The Cedar Lounge Revolution

Vincent Browne has advice for the left in the Irish Times on Wednesday. More particularly he has advice for the Labour Party. He spoke at the weekend at the Labour Party Youth conference in Galway. We’ll get to that advice in a moment.

Firstly he made an interesting point, that:

Labour has been in power 14 of the last 34 years. It has been in office for longer than any other party, aside from Fianna Fáil.

It’s something I hadn’t thought of before, but of course Labour has worked with both Fianna Fáil and Fine Gael in that time, so inevitably it would have a slightly greater slice of the governmental pie than our supposed ‘main’ opposition party. Great, we can blame them for slightly more of the ills of the society than we had already.

But briefly, he argues that:

Labour was … in government from 1982 to 1987 and once more from 1992 to 1997. In the 15 years from 1982 to 1997, Labour was in government for 10 years. And one of the legacies left by Labour in government is demonstrated in a report by the Institute of Public Health entitled Inequalities in Mortality (and I apologise for going on and on about this yet again).

This report reveals that in the period 1989 to 1998, during most of which time Labour was in office and appeared to have succeeded its period in office from 1982 to 1987, for all causes of death, the death rate of those in the lower occupational classes was three times higher than the death rate for those in the higher occupational classes.

The death rate for all cancers among the lowest occupational class was over twice as high as for the highest occupational class and nearly three times higher for strokes, four times higher for lung cancer and six times higher for accidents. Ruth Barrington, a former director of the Health Research Bureau, has extrapolated the data from the Institute of Public Health report and concluded that 5,400 people died prematurely every year because of inequality. This is part of Labour’s legacy from its time in office in the 1980s and the 1990s.

I wouldn’t take issue with those figures at all. They’re a crushing indictment of our society as a whole. But to point the finger solely at the Labour Party seems somewhat unreasonable. One might also argue that some context wouldn’t go amiss, for example it would also be important to see whether there was any reduction in the number of deaths over that time period.

And if one turns to P.175 of the original report available here one will read:

3.5 Limitations
Underlying limitations in the data used have certainly affected death counts and
mortality rates. Until the methodological issues described in Part Three are better
understood, some of the results presented here are best interpreted cautiously.
The decade 1989-1998 was a period of great social, political and economic
change throughout the island. The pooling of ten years data, while increasing the
number of deaths involved, means that any temporal trends in mortality are
ignored. The choice of health (and social services) board areas and urban centres
for regional analyses means that variation within these regions is not reflected in
the results. Small area analysis of mortality statistics is not considered and nothing
is reported about special groups such as Travellers and minority ethnic groups.
Finally, we should recognise that patterns in mortality reflect not only underlying
disease and disability in a population, but also the care seeking behaviours of its
members, the way it locates and operates its health care services, the practices of
its health care workers, its methods of death registration, and patterns of internal
migration. Consideration of these and other issues is required when interpreting,
for example, regional differences in mortality.

Here is the problem. 1989 to 1998 was indeed a time of great change. To take the aggregate figures and not consider changes means that we are ignoring a large element of the picture. To then construct a thesis that this is in some sense the responsibility of Labour is a step too far. Not least because it ignores the point that first Labour was in a minority position in all the governments of which it was a member, and that, as with the late 1980s FF government, even more iniquitous policies as regards the health service were carried out. Does Labour get credit for ameliorating the situation, if only slightly? It does not.

But there is some other data which points to the direction the graphs were moving in over the time period.

If we look at the World Health Organisation we can see here a slightly different picture over the years from around 1995 to 2001.

As the WHO notes:

Vulnerable populations
Income

The evidence on determinants of health shows that people who are socioeconomically disadvantaged bear the greatest burden of disease. Among determinants, income is related to an accumulation of factors that affect mortality (Martikainen et al., 2001). For example, it influences and is influenced by education and employment.

It continues:

Even in the richest Member States in the WHO European Region, wealth is not equitably distributed and pockets of relative poverty exist (WHO Regional Office for Europe, 2002a; WHO, 2002). The association between poverty and urban areas is particularly important in Europe. As populations migrate and become more urban, there are increases in the number of urban poor whose housing, employment conditions and diet expose them to greater risk of illness and disease (WHO Regional Office for Europe, 2001b). The nature and impact of poverty on people can vary according to factors such as gender and age group (Ziglio et al., 2003).

According to the GINI index, Ireland’s income inequality was rated at 35.9 in 1996, which is relatively high when compared to the Eur-A average of 30.8 (WHO Regional Office for Europe, 2002a). During the period 1987-1997, about 12% of Ireland’s population was living below 50% of the median income level, ranking fourth among Eur-A.

Again, these are not good figures, particularly for a state entering into it’s longest sustained period of significant positive economic growth.

