Human beings are not mentally immune to the effects of rising elitism, exclusion, prejudice and greed. They react like rats in cages to having their social environments made progressively more unpleasant. It is because we can now measure how humans have reacted and where they have reacted most badly that many now claim with great conviction that all the injustices and inequalities which underlie most rich societies are having a ‘dose-response’ effect on the mental well-being of populations: the greater the dose of inequality the higher the response in terms of poor mental health.1
In this penultimate chapter, Section 7.1 brings together new evidence to show how there appears to have been an especially strong rise in depression among children living in the most unequal of affluent countries, as recorded from the mid-1980s and throughout the 1990s. This is yet another new finding which suggests that poor mental health among affluent nations is worst in the US and least common where social inequalities are lowest. It suggests strongly that it is being brought up (and living through life) in more unequal environments that increases recorded poor mental ill health most strikingly.
The mechanism behind the worldwide rise in diseases of despair is suggested, in Section 7.2, to be the anxiety caused by particular forms of competition. School children’s mental health appears most damaged as they are given progressively more and more examinations to undertake. The effects of the advertising industry in making both adults and, especially, children feel inadequate (if they are not constantly competing to consume more) are also documented here and many of the latest calls from all quarters – from psychiatrists to psychologists to archbishops – to curtail that advertising are listed.
The powerful have little immunity from the effects of despair if they live in more unequal countries. The most detrimental damage to ill health is found near the geographical hearts of the problem – the widest health inequalities in rich countries are to be seen within the very centres of London and New York. Section 7.3 shows this and also illustrates the fractal geography that results from psychological damage and social inequality. Section 7.4 illustrates just what kind of ‘bird-brained’ thinking was required to get us into this situation and how such thinking has continued throughout the economic crash despite its credibility having come to an end. It is not just that the mental health of human beings is damaged as social injustices increase, but our collective capacity to think well and work well together to do the right thing is also clearly much harmed. Under high levels of inequality great untruths become presented as truths and much effort (that could otherwise have been spent for good) is either used for harmful purposes, is wasted outright or is exerted by many trying to explain that some particular rise in inequality is not some great achievement.
Finally, Section 7.5 documents the rise in mass medicating of populations that has resulted from this situation in the context of a very brief history of psychiatric prescribing practices. The pressure on pharmaceutical giants now to make a profit is so great that if a pill was discovered that would cure mental illness with one dose, it would almost certainly have to be destroyed. However, it is unlikely that such an effective ‘happy pill’ could exist. The human condition (drive, questioning, angst and concern) means that we cannot always be happy, but learning to live better with each other is beginning to be seen as the key to learning to live better within our own minds, to be happier or at least more at ease with ourselves. Not making children anxious, tearful, fearful and stressed in the first place is the best place to start. By looking to see in which places children are most anxious we can also begin to see what might underlie the problems of adults who grew up under different social regimes.
