Reasons to be cheerful: the ‘count your assets’ approach to public health

by Lynne Friedli

Living on nothing is trying not to hear the intellectual

arguments and lofty ideals about

living on nothing put forward by those who

are not living on nothing.

Living on nothing is dying.

Out of the Shadows: Liz Prest (ed)

At the close of 2010, Harry Burns, the Chief Medical Officer (CMO), launched an Assets Alliance for Scotland.[1] Designed to tackle Scotland’s ‘intractable problems’, the report on the event makes some powerful assertions, both about the role of the public sector ‘what we have tried to date (although well meaning) has not worked’ and about the nature of the problem in poor communities. In a significant sleight of hand, Scotland’s health problems are now said to be ‘exacerbated by’ poverty, unemployment and poor physical and social environments. In other words, the root causes lie elsewhere. These are described as a combination of the culture of dependency engendered by public services (which also stimulate unaffordable demand) and ‘something within the spirit of individuals living within deprived communities that needs healed’. As one of the participants at the event said: ‘the issue is one of spiritual disease – people are buying out of life’.

This move to cultural and psychological explanations for inequalities in health and other outcomes in Scotland is not new. It serves to disguise the link between health and living conditions and has been seen by anti poverty campaigners as part of a wider process of ‘othering’ the poor (McKendrick et al 2011). As ‘assets based approaches’ look set to become a central driver, reshaping the direction of public health in Scotland, it’s worth reflecting on what’s at stake. What lies behind the assets agenda – ‘supporting the inner and innate assets in these individuals and communities’ – and what does it mean for the politics of public health?

Interest in assets was a strong feature of the CMO’s latest Annual Report, which rehearsed the now familiar argument that deprivation cannot explain Scotland’s poor health. Other European regions, (notably Eastern European), appear to have a resilience which has allowed them to benefit from changed socio-political circumstances.[2] As has been widely commented upon, the rise in mortality from 1980 in Glasgow is greater than in Manchester and Liverpool, the other most deprived cities in the UK.

It’s not clear what explains Glasgow’s recent excess mortality from drugs, alcohol, suicide and violence, largely among working age adults. In a systematic assessment of seventeen hypotheses, Gerry McCartney and colleagues argue that the health and social patterns that emerged during the 1980s and 1990s were strongly shaped by the abruptly changed political and economic policies of the UK. The political attack on the organised working class during these years had a distinctive impact on Scotland, triggering many other factors. Scotland was particularly targeted and particularly vulnerable, with a high dependence on industrial jobs and social housing (McCartney et al 2011). These are important issues, still influencing the political and emotional landscape in Scotland, and a reminder that an analysis of class conflict can (still) contribute centrally to understanding health.

At the same time, the Glasgow effect can become a distraction. Chronic diseases continue to contribute to excess mortality and even if life expectancy in Glasgow was on a par with Liverpool and Manchester, it would still be among the worst in the UK (and Europe). Public health could focus on addressing the 50% or so of the West of Scotland’s health deficit that is explained by deprivation. The Report of the Commission on the Social Determinants of Health is a powerful statement of where attention should be concentrated: health inequalities are a symptom, an outcome, of inequalities in power, money and resources. Achieving a more equitable distribution of power requires collective social action (CSDH 2008).

So where does an assets approach fit in? Drawing on Antonovsky, Burns proposes a shift in focus from the determinants of illness to the determinants of health (salutogenesis) and to a ‘sense of coherence’ as the key resource that enables individuals to manage difficult or stressful environments successfully. It’s now well understood that chronic stress contributes centrally to poor physical health, notably through its impact on neuro-endocrine, cardiovascular and immune systems, influencing risk factors for heart disease, diabetes and liver disease. There’s also a familiar social gradient in levels of stress. Chronic stress is strongly correlated with lack of control and low social status, which in turn are directly influenced by levels of material wealth. It’s an ironic, as well as opportunistic twist, that Burns uses a quote from Jimmy Reid on alienation – ‘the cry of men who find themselves the victim of blind economic forces beyond their control’– to support his focus on psychological resources.

