What Makes Us Sick Today?

We can trace the lived experience of the Cratchit family to the lived experience of a great many British families today. Dickens most explicitly focuses on the Cratchits’ experience of a bad boss and poverty pay. Today, we’d be most likely to find Cratchit’s equivalents in zero-hour contracts across Britain’s growing gig economy.

The precarity of that work has some very real health consequences. Studies by Ursula Huws—professor of labour and globalisation at Hertfordshire School of Business—have shown the link clearly. Her qualitative research uncovers harrowing stories of mental illness caused by the stress of insecure pay and uncertain hours, and the physical impact of poor health assessments, sitting in cars for long periods, or working with dangerous equipment without training.

Huws is backed by quantitative data. A 2020 study in the Royal Society of Public Health’s journal showed that workers paid on a ‘piece rate’—by delivery made, job completed, item produced—had worse health than salaried workers. Piece rates are a tool used in businesses like Amazon to push productivity and sustain growth—that is, to profit at the expense of workers’ health.

This is, evidently, also a racialised injustice. Just sixty-eight percent of workers in the gig economy describe themselves as white British. Black workers are twice as likely to be on a zero-hour contract, according to the TUC. And as recently as 2017, the McGregor-Smith Review concluded that workplace disadvantage still systematically undermines the health of Black, Asian, and minority ethnic people.

Beyond employment, the Cratchits suffered from the consequences of poor housing. Their residence is based on Dickens own childhood home in Camden, which he described elsewhere as ‘a complete bog of mud and filth with deep-cart ruts, wretched hovels, the doors blocked up with mud.’

Today, health consequences from poor housing are rife—particularly in the private rented sector, at the hands of landlords. For instance, a massive one in ten people in England—disproportionately those in the private rental sector—live in homes with a ‘Category 1 Hazard’. That might mean asbestos, black mould, dangerous fungal growth, or a risk of carbon monoxide. By official definitions, almost a million households—including six percent of private renters (a figure that’s doubled since 2000)—live in overcrowded conditions. Still today, that puts them at greater risk of tuberculosis. And, of course, it’s a major and continuing risk factor for Covid-19.

That is, our contemporary experience of health injustice often has little to do with differential access to medical care, and everything to do with social injustice—like exploitation by bosses and landlords. It’s this reality that demands our health campaigns go beyond saving the NHS.

We Need to Meet Need Earlier

The NHS is not well suited to address kind of injustice. It’s the medical arm of the welfare state, so designed to pick up the consequences, rather than prevent need at source. But the Bevanite founding principles of the health service could be key in expanding our collective ability to end health injustice.

The creation of the NHS has been defined elsewhere as an act of ‘pragmatic democratic socialism’—an intervention that extended health justice to the extent possible in the 1948 epoch. It provides universal health intervention once we are sick, and once care is most acutely needed. But a broader understanding of health justice encourages us to think about how we can extend Bevan’s project further, opening us to social interventions, not just medical ones.

This is the core argument of my forthcoming book, The Five Health Frontiers. There, I suggest that Covid-19 has demonstrated the link between work, occupation, pay, housing, education, and health beyond any doubt. In the aftermath, we need a system by which we can allocate people good houses, good pay, and a good education, on the principles that founded the NHS: free at the point of delivery, based on need, funded by tax, and on the justification of good health.

Specifically, we need an additional new service—a Universal Public Health Service—designed around intervening on non-medical but health-critical needs. My analysis shows that with a founding budget of £40 billion per annum—just a quarter of the NHS’ own budget—the Universal Public Health Service could provide five core ‘social prescriptions’:

• A social home for everyone who needs one;
• A major increase in education quality, for those at risk of a poor education undermining their health throughout their life;
• Free utilities, for those at risk of fuel or digital poverty;
• A minimum income, for those whose income threatens their health;
• A free, nutritious meal for everyone experiencing food poverty.

These are not random. They answer recent research showing what variables outside the NHS are most responsible for England’s wide levels of health inequality today. Nor should they be controversial. If we’re happy to collectively fund cancer treatment then, surely, we should be happy to fund the home, education, heating, income, and food that we know—from the evidence—will ensure everyone has access to a healthy life. And there are a range of tools we can use to achieve it. Taxation is one; public ownership is another.

Of course, this isn’t an answer to every need people in the country face. For that, we need a full Universal Basic Services model. But as an extension of our current provision, opening up Bevan’s model of ‘free at the point of delivery, based on need’ to a broader definition of ‘health’ should be a priority.

Demanding Health Justice

If illness is often a bodily consequence of social injustice, then there’s an onus on progressives to campaign for ends that reflect that reality.

That might sound abstract, but there are tangible implications. First, it means the NHS shouldn’t be the horizon of our activism. Defending it alone will not deliver health justice. Instead, we need to see the NHS as a case study in good practice—the principles of which need to be urgently spread across our welfare state and economy.

Second, it means a much stronger focus on health as a site of justice. The strongest movements today have a clear critique of political economy—who benefits, and who’s excluded from the status quo. In health, we need to be much clearer about how good health is distributed along the line of class interests—to the richest and most powerful.

Finally, it means having a much broader definition of the economic practices that harm health. Too often, when we think of profit, we only think of the big pantomime villains, like big tobacco. But profit by capital through health exploitation is wired into our economic model. We must have a broader critique that captures that reality.

There is unlikely to be a better moment to bring forward big and bold campaigns around a broad conception health justice. The pandemic has proven to the public that things like good work, sick pay, paid leave, and spacious housing are vital to health (and, in turn, the economy), but these opportunities are only ever fleeting. We need the vision, campaigns, and policies to grasp it.