Post by: Dr Bethan Evans, Senior Lecturer in Human Geography and Morven Cook PhD student in the English Department
“The neoliberal subject is an individual who is morally responsible for navigating the social realm using rational choice and cost-benefit calculations grounded on market-based principles to the exclusion of all other ethical values and social interests[…]” Trent H. Hamann (2009, p.37)
In the last couple of decades, a wealth of academic and activist work has explored the various ways in which responsibility for public health can be understood and critically questioned through the lens of neoliberalism(s). Whilst there are multiple ways in which neoliberalism has been conceptualised, broadly speaking it relates to a political economic context aligned with free-market capitalism, in which previously state-run services are privatised and responsibility is moved from the state to individuals. In this blog post, which summarises our most recent COVID-19 conversation, we highlight a few of the ways in which neoliberalism is evident in responses to COVID-19; focusing on the promotion of individualism over collective responsibility, how neoliberalism impacts beliefs around health, disability, and what is considered a valuable life; how this plays out in claims of rights of access to public spaces, and thinking about how the arts might help emphasise the diversity of our bodies and the spaces we share.
First, a shift from state to individual responsibility is particularly, and starkly, evident in the change in messaging around COVID-19 that happened on the 11th May in England (this change saw Scotland, NI and Wales split from the unified UK approach prior to this). The advice in England at this point changed from Stay Home, Protect the NHS, Save Lives, to Stay Alert, Control the Virus, Save Lives, with considerable confusion around what this meant.
On the Mad COVID blog, Charlotte Walker has discussed the ambiguity and anxiety which the new, vague slogan engenders. In doing so, she importantly points to how this message (Stay Alert) shifted responsibility onto the individual in a way that echoes broader neoliberal health policy. As she argues:
“The Government has pursued what could at best be described as bungling communications strategy, and at worst an underhand strategy for lifting lockdown without saying it is lifting lockdown, thereby absolving itself from responsibility. … This pushing back of responsibility onto the individual echoes neoliberal policies towards health and welfare” (Walker, 2020)
Secondly, this shift to individualise responsibility for COVID is evident in the ways in which variations in rates of COVID morbidity and mortality across different population groups have been explained. As has been documented in Public Health England’s report on disparities in the risk and outcomes of COVID-19, morbidity and mortality rates show stark differences around age, race, class, gender, and disability. The importance of such disparities in understanding public health and responses to it are not new. As Brown and Knopp argue in relation to sexually transmitted infections in Seattle during the Second World War:
‘Power always works through particular, embodied configurations of race, class, gender, sexuality, and other axes of oppression [in relation to] the social and spatial construction, regulation and control of certain bodies and identities …in the imaginations and practices of public health’ (Brown and Knopp, 2010, p.392).
Back to COVID-19 in England, the publication of Public Health England’s report into disparities in mortality and morbidity due to race has been widely criticised for delays in publication and reports that parts of the report had been redacted. Moreover, whilst the report acknowledges that there were calls for work on how structural racism and discrimination may have contributed to the higher impact of COVID-19 on BAME people, the suggestions that the report itself made for moving forward mentioned diet, vitamin D and housing, along with suggestions that higher rates of obesity may be a factor in these disparities. England has not been alone in this, obesity has also been used to explain racial disparities in COVID-19 outcomes in the US too. There is a wealth of critical public health and fat activist work that offers vital critiques of the ways in which fatness has been pathologized, and the ways in which fatness has been used to shift responsibility onto individuals rather than address broader structural factors. In the US, Sabrina Strings’ article in the New York Times titled ‘It’s not obesity. It’s slavery’ offers a vital critique of the use of obesity as an explanation of racial injustice in relation to COVID-19. She explains that:
“African-Americans have experienced the highest rates of severe complications and death from the coronavirus and “obesity” has surfaced as an explanation. The cultural narrative that black people’s weight is a harbinger of disease and death has long served as a dangerous distraction from the real sources of inequality, and it’s happening again.” (Strings, 2020)
This reflects broader work on the intersections between healthism and neoliberalism in which, as Ayo (2012, p.102) argues, “Unemployment, poverty, lack of education, all major established social determinants of health, are rendered as poor personal choices made by freely choosing citizens.”