No doubt a sense of coherence is some people’s birthright. Viewing the external world as meaningful, understandable and manageable may be entirely rational, or, from the perspective of a number of streets in Glasgow or Motherwell, entirely delusional. Either way, are we now to promote a uniformly upbeat way of interpreting the world? Unfortunately, sound Scottish traditions of negative thinking have become taboo in public health circles: it’s more important to be positive than to have an accurate perception of reality.

And yet. By their nature, assets based approaches are about strengths and in particular, resilience or what enables individuals and communities to survive, adapt and/or flourish, notwithstanding adversity. They speak to the resistance of deprived communities to being pathologised, criminalised, ostracised; to being described in public health reports in terms of multiple deficits and disorders: ‘chaotic, unengaged, and disaffected’. Concepts like co-production challenge the ‘professional gift model’, empower citizens and involve recognition and respect for their knowledge, skills, preferences and potential. These themes are familiar in the policy literature on personalisation, expert patients, self management and anticipatory care but have their (more radical) roots in disability rights and the early recovery movement.

The importance of psycho-social assets is also central to critiques of consumerism, materialism and ‘economic growth at the cost of social recession’. These come together in calls to value the contribution of those outside the money economy: the core economy of friends, family, neighbours and civil society. What’s at stake here is a discourse about what hasn’t been valued and the view that ‘wellbeing does not depend solely upon economic assets’ (Sen 2010). The Stiglitz Report, commissioned by President Sarkozy, calls for measures of social progress that include non-market activities, sustainability and quality of life , as does the OECD Global Project on Measuring the Progress of Societies. In the UK, the Office for National Statistics has just completed a public consultation on ‘what influences wellbeing?’ [3] Just as there is a need for measures that go beyond economic performance, that provide a more complete picture of ‘how society is doing’, there is a need for a more complete picture of health, one that includes the determinants of both illness and health. Deficits and Assets.

Both assets approaches and the wider wellbeing debates are strongly associated with a non-materialist position – money doesn’t matter as much as relationships, sense of meaning and purpose, opportunities to contribute and autonomy: there’s a difference between starving and fasting. Recent years have seen significant efforts to acknowledge and measure the non material dimensions of poverty – perhaps most famously in Amartya Sen’s call for ‘the ability to go about without shame’ to be recognised as a basic human freedom. People living in poverty, as well as other vulnerable or excluded groups, consistently describe the pain of being made to feel of no account, which is often experienced as more damaging than material hardship. From this perspective, inequalities greatly exacerbate the stress of coping with material deprivation.

The social gradient in both mental illness and levels of mental wellbeing shows the clear relationship between psychological distress and the material circumstances of people’s lives. Of course communities with high levels of poverty are also rich in friendships, mutual support and social networks. However at a population level, which is what should inform public health policy, loneliness, isolation, lack of support and feelings of anxiety and depression are much more common among those in the poorest deciles (Taulbut et al 2009). The mental wellbeing of children is particularly strongly influenced by household income (Green et al 2004).

The problem then is not that the Assets Alliance addresses psychological and cultural issues, but that it does so without also emphasising the material basis of inequalities in life chances, health, opportunities and everyday experience in Scotland today. Without acknowledging that for the poorest, the material benefits of solidarity – real power to effect change – have been ripped away. Collective traditions of making meaning out of adversity have built strength through a shared analysis of inequalities in privilege, power and resources. Feminism, civil rights, trades unions, gay liberation, disability rights and the survivor movement have all understood psychological distress as a symptom of oppression. Respect for people’s strengths, endurance and resistance should enhance, rather than distract from, the struggle for social justice.

In the CMO’s Annual Report, somewhat selective quotes from ‘assets based’ programmes down South imply that supporting people to work together and take control can be abstracted from the material realities of their lives. In fact, nothing in the case study of Beacon and Old Hill Estate suggests causal factors other than the social determinants of health:

These meetings led the community to conclude that the main problems affecting their health were crime, poor housing, and unemployment, together with the historical failure of the statutory agencies to address these issues (Durie et al undated).

