NEOLIBERALISM AND HEALTH
In the past few years, nursing research and practice has been profoundly impacted by the effects of neoliberalism, particularly from the ways that this economic system shifts attention away from social determinants of health and puts the blame for health problems squarely on individual behavior. Neoliberalism is a confusing term because it has nothing to do with liberal views in the political sense but, instead, is associated with conservative political viewpoints. Neoliberalism is the primary ideology driving our government, economy, and health care delivery today. It involves an erosion of government regulation and funding of health and human services and replaces government funding and oversight with a private market economy. This for-profit orientation shifts the system from an emphasis on human rights and quality to one of cost-savings and efficiency and makes all variety of health services into goods for sale. For readers who are not familiar with the history of neoliberalism, it stems from liberalism on the basis of Adam Smith's book, The Wealth of Nations, in the mid-1770s and was the dominant system of Europe and much of the industrialized world for 200 years. In the United States, it was replaced briefly in the early 1900s with a more humane system of safety nets and efforts to help the most disenfranchised and marginalized with employment, welfare, Medicare and Medicaid, Social Security, Headstart, and many other programs. Beginning in the 1970s and jump-started in the 1980s by Ronald Reagan's policies, this new liberalism (now called “neoliberalism”) or the “trickle-down economics” as Reagan called it, started dismantling our health care system as we know it (and education, business, and the media as well).1 In this system, economic growth is valued over any ethical principles, such democracy, social justice, compassion, or sustainability. What Reagan and now contemporary proponents of neoliberalism have accomplished is a shift in government expenditures. In 1980, 38% of federal expenditures went to individuals, 41% to the military, and 21% to private enterprise. By 2007, money to individuals decreased to 32% and increased to the military (45%) and private enterprise (23%). This was prior to bailouts of the auto industry and banks approved by Congress in recent years. In medicine, funds have shifted to public and private investments in biomedical, biotech, and pharmaceutical solutions to disease and away from less profitable prevention, caring, or healing activities.2
Neoliberalism is based on 3 principles: individualism, privatization, and decentralization.1 Whereas they are all important, the rest of this editorial will focus on the effects of individualism on health research and practice. An overemphasis on the individual capitalizes on our evolutionary drive to survive when put in competitive, threatening situations. Think of all the reality shows in the past 10 years that set up individuals against each other to win some prize. Is their behavior ethical and exemplary? In reality, our survival is more enhanced by cooperation than competition, but neoliberalism has no rewards for collaboration. When health is recast as a commodity or a good to be purchased, we are pitted against each other to obtain the scarce resources. Individuals are valued over the family or the community, and ethical considerations get lost. A neoliberal approach focuses on equal access to health care services, not fairness. In this vein, welfare is considered inappropriate because not everyone has equal access to it. When we focus so predominantly on individual accountability and responsibility for one's own health, it is easy to blame the most marginalized segments of society for their own health problems. Homeless individuals, teen parents, those addicted to drugs, and people who are obese become those who did not take responsibility for their health, whether they are blamed for tipping the salt shaker too many times, eating those Mickey D's fries, not mastering the English language, using a mood-altering drug to feel some pleasure in life, or choosing not to exercise every day. The social structural barriers and environmental circumstances that pushed them to those individual behaviors are ignored and lost in the efforts to “empower” the disempowered to take responsibility for their health. The solution to any health problem is to buy some product or service: drugs to regulate cholesterol, weight watchers to lose weight or worse yet, bariatric surgical procedures to remove the fat, treadmills that become clothes hangers in the basement after a week of use, and nicotine patches to bolster one's “will power.” The cost of health-related products has skyrocketed in recent years because of this for-profit orientation. As I drafted this piece, a new drug to treat hepatitis C was released at a mere cost of $1000 per day or $84 000 for the full course of treatment. The pharmaceutical company that makes it, Gilead, posted a $2 million profit in the quarter following its release. But along with high prices, neoliberal focus on the individual has had another less obvious impact on how we think of health in the United States.
Barbara Ehrenreich, in Bright-Sided,3 described her personal experience with the new individualism as it has manifest in many components of health care as “positive thinking” when she was treated for breast cancer. She noted:
Breast cancer, I can now report, did not make me prettier or stronger, more feminine or spiritual. What it gave me, if you want to call this a “gift,” was a very personal, agonizing encounter with an ideological force in American culture that I had not been aware of before—one that encourages us to deny reality, submit cheerfully to misfortune, and blame only ourselves for our fate.
Ehrenreich found a system that focused on breast cancer survivors banding together to “empower” themselves through positive thinking and pink ribbons, rather than getting angry and challenging the environmental toxins in our food, water, medications, and air that might be responsible for increasing rates of cancer.
