developing this argument he's drawing parallels with the spread of pathogen based epidemics, hence the expression neoliberal epidemic, his approach can be described as a political economy perspective, where the causes of disease distribution are related to political and economic structures and processes, and also the unequal distribution of power.
DR: Also in the book, Richard Horton writes that austerity is the calling card of neoliberalism. Can you tell us a little bit about how austerity fits into this picture?
JG: What Horton meant by the effects of austerity is that he claims it follows an inverse harm or, in other words, the greater the austerity, the less the ability of communities to protect themselves. And we can see this with the impact of austerity on health and welfare spending and provision. For example, austerity policies resulted in cuts in nurses and doctors in the National Health Service in England, a reduction in the number of hospital beds, an increasing wait for operations. And one of the consequences of the reduction number of hospital beds with COVID is that there's been a, particularly the reduction in number of intensive care beds, has been that there has been a huge issue to do with whether the health service can cope with the number of COVID patients. Horton also talking about the benefit cuts and caps which have included those people with disabilities or on long term illnesses as a result of COVID and this in turn has led to responses like voluntary organisations providing food bags. Then we have cuts to local authority provision as a result of austerity. For example, cuts to provision for children, cuts to social care provision for people with disabilities, the loss of subsidies to bus operators. So, the cost of travel on buses has increased and of course, it's poorer people who are more likely to use buses. Then we've had the impact of austerity on the ability of people to be resilient, security was routed, for example in an increase in precarious employment with no guaranteed minimum hours worked or income, an increase in housing insecurity with austerity policies, greater evictions from rented accommodation and increasing homelessness. But, of course, there's also been a growth in personal debt. All of this has meant that there's been greater stress on people, for people, and that has impacted their ill health.
DR: I’d like to turn to Angela now to talk about her chapter Health Inequalities in Europe. Angela in your chapter you write, “our health is inextricably linked to our geographies.” Can you explain what you mean by this and tell us what you found in your research?
Angela Genova: Hi Daniel, sure. This study I conducted with my colleague Simone Lombardini, which is presented in the book Health and Illness in Neoliberal Era In Europe, focuses on healthy life expectancy for older people in a comparative perspective in Europe, data show that there are several differences between EU countries. So, we know in Europe, we are living longer, but it is important to investigate how we are living in the last years of our life. Healthy life years, which is also called disability free life expectancy, is defined as the number of years that the person is expected to continue to be in a healthy condition. So, how healthy life year has change in neoliberal era in Europe. So, we investigated healthy life years changes, we think, each countries, and between European member states. So, we look at places, we look at countries and we did this through a few variables: income inequality and welfare regime. So, a welfare system related to changes in healthy life years and also our income inequality is related to changes in healthy life years, both of the answer, are yes, because in the last 12 years, 13 countries in Europe had improved their healthy life years in a statistically significant way. Scandinavian welfare regime countries, mainly present the positive trend, while other countries like Bulgaria, Italy, and Greece have a negative trend, because they worsen their healthy life years. So Southern European countries have reduced the healthy life years. So, higher income inequality, which is a key side effect of neoliberal policy, is also associated with lower healthy life years. So, yes, place matters because differences in countries are very high.
DR: So, specifically in Italy, what did you find about these healthy life years?
AG: In Italy, healthy life years worsened after 2006, and the data clearly show that the situation was really worse for women. So, in Italy, as in other South European welfare countries, welfare regimes, the healthy life years get worse during the last decades.
DR: Well yeah, so I saw that you, you did write a quite a bit about gender differences. Can you tell us a little bit more about what your research has revealed about gender differences?
AG: The sex differences in healthy life year, which has confirmed in this study, have been already observed in other studies showing that, on average, women tend to live longer than men and in better health, mainly in European countries and Western countries. Nevertheless, health inequalities is higher for the female than for the male population, showing that females are impacted more severely by this trend. The female population, more than the male population, has been more exposed to the inequality epidemic, paying the price for a decree of a decrease in healthy life years. In Italy and in Greece, compared to the average of European countries, females present worse healthy life years, especially after the year 2006. So… another interesting data concern, a comparative perspective with other European countries, Denmark, show a decrease in healthy life years. But in this country, the female population has been less affected by this trend. On the other side in Sweden, the increase in healthy life years has been greater for females compared to male, showing, so in any case, differences related to different contacts. But to better understand this data, we have to consider gender perspective because structural gender differentiations characterise the pension systems in European member state, and also the gender pay gap is one of the most evident indicator of disadvantage. Moreover, austerity represents a major challenge for gender equality influencing demand for female labour, but also access to services that support women as carers and therefore increasing the risk of pushing women back into unpaid domestic labour. So, the neoliberal policy context increases women's vulnerability in society with regard to gender segregation in the labour market and in the family care role. And taking the life course approach this is affecting female healthy life expectancy for women in Europe also in the next years.