The Annual Report reinforces the view that the primary determinants of health in Scotland these days are moral and psychological – dependency and spiritual malaise. But success stories of community activism and empowerment involve resources to address structural issues – for example the central heating installation in the Beacon Project:

Among the outcomes initially achieved by the Partnership was a successful bid led by Penwerris Residents Association for £1.2 million of Capital Challenge funding, matched with a further £1 million funding from Carrick District Council. This money was used to fund the central heating and energy efficiency measures, and led to the installation of central heating in 300 properties, with a further 900 properties being reclad (Durie et al).

Perhaps a more central question is why the assets based approach in Scotland should be so narrowly focussed on inner and innate assets, rather than on people’s rights to a greater share of Scotland’s wealth. More comprehensive asset mapping provides a framework for increasing equitable access to a wide range of valued resources. These might include green space, blue space (canals, rivers and lochs), land for growing, public squares and buildings, cultural treasures, a bus or taxi service, fresh food, affordable credit, a well loved pub, library, corner shop, hairdresser or pharmacy. They might of course also include public services and the values of pooled risk, safety nets, and collective responsibility for need. This wider approach can link asset mapping with action to gain or preserve resources for disadvantaged communities: access to public sector buildings, evening use of school facilities, restoring footpaths, transport to the nearest loch or beach, clearing waterways, planting an orchard, recycling electrical appliances. The dismal state of many of Scotland’s railway stations – bleak, identikit zones, policed by CCTV and tannoy, devoid of staff, comfort or charm – a potent example of an eroded asset with potential for transformation.

What’s tragic about all this is that the wider Scottish policy environment for reducing poverty and inequality is favourable, but sustaining progressive elements in the current climate will depend on support, not least from public health. Positive trends in poverty rates in Scotland are stalling but the improvements made in the decade 1996/7 to 2005/6 (a marked decline in the proportion of people living in absolute and relative poverty; a reduction in child poverty rates from 33% to 24%) show what can be achieved (McKendrick et al 2011). The fact that this still leaves child poverty far higher than in the late 1970s/early 1980s shows the extent of the challenge and is one of the contexts for assessing what has worked to improve health.

Public health also needs to be a strong and consistent voice on income. The Scottish government’s commitment to reducing income inequality (the solidarity target) has some limitations – what is happening to the poorest is hidden by targets that focus on the bottom 30% – but it’s a hugely important aspiration. Public health could provide crucial leadership and evidence here, pointing out that the extreme widening of the gap in income growth between the poorest 10% (growth of 2%) and the top 10% (growth of 48%) has profound consequences. It’s perhaps a cheap point to note that income in the higher echelons of public health situates these professionals well within the top decile, where the feeling that life is meaningful is daily reinforced by material reward.[4] And the social and emotional distance between those who design interventions and those who experience them widens.

The Assets Alliance situates itself as part of the solution in achieving public spending cuts, promoting a DIY response to loss of services and loss of benefits. It has nothing to say in its ‘glass half full’ vision about the true causes of disempowerment: “a man goes to work full time and still has to get the social because wages is so low; he needed that money to keep his kids”. Nothing to say about the lived experience of ‘incentivised employment’, the impact of restricted eligibility and cuts in social care. Instead of pointing out that the current welfare system erodes the foundations of community health, it rehearses slurs about dependency that would not be out of place in one of David Cameron’s ‘big society’ speeches.

Or is this unduly harsh? The radical agenda that inspired commitment to assets based approaches still needs addressing. Of course services can and should deliver in ways which are more responsive, empowering and equitable; which address the public sector’s own role in creating and reinforcing barriers to collective efficacy. But it’s deeply disappointing to see what should be a debate about transforming the relationship between services and people who are disadvantaged, replaced by efforts to stigmatise need. The problem is not dependency: dependency is a fact of the human condition, not a moral failing. The problem is responding to people’s needs in ways which are demeaning and undermine choice and self determination. If public health doesn’t know this, with its special responsibilities for those who are vulnerable, is it any wonder that the public often experience the NHS as ‘lacking in compassion’? [5]

Respecting and valuing people cannot be separated from their human rights, nor issues around vulnerability, control and autonomy from questions of social justice.[6] Economic and environmental disadvantage structure the relationship between deprived populations and services. Cultural change in professional practice cannot be achieved without facing up to the impact of steep income and status hierarchies within the public sector. Or the wider debates that should inform public health advocacy: on rights, on redistribution, on minimum incomes, on policy shifts that have diminished social housing stock and its status and have privileged home ownership. Without these debates, assets approaches serve to encourage the fantasy that Scotland’s problems can be tackled without the awkward task of addressing power and the reality of competing interests.