Ireland measures poverty in terms of consistent poverty and at risk of poverty. Consistent poverty is measured using a combination of relative income (in this case mean income) and deprivation, the indicators of which are based on surveys of what Irish people consider necessary to ensure an adequate standard of living. At risk of poverty is based on relative income and identifies those with an equivalised individual income that is below a certain threshold. For the European Union, the threshold is 60% of the median income level.

IMAGE OF CONSISTENT POVERTY

Between 1994 and 2001, the percentage of the population in Ireland in consistent poverty fell (ESRI, 2003). Among children, consistent poverty fell between 1997 and 2001 (from 15.3% to 6.5%). However, during the same period, the percentage of households deemed to be at risk of poverty increased.

I think the latter figure (and let’s not ignore the possibility that these figures are open to question) is interesting, and points to a political issue, relating to government formation, which I’ll return to in a moment.

But let’s look at the mortality data for the period 1995 to 2001. This doesn’t take into account occupational classes, although implicitly we can draw tentative conclusions from age cohorts. What is most striking is firstly that mortality rates are in decline (with percentile decreases tending towards the high teens and right through into the thirties) across a range of areas, bar digestive diseases. Even in the particularly vulnerable 65+ age cohort we see significant declines.

And this tallies with a graph that notes that life expectancy in the EU is increasing (particularly in contrast to other regions of the planet), and has done so since the 1970s.

Which points to another problem with his argument. We are not presented with evidence of mortality figures in the decades preceding the period in the IPH report. So it is impossible to judge whether – grim as they are – the IPH figures actually represent an improvement or not in inequalities.

And all of that taken into account I genuinely don’t understand Browne and a leap of logic in the next part of his article:

That might be regarded as “history” and one has to “look forward”. But wouldn’t you think that Labour would reflect on how it was that it allowed such gross and obscene inequalities to persist while it was in office? Would you think they would wonder how it was that removing or at least radically reducing such inequalities would have been a priority for them in office, and wouldn’t you think they would now analyse why this did not turn out to be the case?

Might it not now reflect that its purpose, as a Labour Party, is to remove or radically lessen such obscene inequalities and that it would appreciate that this cannot be done without changing the political culture that regards such inequalities as “unavoidable”? And that such a change in the political culture would take time and persistence and also, inevitably, would require Labour forsaking office for the foreseeable future?

Firstly, it could be argued that as they have been in opposition for over a decade they have had just such an opportunity to rethink and reprioritise, and there is some evidence to suggest that they have attempted a number of political tactics to reposition themselves. But it’s also based on the assumptions that firstly the Labour party is entirely serious about redistribution and in favour of radical measures to curtail inequality – two interesting theses I think most will agree, and secondly that eschewing office is going to ‘change the political culture’. He may be right as to the latter, but how precisely he does not spell out (Unless his argument is that Labour, in some indeterminate, or at least unstated, fashion increases inequality. And I’m not sure that that party, whatever it’s flaws, is responsible for that).

But consider the term “radically lessen”. There is no way to determine from the IPH report whether there has been a decrease, increase or stasis in mortality rates. By contrast the mortality figures from the WHO present us with significant decreases. What is now needed is clear data on mortality in occupational classes during that period so that we can see whether there has been a parallel in mortality decreases for those in disadvantaged socio-economic groups, although it’s hard to see why there wouldn’t have been (my prediction though would be that while decreases would exist they would be lesser).

But had Browne tied the WHO data to the IPH data then he’d have had to write a different article, one which was less condemnatory of Labour, while recognising their hand in overseeing income and health inequality. This is problematic, obviously, and it’s worth noting how Browne is a better correspondent than this. His column in the SBP throws up some usefully provocative thoughts, all the better for the generally moderate tone of them.

And indeed in the first part of his piece he makes a much better case for Labour rethinking its position when he notes, as Donagh has on Dublin Opinion, their complicity in Cabinet in the 1970s sitting on the Kenny Report on Building Land which “advocated that just slightly more than the agricultural value of land would be awarded in compensation to landholders whose land was deemed appropriate for the building of houses”. Now that was a disgrace. But even still, there’s something a little bit unconvincing about it… that also was in the early 1970s under an entirely different generation of Labour party leaders. And since then we’ve seen arguably two – perhaps three – other generations come and go. This may well amount to a sort of political original sin. Or it may not. The crucial thing is that the Kenny report has been shelved in the intervening years by governments of all stripes. A different way of putting it would be, well, what did he expect of that version of the Labour Party with people like O’Brien et al in Ministerial positions? And let’s reverse the argument. Does the introduction of the NHS in the 1940s exonerate Blair et al for their misdeeds? It does not. So why should the reverse process be in operation for the ILP?

And what of other countries? Presumably Browne has some ideal, although he does not articulate it. So what of inequality of outcomes in health in, say, Sweden?