There are dangers in all shapes and sizes; it is the little numbers you have to look out for. The danger of saying that a certain proportion of children or adults suffer a particular mental illness is that it sustains the fantasy that everyone else is fine. All but the psychopathic have an ‘… innate need for social connection and egalitarian community’,2 and it has been shown that psychosis (mental ill health) is a natural human reaction to being deprived of the sustenance of that need. Being deprived of feeling valued, connected together to others as equals, makes us mentally ill. Evidence is now emerging that psychosis is normal behaviour for the human social brain when living under social isolation. Psychiatrists now suggest that our brains have developed in a way that means we cannot cope when not treated as equals.3 The effects on our psychological states of mind of living in some of the most unequal of times in the most unequal of places have recently been recorded as enormous, so great in fact that we have become normalised to mental ill health. In Britain: ‘According to the respected Psychiatric Morbidity Survey, one in six of us would be diagnosed as having depression or chronic anxiety disorder, which means that one family in three is affected’.4
Mixed anxiety and depression is the most common mental disorder in Britain, with almost 9% of people meeting the criteria for diagnosis. Between 8% and 12% of the population in Britain experience depression in any year. Women are more likely to have been treated for a mental health problem than men (29% compared with 17%). A quarter of women will require treatment for depression at some time, compared with a tenth of men. Women are twice as likely to experience anxiety as men. Of people with phobias or obsessive compulsive disorders, about three fifths are female. One in ten children between the ages of 5 and 15 has a mental health disorder. And the figures for the US are worse.5
In Britain around a fifth of children have a mental health problem in any given year, and about a tenth at any one time. Rates of mental health problems among children increase as they reach adolescence. Disorders affect 10.4% of boys aged 5–10, rising to 12.8% of boys aged 11–15, and 5.9% of girls aged 5–10, rising to 9.7% of girls aged 11–15. Not all mental disorders have their origins in the way we live, but the way we live greatly affects how we are able to live with people suffering all kinds of distress or confusion and whether we exacerbate or mitigate suffering. At the other end of the age range to children, as the number of older people increases, the total number of people with dementia in the UK is forecast to rise to over one million by 2051.6
Studies undertaken since 1974 have found a rise in what are known as ‘conduct problems’ among British children aged 15 and 16, accelerating in the 1990s and providing ‘… evidence for a recent rise in emotional problems’7 among these children. The conduct problems included in these studies were a propensity to be involved in fighting, bullying, and/or stealing, lying, disobedience, fidgeting, restlessness, inattention and fearfulness of new situations. This particular study found that for both boys and girls the increase in these problems had been substantial, with faster rises between 1986 and 1999 than those found in earlier years.
The proportion of British children with severe problems doubled over the period 1974–99. The increase in the number of children suffering emotional problems was even starker, with almost all the increase having occurred since 1986. An earlier study of children in Scotland found similar results, with rising levels of distress from 1987 to 1999 but concentrated among girls and most acutely felt among the most affluent of girls. Overall, by the start of the 21st century, a third of adolescent girls in Scotland were reporting symptoms of being depressed as compared with just over a sixth in 1987. The fact that these figures are so high is in all probability related to the part of Scotland where the study was undertaken, a part which also has one of the highest rates of anti-depressant prescription levels for those aged 15 and over. A tenth of the entire population of Greater Glasgow were being given an anti-depressant dose-a-day by 2006 (see Section 7.5, page 304). The researchers of this study of adolescents reported that a significant relationship was found between these children’s distress and how near to school examinations they were when surveyed again, in 1999. The authors of the same study concluded that it was changes in society that had harmed the mental health of so many adolescents, not any increase in sensitivity.8
Recently contrasting research was reported which suggested that there was no epidemic of increased anxiety in adolescents. Here I use the same data from this research to suggest that there is. This research, published in 2006, reported on 26 studies producing some 45 data points (each point being a rate of mental illness reported for a particular group of children at a particular time). The conclusion of the authors of the study was that there was no long-term rise to be seen in the rates of depression being reported. However, the authors had taken studies from a wide range of countries.9 The full set is shown in Table 7. If a subset of their studies is selected, just those studies undertaken among children living in North America, then a different trend results. In North America rates have more than doubled since 1984, one extra adolescent girl in ten suffered symptoms of depression by the start of the current century as compared with two decades earlier; 14% prevalence rates are projected for 2008 and are the highest recorded in Figure 21, as compared with rates of around 4% being reported in 1988. Thus one in seven adolescent girls in North America now suffer mental ill health, as compared with possibly as few as about one in 25 of their mothers’ generation at their age.10
Figure 21 is constructed by taking those studies that reported depression rates for girls aged between 13 and 18 and which were undertaken in countries in North America. These studies were mainly undertaken in the US, but two were based in Canada and one in Puerto Rico. The average year in which the adolescents’ state of mental health was being assessed is calculated as the average of the study group birth years plus their average ages at interview. The collection of 16 studies shown in Figure 21 suggests a rise in rates of depression as diagnosed among girls in their teenage years. The Pearson product-moment correlation coefficient of the strength of the rise with time is 0.56 (p=0.024). That ‘p’ value means that there is a 2.4% chance that there is no relationship over time, or to put it another way, a 97.6% chance the rates really are rising. The data are not sufficient to be sure with much precision how quickly rates are rising. The rise of about 0.46 points per year (10 percentage points in 22 years) has an approximate confidence limit around it of plus or minus 0.37 per year. It is thus unlikely to be zero, but it could be much lower than 0.46, or it could be substantially higher. Furthermore, weighting by the number of observations in each study increases the strength of the estimated annual increase slightly, to 0.53 points per year. However, if we include studies from the US alone, the estimated chance that the rate is definitely rising falls to just below 95% given the slightly smaller number of studies. For boys there is only a 0.42 correlation coefficient (p=0.108) and thus ‘only’ an 89.2% chance that the rate is rising. Studies usually require a higher chance than this to be taken seriously. So let us just talk about the girls for now.