Even so. Can anything be retrieved? Can something be salvaged? There are conversations to be had about reclaiming the language of assets, perhaps as part of struggles to regain community co operation. In many different contexts, we’re seeing new routes to resistance and new forms of expressing solidarity. These may be the collective traditions of the future, but let’s not forget they’re still about people fighting for a fairer share of valued resources.

A key strength of assets based approaches is to insist on the power of the human spirit: in any circumstances, ‘the air I breathe is mine’ as Micheal O’Siadhail notes. But would public health be better occupied insisting on a fairer distribution of Scotland’s more material assets?

Thanks to Margaret Carlin

Notes

Assets Alliance Scotland http://www.scdc.org.uk/assets-alliance-scotland/
CMO Annual Report 2009 http://www.scotland.gov.uk/Publications/2010/11/12104010/0
ONS National Wellbeing http://www.ons.gov.uk/well-being
Institute for Fiscal Studies Income Calculator http://www.ifs.org.uk/wheredoyoufitin/
Ombudsman http://www.ombudsman.org.uk/improving-public-service/reports-and-consultations/reports/health/home
Centre for Welfare Reform http://www.centreforwelfarereform.org/

Sources

CSDH (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization

http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf

Durie R, Wyatt K, Stuteley H. Community Regeneration and Complexity http://www.healthcomplexity.net/files/Community_Regeneration_and_complexity.doc.

Friedli L (2009) Mental health, resilience and inequalities – a report for WHO Europe and the Mental Health Foundation London/Copenhagen: Mental Health Foundation and WHO Europe http://www.euro.who.int/document/e92227.pdf

Green, H., McGinnity, A., Meltzer, H. et al. (2005) Mental Health of Children

and Young People in Great Britain, 2004,

www.statistics.gov.uk/downloads/theme_health/GB2004.pdf

McKendrick JH, Mooney G, Dickie J and Kelly P (2011) Poverty in Scotland 2011 – towards a more equal Scotland? London: Child Poverty Action Group

McCartney G, Collins C, Walsh D & Batty D (2011) Accounting for Scotland’s excess mortality: towards a synthesis Glasgow Centre for Population Health

http://www.gcph.co.uk/assets/0000/1080/GLA147851_Hypothesis_Report_FINAL_high_resolution.pdf

Prest Liz (ed) Out of the Shadows

http://www.atd-uk.org/publications/Pub.htm

Scottish Government Social Research (2011) Tackling Poverty Board: a summary of the evidence http://www.scotland.gov.uk/Topics/People/tackling-poverty/EvidenceReport

Sen A (2009) The Idea of Justice Allen Lane

Taulbut, M., Parkinson, J., Catto, S. and Gordon, D. (2009) Scotland’s Mental Health and its Context: Adults 2009 Glasgow: NHS Health Scotland

[1] http://www.scdc.org.uk/assets-alliance-scotland/

[2] http://www.scotland.gov.uk/Publications/2010/11/12104010/0

[3] http://www.ons.gov.uk/well-being; the event in Dundee, organised by the local Equally Well team, focussed on the question ‘does unfairness affect wellbeing’ and attracted over 70 people, many with a wealth of direct experience of this issue in the context of poverty, disability, low pay and benefits.

[4] http://www.ifs.org.uk/wheredoyoufitin/

[5] http://www.ombudsman.org.uk/improving-public-service/reports-and-consultations/reports/health/home. This investigation concerns England; the extent to which these findings would be replicated in Scotland is an important question.

[6] http://www.centreforwelfarereform.org/