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Luke Malpass

Where Welfare Dependence and Public Health Collide

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Recently I wrote an opinion piece with Jeremy Sammut criticising an editorial in the New Zealand Medical Journal (NZMJ).1 We argued that health is ultimately an issue of personal responsibility and that there is a link between welfare dependence and bad health, which is caused in part by lifestyle choices. Sinking yet more taxpayer money into public prevention campaigns, for example to warn people of the dangers of not exercising, seems foolish and wasteful. It does not address the underlying problems.

We argued that there is an indisputable link between levels of welfare dependence and health outcomes. The more dependent a person is, the greater their likelihood of suffering from a lifestyle illness such as obesity, diabetes, lung cancer, or heart disease.2

The NZMJ editorial’s author claimed that New Zealand has fallen victim to a toxic combination of bad social and economic policies, and that these policies are responsible for killing thousands of New Zealanders each year. To cut the premature death toll associated with smoking and obesity-related diseases such as lung cancer and Type II diabetes, Professor Tony Blakely, Director of the Health Inequalities Research Programme at the University of Otago urged the New Zealand government to provide better ‘social protections across the lifecourse.’

Blakely used a recent report from the World Health Organisation, Closing the Gap in a Generation, as his basis in evidence. The report examines the so-called social determinants of ill-health around the world, and principally attributes unequal health outcomes across different socioeconomic groups to the ‘inequitable distribution of power, money and resources.’

Attempting to rectify ‘social injustice’ in New Zealand might induce a warm inner glow, but simplistically blaming health problems such as obesity, lung cancer, and diabetes on relative measures of poverty is a highly political and contestable finding that ignores the reality of the situation.

Does public health have a role to play? Certainly, the reason for public health research is to examine factors that influence the health of the public at large, and how a health system (in New Zealand’s case almost exclusively government-run) can plan for and cope with the population’s health needs. Public health academics such as Blakely do a vital job in working on these issues—reliable, quality information about the choices we make is important.

But there is now little doubt that the facts are known. People do know that drinking, smoking, not exercising, and eating fatty foods are harmful to health. They have learned this, at least in part, through various advertising campaigns, brochures, and reprimands from their doctors. The problem is that some people—largely in the middle classes—have heeded this advice and started jogging their way to wellness, but others—concentrated in lower-income groups—have not.

In the final analysis, governments, no matter how well-intentioned, have limited control over personal behaviours which ultimately depend upon people deciding to modify unhealthy habits. Instead of funnelling more public money into behaviour-modification programs, we need to undertake an honest and frank examination of what fuels a lot of this behaviour—including New Zealand’s culture of dependence.

Does the market deliver poor health outcomes?

Incentive structures play an important role in shaping our thinking about welfare dependency. Over the past few years, research and international experience have shown that generous long-term welfare benefits do not ensure better outcomes. In fact, they often entrench the opposite.

In a reply to the piece I wrote with Jeremy Sammut, Tony Blakely and Don Matheson argued that any provision of healthcare outside of a largely universal ‘free’ model is inequitable.3 They also argued that increased social welfare measures have substantially improved health outcomes in the past ten years. Coincidentally, this was also a period of substantial economic growth and very low general unemployment, a fact that is barely acknowledged.

Earlier this year, Ruth Dyson admitted that inflation and cost of living had eroded the real value of welfare benefits, and that they are now ‘comparatively lower’ than they were immediately following the 1991 cuts. Yet, as Blakely and Matheson point out, health outcomes over this time have improved. The real value of welfare has dropped, as have its uptake rates, and yet outcomes are improved. The facts largely invalidate their argument.

Acceptance of the idea that ‘the market,’ ‘inequalities,’ and social injustice’ are to blame for social ills is becoming more widespread. The more we pin such problems on these unseen forces, the less we expect people to take personal and, in the case of child obesity and behaviour, parental responsibility for maintaining their own good health and that of their children.

As in all things, it is easier to lay the blame at someone (or something) else’s doorstep than to acknowledge personal failure. The promotion of learned helplessness by more people becoming more reliant on state-provided payments and services is at the root of people’s unwillingness or inability to make healthy choices, not capitalism and underhanded marketers selling hamburgers and chocolate bars.

Social welfare or public health?

Once the new government is in place, whatever its composition, it seems certain that we will see health lobby groups such as the Obesity Action Coalition renew their efforts to present personal choices and wider social problems as public health issues. The reason for this is simple and insidious. People generally have few objections to government provision for those who genuinely need it, but most don’t see this as an excuse for shirking personal responsibility. Good health services on the other hand, are seen as a right—a result of paying taxes —and as such are viewed as open to legislative reform to secure taxpayers better value for money.

Health campaigners are aware of this, and dress up social issues and intemperate behaviour as ‘public health’ issues of grave importance, making them politically acceptable targets for state action. Many of these health pronouncements also rely on implicit moral judgements about intemperance. The assumption is that that somehow government will have more success in changing intemperate personal behaviour than private efforts were able to achieve. This implies using the full coercive power of the government to change behaviour, and somehow assumes that an impersonal bureaucracy will have more luck ‘getting through’ to people than their friends, family, and colleagues currently do.

The new poverty

In a recent interview, British chef Jamie Oliver rather insightfully referred to something he called ‘the new poverty’:

It’s nothing to do with famine or war—quite the opposite. England is one of the richest countries in the world … the people I’m telling you about have huge TV sets—a lot bigger than mine! They have state-of-the-art mobile phones, cars, and they go and get drunk in pubs at the weekend—their poverty shows in the way they feed themselves.