An interesting report is available as PDF here of a study published in the British Medical Journal from Gothenberg into coronary heart disease which concluded that:

After a mean of 11-8 years’ follow up the incidence of
coronary heart disease was found to be strongly and
inversely related to occupational class. For death
from coronary heart disease this association fell just
below significance when other risk factors were
taken into account, but the inverse association
between non-fatal myocardial infarction and
occupational class persisted even in multivariate
analysis. A weak but independent inverse relation
was found between occupational class and fatal
cancer. Mortality from all causes in the lowest
occupational class was 12% compared with 6% in the
highest class, and this difference could only partly be
explained by other factors. After 10 years a subsample
ofthe men were examined again. Risk factors
had decreased in ali occupational classes, but the
changes in risk were not associated with occupational
class.
Social class, defined by occupation, in Sweden is
clearly related to the incidence of coronary heart
disease.

The percentages? Curiously similar.

Table II shows the, strong inverse relation between
occupational class and all coronary end points. The
rate of coronary heart disease in occupational class 1
[unskilled and semi-skilled workers] during follow up
was more than twice that of occupational class 5
[employed and self-employed professionals,
higher civil servants, executives] (8.8% v 3.8%).
For non-fatal myocardial infarction and total
coronary heart disease the odds
ratios for the lowest in relation to the highest class were
only slightly reduced ~when other risk factors were
taken into account. Coronary death, however, was not
independently associated with occupational class, even
though the lower limit of the confidence interval was
close to one. The incidence of stroke (fatal and nonfatal
combined) during follow up was similar in all
classes. Deaths’ from cancer and all cause mortality
were significantly and inversely associated with
Iforemen in occupational class. The figure shows the cumulative
nals, higher mortality of the different classes and shows a continuously
widening gap between the highest and lowest
occupational classes over time.

The study was conducted between 1970 and 1983. Granted, some time ago, but surely in the context of a highly efficient longstanding health system such as the Swedish one indicative of the difficulties in ameliorating such inequalites, and also, arguably, the impact of lifestyle elements on health. This latter is an important factor.

A retrospective analysis of the
data showed that low occupational class was associated
with slight increases in smoking rates, systolic
blood pressure, serum cholesterol concentration,
body mass index, and heart rate. Alcohol abuse was
strongly associated with low occupational class.

That said there is no dismissing the conclusion that:

Our data suggest that the impact of socioeconomic
factors is far from negligible. If the low mortality in the
highest occupational class had prevailed for the entire
study population (participants and non-participants)
fewer than 600 men would have died during the follow
up period, instead of nearly 1300-a net loss of more
than 700 lives. The results from this study, however,
must be interpreted with caution. The classification
used was developed several years after the screening
examination, and the classification of the men into the
different categories was also done at a later date,
though the data on occupation were collected at the
first screening. This also means that there was no prior
hypothesis, and the results must be seen accordingly.
Also the data are not consistent with earlier Swedish
investigations even if more recent reports seem to
confirm the results of our study. More national
research on this subject is certainly warranted.

And it argues:

In conclusion, we found a clear inverse relation
between occupational class and the incidence of
coronary heart disease and total mortality entailing
many excess deaths in the lower socioeconomic strata.
Possible reasons include differences in patterns of risk
factors, and in lifestyle, effects of occupational
hazards, and low social support, but no clear answer to
why class differences persist has been forthcoming.
The magnitude of the problem certainly warrants
further study, not least from a preventive point of
view.

Or the UK with an equally well embedded health service, albeit one fractured by a decade and more of Toryism? The Independent Inquiry into Inequalities in Health of 1998 found that;

Mortality
Over the last twenty years, death rates have fallen among both men and women and across all social groups25,29. However, the difference in rates between those at the top and bottom of the social scale has widened.

For example, in the early 1970s, the mortality rate among men of working age was almost twice as high for those in class V (unskilled) as for those in class I (professional). By the early 1990s, it was almost three times higher (table 2). This increasing differential is because, although rates fell overall, they fell more among the high social classes than the low social classes. Between the early 1970s and the early 1990s, rates fell by about 40 per cent for classes I and II, about 30 per cent for classes IIIN, IIIM and IV, but by only 10 per cent for class V. So not only did the differential between the top and the bottom increase, the increase happened across the whole spectrum of social classes29.

I have to stress that I’m not arguing that nothing can be done, or ignoring or dismissing health inequality. Quite the opposite. I fervently believe that much much more can be done, that the outcomes in a comprehensive national health service will be much better and that, to echo the piece above, preventative actions encouraged by an Irish NHS are not merely desirable but essential.

I am suggesting that Brownes charges may be – somewhat – misplaced and that since health is at the heart of a progressive agenda the way in which we frame the arguments must be thought through carefully in light of actual data about outcomes.

