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A REVOLUTIONARY APPROACH TO WORKPLACE HEALTH AND WELLBEING
Workplace wellbeing initiatives have become increasingly popular in recent years, on the basis that a healthy workforce is more likely to be a productive workforce. (Gov.uk)
Wellbeing programmes typically address weight loss, exercise and smoking cessation. Modest benefits can be achieved from these interventions.
However, there is now a wealth of very good evidence that wellbeing is more a social than a medical issue, and indeed that good health itself is affected more by social factors than medical interventions.
Inequality within a population is very toxic for health. Unfortunately, inequality has increased dramatically in the UK in the last 20 years, with measurable impacts on social wellbeing in general, and illness in particular.
Current political systems are considered, together with an alternative approach to addressing the situation.
Workplace wellbeing programmes have grown in popularity in recent years. The key driver is generally held to be that these programmes, by improving the health of the workforce, will improve productivity, reduce absenteeism, and therefore improve the organisation’s performance. (cdc.gov).
Various interventions have been implemented. Weight loss programmes help employees to lose weight. A bit. Readers may be familiar with the ‘body mass index,’ (BMI), which compares the height of the individual to his/her weight. The more you weigh, the taller you need to be to have a healthy BMI. We’re encouraged to have BMIs between 20-25, and we’re overweight if our BMI is between 25-30. We’re obese once the BMI is greater than 30, and morbidly so when it’s above 40. Weight loss programmes help individuals to reduce their BMI on average by 0.5. Given that 37% of the population is obese, and 2% morbidly so, (UK obesity figures from 2009), the real benefit of these programmes is modest at best in clinical terms, and of doubtful value at all for organisational productivity.
Smoking cessation is also popular. These programmes can lead to a 50-70% increase in helping smokers to give up. (Stead, 2008). Without these programmes, about 5% give up. With them, 8% give up. Which means that an additional two in every 100 smokers will stop.
Interestingly, in the 1970’s, rates of smoking were much higher across all social classes. 20 years on, just 13% of social class 1 continues to smoke, whilst over 70% of social class 5 continue to smoke. Campaigns that have helped reduce smoking in the rich have failed to have any impact on the poor who smoke. Why will more of the same campaigns work?
Exercise is also encouraged, with discounted gym membership being particularly popular. We know that exercise is associated with a reduction in coronary heart disease, (Marmot, 2005), but this may simply be due to confounding. (This is a statistical term, where you think something may be important, but actually you’ve failed to notice the factor that is actually responsible for the benefit). The likely cause for the ‘benefit’ of exercise is discussed later.
So, wellbeing programmes are popular, and benefits are seen, albeit somewhat modest. But there is now compelling evidence that other factors may be far more important. We now know that social factors have a direct impact on health, and that these impacts are more important than medical interventions. We need to explore the evidence.
Social Class and Health
On average, poor people die at a considerably younger age than rich people. Those in social class 5 die 8 years earlier than those in social class 1. (Marmot, 2005). This impact is independent of many of the traditional risk factors, such as smoking and obesity.
The Whitehall study demonstrated that your work grade was more predictive of heart disease than whether you smoked, your cholesterol level, or whether you had high blood pressure. (Marmot, 2005)
Your blood contains a compound called HDL, which is protective against high cholesterol. HDL levels correlate with your position in the hierarchy, with those at the top doing better than those at the bottom. (Marmot, 2005). This effect is seen in various primate studies, including baboons, macaque monkeys, and civil servants. (Perhaps you feel it’s unfair to put these groups together. Perhaps not).
We have already acknowledged that exercise reduces heart disease. But what we discover is that the rich exercise more than the poor, presumably because the poor often have more strenuous jobs, and can’t afford gym fees. So is the benefit of exercise simply that rich people are healthier, and rich people also exercise more? Thus, the benefits of exercise may simply be confounded by the benefits of social class.
And talking of cardiovascular risk, we know that increased demands and reduced controls over work are associated with increased risk. (Marmot, 2005). A workplace where you have excessive demands, and no control is unhealthy.
But there is more to health than social class, because inequality within a population is also toxic.