DR: So that fits in to neoliberal epidemics doesn’t it, that’s something Jon and I were talking about and in his chapterTed Schreker writes that the benefits of austerity have been oversold. And it seems that austerity measures in the UK have not provided the benefit that they once promised and have caused a lot of harm to low income households and individuals. Can you talk a little bit about austerity measures and how they've affected this specific segment of the population?
AG: Austerity measures have been introduced in the last decades in most of Western countries through different practices, and policy measures. Austerity measures assume different forms. We saw small changes in accessing criteria to social and health services. We also saw small change, for example, in the number of hours for services for disabled or also we considered the reduction of community health services. In Italy, for example, the reduction of personnel working in health care services has been constant during the last three decades, and it is very well documented, especially concerning GP, family doctors and primary care service under the umbrella of manager realisation of health care services, and new public management. So, caps and the reduction in workforce services differently affects women, men, elderly, young people with different economical resources, and income inequality is one of the main outcome of neoliberal policy. And we know that socio-economic condition is one of the main elements affecting health of the population.
DR: At this early stage in the pandemic, well I mean, it's been going on for more than six months now, but I'm wondering what the pandemic has revealed about health care inequalities.
AG: As you know, the book was born before the pandemic. But the book outlines key aspects of health issues and health policy that have turned crucial in the pandemic time. Inequities, self-responsibility. capping health services, all of these aspects as being of paramount importance today. Inequities are avoidable. Self-responsibility shifts the focus from social dimension to individual. Neoliberal budget constraint, as term in cutting services that have been crucial in front of pandemic, such as the community care services in Italy.
DR: At the beginning pandemic we all watched it as northern Italy experienced a terrible outbreak the resulted in many deaths and so I'm curious looking at Italy is there are a difference in the way healthcare is administered in different states?
AG: Yes, actually, as Italian Association of Sociology, the sections for sociology of health and medicines, we are working together to investigate process of such suffering because Lombardi in the north of Italy, the region of Milan and Bergamo at a very high level of death. And we know that Lombardi is the more dynamic region from the economic point of view, but it is also the region with the highest level of air pollution. And moreover, its original regional health system strongly has moved towards private healthcare system the last decades under the neoliberal reform process. We are not in the condition now to show any kind of correlation, but data about the reduction of GP and primary care in Lombardi in the north of Italy, in comparative perspective, with other Italian regions, I'm afraid these data are going to tell us something about different regional health care models. And again, differences in health care regional experiences and models are example of the decentralisation process, which is another key element in neoliberal policy, as well as the managerialisation of our system.
DR: I'd like to turn to Mario now. Mario in your chapter The Neoliberal Politics of Otherness in Italian Psychiatric Care you write about the Basaglia’s law passed in 1978. I had never heard of this before and I found it really fascinating. Can you begin by telling us about psychiatry before this date, and then about the law and what it changed?
Mario Cardano: Ok, I’ll try. In the past century, the Italian psychiatry was based mainly in a network of mental hospitals. The inpatients condition were very, very similar, very close to those of any other European countries, the psychiatric cure in the last century was a disaster, and the cures were very primitive based on a mix of coercion and very rudimentary procedures meant to extract the madness from the body of sufferers, like hydrotherapy, malaria therapy and electroshock with many other coercive measures. Things changed radically in the 50s when we, when new medication were discovered. And the psychotropic drugs, promoted rather the possibility to create a relationship with the patient, but also radicalisation of the bio pharmacological approach to madness. That was the cipher of the first season of psychiatric story. And during the 60s and the 70s, all in the Europe, a critical view against the asylums, against the bio pharmacological approach to madness emerged. And in Italy with many enlightened minds and among them one of the most effective was Franco Basaglia in changing all the things. At first, Basaglia tried to demolish the asylum within its own walls, even remove the railing from the window, banned the use of electroshock, mechanical restraint and eliminate uniforms, both in the staff and the inpatient. But in the end, he realised that all these measures have produced nothing more than a form of repressive tolerance. So, the mental institution, Basaglia conclude, these the topic of the Brazilian conference that asylum cannot be reformed, it must be denied. So, in 1978 we started with the, what can be considered the most relevant reform of the Italian law, the closure of asylums started. But to conclude, of the process, we have to wait the beginning of this century, and it takes about 30 years. A new practice of cure and care was introduced that into the underlined the role of community based services. And this is the Basaglia revolution, but it was not so a permanent result because recently, the political climate has changes dramatically. And the Italian National Health System has carried out some very important cut in the funding reduction of investment and these following the idea of the neoliberal philosophy, jeopardising deeply the scope of the Basaglia revolution.