I’m certainly not suggesting that the IPH report is in some sense wrong. Again, quite the opposite. It is the essential first step towards diminishing health inequality. And further contextualisation is necessary because as we can see from the UK health inequality can increase as well decrease. Everything depends – to a large degree – upon the nature of the political context.

And this leads to some interesting thoughts about how our present situation might have been had we had an FG/Labour coalition over the past decade. I’d suspect that had we been spared the excesses of the FF/PD coalition of the past decade we might have seen a marginally lesser increase in inequality under an FG/Labour coalition. I can’t be sure, but I tend to think that co-location for one, might not have been placed front and centre of political activity in this state. And as with that so with other smaller issues, including the introduction of marginally greater labour law protection which potentially could have mitigated the ‘at risk of poverty’ figures due to a broader sense of a social contract due to the involvement of the Labour Party, minimalist as it is – and not least a voice for the unions actually at the Cabinet table.

I genuinely can’t see how public expenditure could have been directed to less socially progressive ends in the event of such a government, particularly during an economic boom – and as someone with no love of Fine Gael as a political vehicle that’s not an easy statement to make.

But I recognise that that argument is one that takes the line of the ‘lesser evil’, the bane of progressives everywhere. We know governments were going to be formed. We know these governments would have negative impacts on issues of equality. What is better, to go for the one that results in lesser negative impacts or to permit the one that will generate greater negative impacts in the hope that the electorate will eventually see sense? And what then of that greater number of people who suffer in the latter case? Add to that the reality that political choices don’t exist in a vacuum, that for example, arguably the Peace Process might have taken a different route as well. So, how to judge?

This brings me to my central problem with the article. It’s fine to say Labour should step back. I agree and a number of us have argued the same here and here on numerous occasions [and again, Donagh at Dublin Opinion has a take on the broader message for the Labour Party which I agree with]. But there is no point, none at all, in doing that without a political strategy, one that seeks to link with other progressive forces and to move the situation forward. Yet curiously Brown doesn’t articulate that strategy, not in the slightest. He lashes Labour by pointing to a disgraceful episode over a quarter of a century ago, then by selecting figures which while atrocious simply can’t be used to support an argument on this specific issue one way or another, and then as if there is some logical connection argues that by recusing itself something will happen. Not sure that it will. Not sure at all. Not least because having viewed the progress of the Green Party in the last year, I believe that given the choice Labour wouldn’t run towards power. This last time out due to a very specific set of circumstances that wasn’t an option. Next time? Let’s not bet the house on them staying out.

And the problem is that there are strong counter-arguments which the data would support for making a decision to go into government in order to ameliorate the issues he points to. If Labour must take the rap for the IPH report then surely it must equally be given some credit for mortality decreases found in the WHO data? After all, the years the WHO looks at overlap at the start the last period Labour was in government, a full five year term as it happens.

Or could it be that the reality is that mortality rates, while linked to political, societal and economic decisions, aren’t dependent on political dynamics in the sort of crude casual fashion Browne posits in order to make his political point. That, it is true that a strong and sustained campaign will decrease inequalities, but that the outcomes may not be quite as he expects. And how does this work politically? By rights, using health as one axis, using others shouldn’t Fianna Fáil, or indeed Sinn Féin, stand down from government or thought of government since they have been evidently unable to bring about a United Ireland during the same time. What of Fine Gael (of which Browne, curiously, was in discussions with, how serious is uncertain, at one point about standing as a candidate – during the John Bruton era no less!) which delivered neither Christian or Social Democracy.

Is it that Browne is using a rhetorical yardstick which at the end of the day is meaningless in the way in which he proposes it. That’s not to say that Labours self-evident deficiencies aren’t cause for analysis and reflection. Their time in government has hardly been marked by radical reform. Indeed I find it odd to be making a sort of apologia for that party. But this time, this yardstick, seems just too loaded – whatever the clear importance of the source material – both as a rod to beat the LP or to be useful as a basis for future political action. There is a better argument, one rooted in the data, which is that Labour should be doing all it can to reduce inequalities in health – that such reductions are possible as can be seen from other European countries with progressive left agendas – and that part of that process is to fashion a means of replacing our centre-right parties as the dominant government force which will almost inevitably require Labour to avoid entering coalitions as a subsidiary partner.

But here’s a thought to consider. So far to Thursday evening/Friday morning – and I haven’t checked this mornings IT, no responses from any Labour Party members (at least none in the IT). Sure, perhaps the accusation that their Party is complicit in the worst excesses of capitalism in this ‘liberal’ democracy is neither here nor there to them, or perhaps they can’t be bothered to respond to an article in our ‘paper of record’. Or perhaps they think a response would be self-serving (and, sure, it probably would). But it also points to how disengaged they appear to be even from the terrain they stake out themselves to work upon. That’s odd, which leads me to a parting thought that however much I dislike VB’s argument in this particular instance, he may well be right on his broader thesis…