Healthism, disability, and forms of valuable life
Neoliberalism offers us a lens that allows us to see the ways in which inequalities that are structural and political at the highest level are masked by ideas that health is a personal responsibility and down to individual lifestyle choices. Beyond that, a focus on healthism also allows us to see the ways in which health and disability are political in a biopolitical sense, that is how health and disability play a part in decisions about what forms of life are to be protected and what forms of life are seen as collateral damage. As Tyner (2013) argues, it allows us to see ‘the political negotiation of life; how life, it’s existence and vitality is linked to the regulation and contestation of who has priority to live and flourish, and who might be left to wither and die’ (p.702). In relation to COVID this has been evident in particular in relation to the delay in including care home and community deaths in national mortality statistics, in the repeated playing down of the seriousness of the illness with reference to ‘mild flu like symptoms’ for many (see Felicity Callard’s excellent blog post on this) and ‘underlying conditions’ used to explain deaths. As Kirsty Liddiard explains, the latter, used to reassure the general public, is ‘ontologically violent’, as that reassurance is ‘at the expense and distress of some of the most vulnerable’. Moreover, the ‘herd immunity’ approach floated in the UK at the beginning of the pandemic actively sought to allow the majority of the population to get infected, accepting that this would result in large scale deaths. As Isabel Frey (2020) writes in The Quarantimes:
“Herd immunity is epidemiological neoliberalism. Much like the unconditional belief in the free market, herd immunity relies on the assumption that an epidemic is best overcome by leaving it unregulated. But just like neoliberalism, it results in violence against the weak and the poor: elderly and disabled people, homeless people, refugees and people with severe health conditions – many of whom are likely to also have a lower socio-economic status because of the correlation between poverty and illness. These are the people, who are at the highest risk of dying from COVID-19 – especially if the healthcare system is overwhelmed and doctors have to perform triage.”
As Frey mentions, triage decisions relating to who gets access to the limited supply of ventilators is another way in which we can see neoliberalism playing a part in shifting attention from structural issues and shortages to an assessment of an individual’s worth. Whilst on the surface, the triage guidelines released by the National Institute for Clinical Excellence (NICE) were about an assessment of benefit vs harm and about who is more likely to survive, the way these were drawn up, using clinical frailty assessments, were actually about an assessment of ‘quality’ of life that was inherently ableist.
As Kirsty Liddiard explains, the NICE guidelines advise medical professionals to assess adults (regardless of age) using the Clinical Frailty Scale (CFS) which assesses frailty on the basis of, among other things, the ability to do certain everyday tasks unaided. Far from an assessment of survivability then, this assessment is in relation to an ableist idea of quality of life:
“NICE guidelines state that on admission to hospital, medical professionals will assess all adults for frailty … My point here is to make visible the inherent ableism that determines whether someone lives or dies based on the support they require in everyday life. For example, how did we get to the point where ‘frailty’ that ‘impairs shopping, walking outside alone, meal preparation and housework’ (#5 CFS) is integral to human value? And where those who ‘often have problems with stairs and need help with bathing and might need minimal assistance with dressing’ (#6 CFS) have less of a right to survival than those who are deemed ‘robust, active, energetic and motivated’ (#1 CFS)?“
It’s not difficult to see disableism in this guidelines when, as Dan Goodley (2014, p.xi) explains, ‘Disablism relates to the oppressive practices of contemporary society that threaten to exclude, eradicate and neutralise those individuals, bodies, minds and community practices that fail to fit the capitalist imperative’. Similarly, Frances Ryan, writing in The Guardian, cautioned that these guidelines might discriminate against disabled people.
When interviewed about her show Assisted Suicide: The Musical, Liz Carr commented on the way in which the need for a personal assistance is considered incomprehensible to those who do not require it:
For those of us with personal assistance needs the implication of attitudes imposed on us is that our deaths are welcome. ‘I would rather be dead than live like you’ is a daily message relayed often by casual strangers whose message may be intended to be well-meaning but is crucially hurtful. Under the pretext of justifying a change of legislation that is for the ‘terminally ill’, the real message disabled people are getting is that this means ‘us.’ The reality is that having need of personal assistance in everyday tasks has no bearing on quality of life.’
We must question how current guidelines support pervasive notions about disability as unbearable, failing to properly acknowledge that assumptions about what constitutes a livable experience are often based on ableist ideas of happiness, attractiveness, suffering, and dignity. Again, this reflects broader critiques of healthism in relation to neoliberalism which make evident the value judgements at the heart of what is considered to be ‘healthy’. Ultimately, ideas about health depend on our value judgements about others and on our ideologies about what makes a ‘good life’. As Metzl (2010, p.1-2) argues: ““Health” is a term replete with value judgements, hierarchies, and blind assumptions that speak as much about power and privilege as they do about well-being. Health is a desired state, but it is also a prescribed state and an ideological position.”