DR: So, you discuss how private industry in psychiatry developed after Basaglia’s Law passed, so after 1978. Can you talk about this business of madness that developed after this?
MC: To be effective, the shut-down of the asylum required a huge investment in the community care and also in the training of health staff, nurses, doctors, and so on. These kind of investment contrasts with the neoliberal idea of a state as a night watchman, and the deep cut in the national health system seem to inspire to this idea. So, where the community services are not developed the market arrive offering beds are not properly to a therapeutic community for individual without a place in society, offering personnel to guard them when they are dangerous, or considered dangerous, offering some kind of private prison in that direction. So, the idea is that having not fully realised the movement from the hospital to the community service in the middle, the market arrived, and there is the business of madness.
DR: Well, you also talk about the politics of otherness in your chapter and you give two specific examples of what you mean by this and you talk about inappropriate hospitalisation and extreme physical restraint. Can you tell us about otherness and how it is treated in psychiatry?
MC: Okay, with politics of otherness Luigi Gariglio and I, Luigi Gariglio was the co-author of the essay, we mean any kind of politics adopted toward all kinds of differences, which inhabit all of us, ethnic, sexual, religious, any different way of being in the world. In our essay we consider the two main strategies to tackle the otherness typical of the asylum, but still present in the acute psychiatric ward where we carry out the ethnography recently. So, we observe, both the inappropriate hospitalisation and also the extreme physical restraint. With inappropriate hospitalisation, we mean the custody in an acute psychiatric ward of people without any very real psychiatric diagnosis. These can be due to the hospitalisation of criminal, but also people like homeless, immigrants and so on and this can be read in a double way. Acute psychiatric ward became a sort of garbage can where any kind of people that do not satisfy the requirement of dignity, and the civility typical of the liberal, neoliberal ideology were sent. And the other idea is that of the medicalisation of any kind of difference, any kind of otherness that became a clinical label to be treated with medication and so on. The second politics that we observe is the extreme physical restraint that meant to tackle unmanageable and disruptive behaviours.
DR: You mentioned it just now and I read about it in your book, about how you give an example of a homeless man who had been picked up and had been brought to a mental hospital. And I'm wondering if there has been reform to prevent things like that from happening. Has there been any type of a movement to reform so that hospitals aren't sort of catch-all’s for these others that we pick up in society that don't seem to have a place?
MC: In a way there is, but it is not so easy to manage because homeless or migrant who arrived in an acute psychiatric ward are in a way the start, but their kind of illness is not a psychiatric illness. It is the illness of poverty, the illness of exclusion, and they react, maybe in a very dramatic way to this kind of situation. So, it's not a matter to reform psychiatry, it’s a matter to reform society, avoiding this kind of discrimination against poor people, against different people due to their migration trajectories, and so on.
DR: That's really interesting. At this early stage, what are your thoughts on mental health and its treatment in Italy during the pandemic?
MC: Okay. During the pandemic we had two different impact, in my view, from psychiatric patient. The duress to carry on living in a tense familiar context can produce an increase of suffering, both for them and for the caregiver. In the other side for the help, staff, either the one committed in the cure of mental health, and the other committed in the cure of any kind of disease, mainly the COVID infection, we realise any severe attack to their mental health, and we are going to pay the consequence of this kind of overworking and over emotional involvement in the next months and also maybe in the next years.
DR: Yes, we're going to be seeing the effects of the pandemic for a very long time. But thank you for joining me today to talk about this.
MC: Thank you.
AG: Thank you.
DR: We'd like to thank you for listening to today's episode. For more information about Health and Illness in the Neoliberal Era in Europe, please see our show notes on our website along with the transcript and more information about our guests. I'd like to thank Jen McCall for her work on this episode, and Alex Jungius from This is Distorted.