Table 7: Studies of adolescent depression available for meta-analysis, 1973–2006
Notes: * Country of study not obvious from article title or journal. It is assumed that the final study was located in Seattle assuming the reference in the source is to: Vander Stoep, A. et al (2005) ‘Universal emotional health screening at the middle school transition’, Journal of Emotional and Behavioural Disorders, vol 13, no 4, pp 213-23. In the graph the two results from one study (4 and 5) are excluded because the figures reported in the original article are for 15- to 16-year-olds only, not 15-24-year-olds as reported above, and rely on 12-month recall under a diagnosis method which reports higher rates in general: composite international diagnostic interview (see Kessler, R.C. and Walters, E.E. [1998] ‘Epidemiology of DSM-III-R major depression and minor depression among adolescents and young adults in the National Comorbidity Survey’, Depression and Anxiety, vol 7, pp 3-14). If rates were not reported for girls or boys separately, or at all, in the original source they are also not shown here.
Source: Costello, E.J. et al (2006) ‘Is there an epidemic of child or adolescent depression?’, Journal of Child Psychology and Psychiatry, vol 47, no 12, pp 1263-71, Table 1.
The original meta-analysis of many studies that formed the basis for this repeat study came to the opposite conclusion to that shown here. Its authors suggested that there was no rise over time. They made this suggestion because they thought that it was fine to include all affluent countries as they assumed all such countries provided at similar times sufficiently comparable environments for children growing up. Countries outside North America mainly studied their children in later years, and so in the original study in later years the authors included studies from Australia, Brazil, Finland, Germany, Japan, the Netherlands, New Zealand, Sweden and Switzerland where, in many cases, the rates reported for children in these age groups were lower than those found in North America. Apart from Brazil, all these countries are also more equitable than is almost all of North America. In earlier years most of the studies available to the original meta-analysis used samples of girls assessed in North America.
Note: Each circle represents a study; the area of the circle is drawn in proportion to study size. See Table 7 for the details of when and where each study took place.
Source: Re-analysis of Costello, E.J. et al (2006) ‘Is there an epidemic of child or adolescent depression?’, Journal of Child Psychology and Psychiatry, vol 47, no 12, pp 1263-71. The data shown above are for those studies where the children lived in the US, the US territory of Puerto Rico, or Canada (excluding one study that used different diagnosis methods from the other 16, see notes to Table 7). Those included are study numbers: 2, 6, 8, 9, 10, 17, 18, 20, 22, 26, 29, 30, 31, 34, 35 and 41.
Given that we have only recently begun to understand how crucial differences in human geographical context are to social well-being it is not surprising that the authors of the original meta-analysis that Figure 21 is derived from assumed that they could pool studies from different countries. One study they included, itself reporting in 2001, found that the rates of adolescents suffering major depression without (and with) impairment were: in the US 9.6% (and 4.3%) for Anglo-American children aged 12–15, 13.4% (and 6.1%) for African-American children, 16.9% (and 9.0%) for Mexican-American children, and for children compared in the same way living in Japan: 5.6% (and 1.3%) respectively. That study suggested that these huge differences, with Mexican-American children living in the US being seven times more likely to suffer major depression with impairment than Japanese children living in Japan all ‘… disappeared after sociodemographic adjustments … [concluding that] ethnicity does not have a significant impact on the risk of adolescent major depression after sociodemographic adjustments’.11 The implication of this finding is not that it is fine to compare children living in different countries, but that the sociodemographic differences between the lives of children living in different countries are so great that those differences can account for such great inequalities between countries. The children living in Japan are excluded from the re-analysis above, as are all other children not living in North America.