Fighters, saints and unskilled workers
In the context of neoliberalism and the forms of healthism described above, health becomes something more than an indicator of the state of the material body, but comes to reflect the strength of will and commitment of the self. This is evident in, for example, the language used around cancer which speaks of battles, fights, wars, winners and losers. As Ennis-O’Conner (2019) (on the Patient Empowerment Network blog) explains, this language places the burden of healing on patients themselves.
These narratives were evident in relation to COVID-19 in reaction to the UK Prime Minister Boris Johnson being moved to intensive care due to contracting the disease. Politicians Dominic Raab and George Osbourne both said that Johnson would pull through because he was a fighter, US President Donald Trump added that Johnson was “strong, resolute, doesn’t quit, doesn’t give up” and former Prime Minister David Cameron said that Boris is “a very tough, very resilient, very fit person” (Independent, 2020).
Drawing on historical work on plague in the late 16th and 17th centuries, Susan Sontag (1978) explains that “theories that diseases are caused by mental states and can be cured by will power are always an index of how much is not understood about the physical terrain of a disease” (p.55). She goes on to argue that “A large part of the popularity and persuasiveness of psychology comes from its being a sublimated spiritualism: a secular, ostensibly scientific way of affirming the primacy of spirit over matter” (p.55-56). In the context of neoliberalism and a pandemic disease about which very little is known, it is perhaps not surprising that narratives of individual will power and control provide an easy way for those who are privileged to make sense of the significant inequalities in the impact of the disease.
In contrast to these narratives of self-control, as Garland-Thompson (1997, p.27) explains:
Bodies that are disabled seem dangerous because they are perceived as out of control. Not only do they violate physical norms, but by looking and acting unpredictably they threaten to disrupt the ritualized behavior upon which social relations turn. The uncontrolled body does not perform typically quotidian functions required by the elaborately structured codes of acceptable social behavior. Blindness, deafness, stuttering, for instance, disturb the complex web of subtle exchanges upon which communication rituals depend. Wheelchairs or paralysis require different ambulatory choreographies. Furthermore, the disabled body transgresses individualism’s codes of work and autonomy by enacting patterns that differ from the norm[…]
The need for care is universal, all human beings, throughout their lives, are dependent on being cared for by others, yet this is not reflected in attitudes and practices surrounding care, where it is poised as exceptional – either in the sense of being extraordinary or entirely unnecessary. The cultural images and dialogues around caregiving are somewhat contradictory, where caregivers are sometimes depicted as ‘saints’ and at other times referred to as unskilled or low skilled workers. Whilst the former image may sound like a positive characterisation of caregivers, to identify those who provide care with a kind of transcendental altruism is to guarantee their devotion without the need to clarify their rights. The gratitude shown for those working in the NHS during the pandemic in terms of the weekly ‘clap for carers’ in the UK has been culturally meaningful; however many recognise it must be followed up with something more substantial – Anna Fazackerley for instance has reported on the growing support to cancel nurses’ student debt, and important questions need to be asked about delays in provision of PPE to health and care workers, rates of death amongst care workers and the higher rates of death amongst BAME care workers.
Of course, the re-valuing of care also has implications for recognising caregiving which is unpaid. Nancy Fraser’s book Fortunes of Feminism explains how neoliberal ideologies make the caring relationship and, those involved in it, subordinate. Fraser summarises the arguments of her book in an article for The Guardian where she writes that ‘feminists need to break off our dangerous liaison with neoliberalism’ which assumes caregiving is degrading for women and instead accept and embrace the fact of human dependency.
The critical value of disability studies in these conversations is clear as it has, for many years, spoken out about the risks of neoliberal cultures in influencing our conceptions of bodies and care. In Dan Goodley’s (2014) book Dis/Ability Studies: Theorising Disablism and Ableism he writes that ‘Our bodies are shaped by the alienating choreographies of capitalism. All of us are left lacking in the market; debilitated by the dance of capital’ (p.xv). Conversely disability studies has sought to recognise human bodies as diverse, changeable, unpredictable, vulnerable, and the need for care as universal. In learning from ‘disability communities’, Goodley argues that we may establish forms of living which emphasise interdependence rather than independence. Ultimately, the COVID-19 pandemic has re-focused our attention on the unrealistic and individualistic demands of neoliberalism – what Goodley astutely describes as ‘neoliberal-ableism’ – which obscures, excludes, or even seeks to eradicate those whose very existence or role in society challenges the delusion in how self-reliant we really are or can be.