Describing this state of affairs as poverty is misleading, because what he is talking about is lifestyle choice. But it remains interesting, because it highlights that poverty is a highly contestable and politicised term, and can be used to describe something wider than material deprivation. Oliver implies what politicians and policy wonks the world over are scared to say: it is not material poverty that is the problem, but complex social issues and poor lifestyle choices. The people Oliver refers to buy big cars, TVs, flash cell phones, spend a lot on booze and tobacco, and yet somehow seem to lack the most basic life skills, such as boiling water or preparing a nutritious meal.

There must have been something else that led to this state of affairs. Banning or restricting certain unhealthy foods and ‘junk food’ advertising (as the Public Health Act would have done) will not address the cause of these problems. Comparative lack of resources and formal education has not led to these particular social problems in the past, but we blame these things now that we are wealthier than ever.

So, what will it be? Are people are too impoverished and need welfare to get by, or are they too prosperous and need government to moderate decisions they are incapable of making in a complex capitalist world? It can’t be had both ways.

Farming beneficiaries

Because the government now provides so many ‘free’ or ‘low cost’ services, New Zealanders have become more reliant on them, see them as rights, and take them for granted. We are meant to—the incentives are structured that way. We are all beneficiaries of the health system at some level, and with Working for Families (WFF) becoming more widespread, a much larger chunk of New Zealanders rely on government for part of their income. Historian Michael Bassett uses a neat, albeit dishearteningly accurate, term when he describes the Labour Party as ‘farming beneficiaries’: governments create dependent groups so they always have a natural constituency.

In New Zealand, both major parties farm beneficiaries—there is just a slight difference in which groups they target, as is obvious in the National Party’s recently announced tax policy. Their independent earner rebate could accurately be termed a ‘benefit for those not on a benefit’—as it would create a (now) dependent set of voters who should have had little need to interact with the government in the first place.

Welfare fosters a culture of dependency and lack of initiative, characterised by a loss of intergenerational skills, corporate knowledge in communities, and good work habits. It encourages constant rorting of the system, as people must order their affairs to take advantage of the benefits on offer. The higher the level of dependence, the higher the social cost, as people lose control of their own destinies.

At the extreme end, poor health outcomes and unhealthy lifestyles are inextricably linked to the higher levels of long-term unemployment and entrenched welfare dependence experienced in lower socioeconomic status communities. In suburbs as similar and as far-flung as the industrial estates of Britain and the mean streets of South Auckland, smoking rates, obesity levels, and the incidence of heart disease remain stubbornly higher than average.

Welfare communities

Take an example from Australia. The seventeen-year gap in life expectancy between Indigenous and other Australians has received widespread public interest. Yet it hides an even more startling picture of Indigenous Australians’ health and wellbeing. By including all Indigenous people, this figure is an average that includes people who identify as Indigenous and who live and work in mainstream society as well as those Indigenous Australians who are trapped in welfare-dependent communities. The Indigenous Australians who earn income through work have the same life expectancy as mainstream Australians, but the group who are reliant on welfare have an even lower life expectancy than the statistic suggests. The real gap is somewhere in the vicinity of twenty-five years.

These figures show that welfare dependence is substantially to blame for lower Aboriginal life expectancy. Tariana Turia’s recent comments here in New Zealand about scrapping the dole, as it wreaks havoc on some Maori communities, shows an honest, forward thinking, and open acknowledgement of this fact.

An honest assessment

Earlier this year, the Dominion Post obtained some material under an Official Information Act request from the Ministry of Social Development. The recommendation was that cabinet give the ministry approval to use an ‘intensified approach’ with the long-term unemployed. It suggested that this was desirable due to the positive effects work has on individuals and their communities. It promotes self-esteem, healthier personal habits, social connectivity, and creativity, and allows people to participate more fully in their communities. The importance of people doing something worthwhile is well known, and it is heartening to see that the ministry is actively pursuing programs with this in mind.

It has come time to reexamine the concept of welfare and public health in New Zealand. Increasingly, problems being addressed through the health system are actually complex social issues that cannot be cured by public health campaigns or prodigious public health spending. Lifestyle choices, welfare dependency, and personal responsibility play a substantial role in broader life outcomes, only one of which is health. Politicising and appealing to ideology that favours public provision will not help solve these problems.

The financial crisis gives us cause for thought and reflection, but not a reason to be complacent around welfare dependency. Times of recession are what benefits were designed for, so welfare rolls can be expected to grow in the near future, and this is completely reasonable. It makes now a good time to talk reform so that when the economy resumes business as usual, the right incentive structures and programs are in place to get people back into work. Closing our eyes and ears to the destructive consequences of welfare dependence is not compassionate—it’s culpable.

  1. Luke Malpass and Jeremy Sammut, ‘Welfare Nanny is Killing Us All Softly,’ Dominion Post (18 September 2008). 
  2. It is important here to note three things. First, illness and disease do not necessarily relate to lifestyle and socioeconomic status—obesity, alcoholism, smoking, and diabetes exist in all walks of life. Second, these things are not the symbols of moral failing they are sometimes portrayed as. Third, and most importantly, many people tragically fall ill or suffer from poor health for reasons unrelated to their lifestyle. 
  3. Tony Blakely and Don Matheson, ‘In Defence of Nanny State,’ Dominion Post (26 September 2008).