Inequality and Health
We know that average life expectancy is higher in richer than poorer countries. However, this only holds true until the average income is $25,000 per annum. Increases in average income beyond this do not improve life expectancy. (Wilkinson & Pickett, 2010).
However, once the country exceeds this average, we discover that the health of the population directly correlates with the amount of inequality, which is defined as the gap in earnings between the richest and poorest. (Wilkinson & Pickett, 2010)
There is very clear evidence that increasing inequality correlates directly with:
• Life expectancy
• Infant mortality
• Homicide rates
• Teenage births
• Levels of trust about other people
• Mental illness
• Lack of social mobility.
Living in an unequal society has profound health and social effects. And regrettably, the level of inequality within the UK and US has grown considerably in the last 2 decades.
Inequality in the Western World
In the USA, the richest 2.7 million individuals have the same number of post-tax dollars to spend as the poorest 100 million. (Duffy, 2008). Average incomes in the USA have increased, but 90% of this increase has gone to the richest 1%. Some of the reason for the rise in income is that workers have increased the number of hours they work per week. This now averages 60.
And when adjusted for inflation, incomes for the bottom 80% fell by 18% between 1973-95. In contrast, the corporate elite enjoyed a 19% rise, which became a 66% rise, after the magic applied by tax accountants.
Things are not so different in the UK, where the top 20% now enjoy average earnings that are 7 times higher than the bottom 20%. 20 years ago, this was a 4-fold difference.
This inequality has recently been highlighted by the Church of England archbishops, and also by Oxfam.
But if we’re thinking about health, what about the NHS? Isn’t that wonderful institution responsible for population health? Regrettably, the benefits of modern healthcare systems have been over-egged. Over 75% of how long you live is determined by the social factors outlined above. These happen before you see a doctor, and medicine has no meaningful influence. (Hadler, 2007). There is a bit of a black cloud hanging over the true benefits of modern medicine, and a tropical storm hanging over the pharmaceutical industry. (Goldacre, 2013)
How did we reach this point? How have we got into this mess?
The two main political systems seen throughout the world in the last 100 years have been based on capitalism or communism.
Whilst I hope you will forgive the oversimplification, capitalism is based on an interaction between capital and labour. Capital, (mainly money) is provided by the capitalists. Labour (the workers) then undertakes the work, to produce goods. The workers are paid for their efforts, but profits go to the capitalists.
Marx saw this as unfair, and that as a consequence, labour and capital were in conflict. Justice would only be achieved if the fruits of labour were shared equally. This led him to believe that this could only be achieved if all owned the capital, and all benefitted from it. Private property was anathema. Socialism holds that justice is achieved by ‘each giving according to his ability to each according to his need.’
The problem is that communism has been a failure, and so capitalism is now trumpeted as the only solution.
But in recent decades, capitalism has morphed, and become more extreme in its ideology. This led to a rise in inequality, which started at the time of Reagan and Thatcher, and is closely associated with their ideals for the free market and neoliberal capitalism. (Duffy, 2008).
Workers are viewed as nothing more than a commodity to produce profit. There have been significant pressures to keep wages as low as possible, to control costs. Jobs have moved from being stable to insecure, to ensure greater flexibility. The influence of trade unions has been reduced, so that profits are not put at risk. And the fruit of this has been increased inequality, and the various health and social consequences described above.
One key feature of capitalism is to maintain a pool of the unemployed, who are then available at short notice for new ventures. But we now have compelling evidence that worklessness is more dangerous to health than many killer diseases. (Waddell & Aylward, 2005). The ill effects are reversed by returning to work. So a system that builds unemployment into it harms health.
Communism has failed, and unbridled capitalism has very real health consequences.
A New Way
In 1891, the Catholic Church issued its first formal teaching about work. This was a response both to what it perceived as the errors of communism, but also the threat of wage slavery associated with unbridled capitalism. It has continued to speak out on this matter.
In our secular times, it would be easy to dismiss the Church’s teaching as irrelevant, particularly because its teaching is directly based on the relationship between God and man. But its teaching on social issues deserves closer scrutiny, because within it appears to be answers to many of the problems we have identified. (Duffy, 2008). And you may begin to worry that you’re off message when you realise the Church of England and Oxfam are saying the same thing!