Finally, the discussion moved to think about how perceptions of public space have changed (or been reinforced) because of COVID-19. Much of the rhetoric around how space is controlled and who ‘owns’ or has a right to exist in public spaces, again reveals neoliberalist ideology as sustaining notions that people should think and act as individuals rather than social groups.
‘Free the healthy’ was one headline that appeared on the BBC homepage, signalling the claim of a ‘natural hierarchy’ who are being oppressed by those considered less worthy. Reading the work of Jennifer Bartlett we spoke during the session about how attitudes towards access are potentially being redefined because of places going into lockdown and options opening up for alternative forms of engagement – see Francis Ryan’s article – as well as thinking about how bodies are interpreted and interact within different environments. In an article for the New York Times Bartlett describes poetry as
a way of “being in the world” that in many ways was not made for us and actively resists our participation. Through poetry, we are able to remake and reinvent that world.
This statement is of course a painful reminder of how hostile the world is for many, and of course COVID-19 has both exposed and exaggerated the impact of social inequalities and injustices. The final part of the discussion touched upon the potential to ‘remake and reinvent’ the world according to the lessons learned during this period, with some more hopeful than others. Nevertheless, most agreed that highlighting the toxic influence of neoliberalism was a start.
 The plural of neoliberalisms here is important as there are different understandings and definitions of neoliberalism and the form neoliberalism takes is of course spatially and temporally variable.
Ayo, N. (2012) Understanding health promotion in a neoliberal climate and the making of health conscious citizens, Critical Public Health, 22:1, 99-105
Brown, M. & Knopp, L. (2010) Between anatamo- and bio-politics: Geographies of sexual health in wartime Seattle. Political Geography 29(7) 392-403
Bartlett, Jennifer. Autobiography/Anti-Autobiography. California: Theenk Books, 2014
Fraser, N. (2013) Fortunes Of Feminism : from State-Managed Capitalism to Neoliberal Crisis. Brooklyn, NY :Verso Books
Frey, I. (2020) ‘“Herd Immunity” is Epidemiological Neoliberalism’, The Quarantimes. Online. Available at: https://thequarantimes.wordpress.com/2020/03/19/herd-immunity-is-epidemiological-neoliberalism/ [Accessed 17/6/2020]
Garland-Thomson, R. (1997) Extraordinary Bodies : Figuring Physical Disability in American Culture and Literature. New York :Columbia University Press
Goodley, D. (2014) Dis/Ability Studies : Theorising Disablism and Ableism. Abingdon, Oxon: Routledge
Hamann, T. H. (2009) Neoliberalism, Governmentality, and Ethics. Foucault Studies. 6, 37-59
Liddiard, K. (2020) Surviving Ableism in Covid Times: ‘Only the vulnerable will be at risk…but your ‘only’ is my everything.’ iHuman. Online. Available at: http://ihuman.group.shef.ac.uk/surviving-ablesim-in-covid-times/ [Accessed 17/6/20]
Metzl, J.M. (2010) Introduction: Why Against Health. In Metzl, J.M. and Kirkland, A. (eds) Against Health: how health became the new morality. New York University Press: New York
Public Health England (2020) Disparities in the Risk and Outcomes of COVID-19. Online. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/892085/disparities_review.pdf [Accessed 17/6/20]
Sontag, S. (1978) Illness As Metaphor. New York: Farrar, Straus and Giroux
Strings, S. (2020) Opinion: It’s Not Obesity. It’s Slavery. We Know Why Covid-19 Is Killing So Many Black People. The New York Times, May 25th 2020. Online. Available at: https://www.nytimes.com/2020/05/25/opinion/coronavirus-race-obesity.html [Accessed 17/6/20]
Walker, C. (2020) #StayAlert: The pushing back of responsibility onto the individual echoes neoliberal health and welfare policies. Mad Covid 10th May 2020. Online. Available at: https://madcovid.wordpress.com/2020/05/10/stayalert-the-pushing-back-of-responsibility-onto-the-individual-echoes-neoliberal-health-and-welfare-policies/ [Accessed 17/6/20]