In another example, Braslow4 critiqued the mental health recovery movement as another example of how neoliberalism has affected health care. Based on the idea that medically based mental health care fosters dependency and hopelessness, the recovery movement makes the individual responsible for his or her own recovery as an independent, autonomous being, and government support is increasingly cut. This system of peer recovery networks, like George W. Bush's famous “1000 Points of Light” campaign, relies on mostly unpaid volunteers to do the work.
This message of dependency is often repeated in the neoliberal discourses. One of the most famous historically was Reagan's address in 1987 about his rationale for cutting welfare, “It's now common knowledge that our welfare system has itself become a poverty trap—a creator and reinforcer of dependency.” Welfare has certainly not provided enough resources to raise the majority of its recipients out of poverty, but to consider it a cause of poverty is nonsensical. What the reduction in welfare has done is to create a class of potential workers who are desperate for a job, and who will take the lowest paying work in unsafe working conditions without complaint, because they have no other choices. The current resistance to raising the minimum wage is a ploy to maintain this lower class of workers to increase the profit margins of big business where the CEOs and higher management folks have been getting richer and richer since the 1980s.
In relation to the practice of nursing, Krol and Lavoie5 described a “neoliberal tide” threatening to flood the discipline of nursing, washing away a caring orientation and leaving behind a barren, ethics-free consumer health philosophy. Some of the developments that show the influence of neoliberalism are the increased emphasis on evidence-based practice, which emphasizes cost-effectiveness over innovation; increase in competition-based programs, such as fitness programs that show data from all group members or group weigh-ins that are meant to increase individual accountability but actually contribute to shame and guilt; and focus on technology rather than humanizing, personal care.
I don't want to imply that we do not address the individual at all, or that some degree of individual autonomy and responsibility is not appropriate. I'm not saying that technology or evidence-based practice is all bad. In fact, they have been responsible for many positive gains in health care. The problem arises when our solutions are not balanced between the individual and the community or greater good, when we do not consider the social determinants of health that drive individual behaviors. When equal access replaces social justice, and the already marginalized in society are further denied humane services, we are violating nursing ethics. In many aspects of nursing education and practice, it is easier to focus solely or primarily on the individual. Upstream influences on health are harder to change, more difficult to measure, and are often in the policy or activist arenas where many nurses do not feel comfortable. Structural barriers to health care often stem from forces of oppression such as racism, sexism, classism, and heterosexism, concepts we are not trained to address in our nursing education programs, and that make us uncomfortable. But it is our ethical obligation to address the whole person, and that person is imbedded in families, neighborhoods, and societies. All of those levels contain factors that influence an individual's behavior, whether that behavior is smoking, nutritional patterns, physical activity, or meditating. Unless we address societal stigma, cultural norms, all the forces of oppression that divide people, zoning laws, food production systems, advertising, urban planning, neighborhood safety, food deserts, pollution, and a host of other factors, our individual level interventions will not be successful in the long run. Until we question why basic human services have become profit-based industries, health disparities will continue to grow along with the widening income disparities.
I urge all researchers to consider the larger context when interpreting results of their studies and at least consider how their interventions might be influenced by social determinants of health. It is not “bad” to study individual interventions, but for these to be successful, they must be imbedded in multilevel interventions that address the upstream factors. What each author of a research paper can do is to imbed his or her own study in the bigger picture and show what community, institutional, legal, and policy solutions are also needed to tackle the health problem he or she studies. As one prominent public health researcher noted, “The study of why some people swim well and others drown when tossed into a river displaces the study of who is tossing whom into the current—and what else might be in the water.”6(p607)
When we focus on the microlevel, the individual devoid of context, such as who drowned, and particularly if we put all the impetus on the individual to take responsibility for getting swimming lessons, we are maintaining neoliberalism in health care.
Michele J. Eliason, PhD
1. McGregor SLT. Neoliberalism and health care. Int J Consum Stud. 2001;25(2):82–89.
2. Navarro V. What we mean by social determinants of health. Int J Health Serv. 2009;39:423–441.
3. Ehrenreich B. Bright-Sided. How Positive Thinking Is Undermining America. New York, NY: Metropolitan Books; 2009.
4. Braslow JT. The manufacture of recovery. Annu Rev Clin Psychol. 2013;9:781–809.
5. Krol PJ, Lavoie M. Beyond nursing nihilism, a Nietzschean transvaluation of neoliberal values. Nurs Philos. 2014;15:112–124.
6. Krieger N. Theories for social epidemiology in the 21st century: an ecosocial perspective. Int J Epidemiol. 2001;30:668–677.