Here are some of the key ideas:
• All humans have equal dignity. We really are all in this together. Communism is wrong to presume that class war is inevitable.
• Humans derive dignity from work. It is right that we should enjoy the fruit of our labour. Therefore, communism is wrong to reject private ownership.
• Capitalists inject capital, and labour injects effort. Profits are generated by the input of both, and therefore it is entirely reasonable for both to share these profits. The John Lewis Partnership provides a perfect example.
• Work is made for man, not vice versa. The end aim of work is to increase the dignity of humans, rather than to produce a profit. Capitalism has got things back to front.
• Work must result in a fair wage for the worker. He/she should be able to afford to live, and to provide for his/her family, and save prudently. It is inhumane to pay below this living wage, and deeply regrettable that the minimum wage in the UK falls short of this basic level. The collapse of marriage in the working classes is directly attributable to the inability of workers to afford to bring up a family.
• Because work gives a human dignity, it is utterly wrong for capitalism to require a pool of unemployed labour. This undermines dignity. Similarly, it is wrong for individuals to be provided with insecure working contracts, which mean they have no certainty about being able to earn enough to live.
• It is entirely reasonable for workers to support each other, to ensure that wages and working conditions are adequate. The removal of unions is unhealthy and wrong.
• The role of the State is to ensure both sides play fair, rather than disempower the worker, because of the power of multinational organisations.
If these concepts were accepted and implemented, many of the problems we currently face would resolve.
Is there evidence that implementing them would improve health, and improve social conditions? Well, there is compelling evidence that more equal societies do better. Additionally, we know that the harmful health effects of worklessness are reversed when individuals return to work. Therefore, this seems entirely reasonable. (Waddell & Burton, 2006).
Health and wellbeing programmes are very popular. In their current format, they work. A bit.
But these programmes won’t address health problems directly associated with social class and inequality.
Communism has failed to improve the lot of the worker. Capitalism has built into its fabric much that undermines the dignity of workers, and rampant neoliberal capitalism has greatly worsened the situation.
What steps could you take? If you’re an employer, you could consider the following:
• Do I pay a fair wage that will allow my staff to live?
• Do I provide stable jobs?
• Who gets the profits? How could this be shared more equitably? (Consider the John Lewis approach).
• Are working conditions safe?
• Do my employees have a voice? Do I encourage unions or staff representatives? Can these have a meaningful input to the company’s direction?
• Do I adopt a “7 Habits” approach, and treat my employees like my best customers? (Covey, 2004)
So, if you want a healthy workforce, full of wellbeing, don’t settle for fashionable interventions of very limited value. Instead, ponder how you can optimise the dignity of your workforce.
If you want to discuss these ideas in more detail, let me know. If you want to persist with traditional wellbeing programmes, I’m sure you’ll find plenty of providers. But at least you’re now well informed about the value of these, and that there’s a morally and scientifically compelling alternative.
About the author
Dr Charlie Vivian is a consultant occupational physician, and director of Icarus Health Solutions. He has a particular interest in biopsychosocial medicine, which considers the interaction between disease, psychological reactions, and the overall social context.
cdc.gov Benefits of Health Promotion Programs.
http://www.cdc.gov/workplacehealthpromotion/businesscase/benefits/ accessed 20/1/15
Covey S. (2004) The 7 Habits of Highly Effective People. Simon & Schuster
Duffy, G. (2008). Labour & Justice. The worker in Catholic Social Teaching. Gracewing.
Goldacre B. (2013). Bad Pharma: How Medicine is Broken, and How We Can Fix It. Fourth Estate.
Gov.uk Health, work and wellbeing: evidence and research. https://www.gov.uk/government/collections/health-work-and-wellbeing-evidence-and-research accessed 20/1/15
Hadler, N. (2007). The Last Well Person. McGill Queens.
Marmot, M. (2005). Social Determinants of Health. OUP.
Oxfam. (2014) A Tale of 2 Britains: Inequality in the UK. Oxfam GB. http://policy-practice.oxfam.org.uk/publications/a-tale-of-two-britains-inequality-in-the-uk-314152 accessed 21/1/15
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Waddell G, Aylward M. 2005. The scientific and conceptual basis of incapacity benefits. The Stationery Office, London.
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