The above re-analysis of data for this volume, suggesting that depression in adolescents is rising in unequal affluent countries, is itself taken from (and hence refutes) a study reporting no increase. It is backed up by many other studies. For adults it is well known that in the US those born after 1955, as compared with those born before 1915 (when tested at the same ages), are up to ten times more likely to found to be suffering major depression, and that similar, if less extreme, trends have been reported from studies undertaken within Sweden, New Zealand, Germany and Canada.12 Given these rises it would be surprising if the rates for adolescents had not been rising, but the implications of the most recent rises are clearly that worse could be to come.
We know from other studies that the average North American child by the late 1980s was already more anxious about life than some 85% of North American children in the 1950s. In fact the average North American child has become more anxious than child psychiatric patients in the 1950s in the US. The reasons found for this have been the collapse of a safe society and an increase in environmental dangers as perceived by children. By 2000 it was said that economic factors had so far played only a little role in explaining these trends. The study that reported these findings concluded that: ‘Until people feel both safe and connected to others, anxiety is likely to remain high’.13 That was written eight years before the economic crash. All these studies either show that rates of anxiety and depression are rising in children in North America and in Britain, or in the one confounding case they once again show that same upwards trend when that one study is re-analysed to avoid mostly comparing rates in North America from earlier studies with rates from Europe and Japan found later.
What is driving the increase in adolescent despair, particularly in North America, but also in Britain? In Britain a remarkably similar proportion of around one in seven children reported in recent official government surveys that they often felt sad or tearful, were often anxious or stressed. Those receiving free school meals due to poverty were, unsurprisingly, slightly more likely to say this,14 but not very much more likely than the rest. In recent years something has been making children feel worse in these particularly unequal of rich countries.
Why should rates of depression be rising among children? What is it about their environments, especially in North America, which has caused not just more adults, but many more children, to become depressed? There is a mix of reasons, but it is worth looking first at those who have said that their actual aim is to make people anxious, especially to make children anxious. These groups are found in that part of commercial industry whose very purpose is to make children in rich countries insecure: advertising. An advertising agency president recently helpfully explained that: ‘Advertising at its best is making people feel that without their product, you’re a loser. Kids are very sensitive to that.... You open up emotional vulnerabilities, and it’s very easy to do [that] with kids because they’re the most emotionally vulnerable’.15 This president is no lone voice; a year after her words were published another advertiser, in 2003, explained: ‘In our business culture, children are viewed as economic resources to be exploited, just like bauxite or timber’.16
The fact that advertisers behave in ways that deliberately have detrimental effects on the mental health of children is not some secret knowledge of conspiracy theorists. In Britain in 2007 the BBC reported that: ‘Children see some 10,000 TV adverts a year and recognize 400 brands by age 10, Children’s Secretary Ed Balls says’.17 The most recognised symbol is the twin arches of McDonald’s, which 70% of British three-year-olds recognise. Less than half of these children know their own surname, but they know Mr Mc’s.18 The head of the established church in England in 2008 explained (in his own press release) that more and more research has found that advertising on television is harming children, making them harmfully competitive, and promoting what he called ‘acquisitive individualism’ to such an extent that: ‘Evidence both from the US and from the UK suggests that those most influenced by commercial pressures also show higher rates of mental health problems’.19 The situation is far worse in the US where exposure to the harmful effects of commercialisation has been so much greater that the young adult population can now be described as having been marinated in the mentally stultifying stuff of advertising.20
Advertising grew first and grew most strongly in the US out of work undertaken to study how best to produce propaganda in wartime and later in public relations. Arguments for using propaganda to alter consciousness in peace-time can be traced to around the time of men like Walter Lippmann (1889–1974). Walter Lippmann was a colleague of Edward Bernays (1891–1995), the man credited with the creation of the industry of public relations. Lippmann worked for the US government helping to manufacture propaganda during the First World War. As a result of those experiences Lippmann came to believe that the ‘manufacture of consent’ must become a ‘… self-conscious art and regular organ of popular government. The whole process would be managed by a “specialized class” dedicated to the “common interests” of society … the key role of the new public relations industry was to keep society in the dark’.21 Modern-day advertising aimed at children grew out of this and is no less sinister. The adverts never say ‘this toy is no fun; you’ll be bored with it in minutes, why not go play in the park’. There are very simple reasons why those who run businesses and favour competition see advertising as essential. People cannot be allowed to be too happy, as (in the most consumer-orientated societies) if they are satisfied with their lot, they might slow down their consumption. If people were ‘… allowed to follow old routines and stick to their habits, [it] would spell the death knell of the society of consumers, of the consumer industry, and of consumer markets.… Consumer society thrives as long as it manages to render the non-satisfaction of its members (and so, in its own terms, their unhappiness) perpetual. The explicit method of achieving such an effect is to denigrate and devalue consumer products shortly after they have been hyped into the universe of the consumers’ desires’.22 Today archbishops preach against advertising, psychologists proselytise for an advertising-free world, philosophers ponder on its harm in their writing, all while it remains the bread and butter of business, especially of public relations.
It is an open secret that it is the job of many people to make us and our children feel uncomfortable, to develop a feeling of failure, of lacking. What is less well known is that, while women record the highest rates of depression (both as girls and as adults), when the results are fatal it is men who are many times more affected. Figure 22 shows, calculated over a 140-year period, the chances of men dying as compared with women, by age and by their decade of birth. It is based on data taken from all the rich nations of the world and combined. These are all the nations rich enough to afford to have systems of recording mortality rates that were reliable at each point in time. What the figure shows is that right across the rich world, for the most recent cohort born in the 1970s, by the time they reached their twenties men had become three times more likely to die than women of the same ages.
Figure 22 shows that at first the rises in mortality inequality between the sexes began in old age for men born in the 1890s as compared with those born in the 1880s (Bernays’ generation as compared to Lippmann’s), those later-born men being encouraged to take up smoking when mass-produced cigarettes became available in their twenties, and so more often dying a little earlier than women 40 years later. In this case it was because women were not usually permitted to smoke (at first) that a difference in mortality later emerged. Similar differences occurred at young ages for those born at times that meant they would be young adults in wartime. However, it was to be born in the 1940s and 1950s and especially later that had the greatest relative detrimental effect on men. This was long after the birth cohorts for whom childbirth had been made much safer.
Note: Each line refers to the cohort born in the decade it is labelled by. The X-axis gives the age of cohort members. The Y-axis gives how many more times a man of that age born in that decade is likely to die in a year as compared with a woman living in the same set of countries born at the same time and of the same age.
Source: Original figure given in Rigby, J.E. and Dorling, D. (2007) ‘Mortality in relation to sex in the affluent world’, Journal of Epidemiology and Community Health, vol 61, no 2, pp 159-64, sample size one billion people.
Men born in the 1940s and more especially in the 1950s were particularly likely to be affected by the worldwide recession of the mid-1970s, and later generations by the recessions of the early 1980s and 1990s. The source from which this diagram is drawn looks in greater detail at the timings to confirm this. Being brought up in societies which increasingly labelled you as ‘failing’, and then being also seen to have failed in the labour market, a market that became ever more competitive, was sufficiently deadly for men to cause changes in mortality ratios greater than those seen either at the height of the smoking epidemic or during wars. There were many ways in which young men in rich countries began to die at greater rates than women: suicide, accidental overdoses, fights, road accidents, even cirrhosis. And the health and welfare services (which might have looked after those whose early deaths were more preventable) were also beginning to fail due to competition in recent years so that almost all adult men of almost all ages up to at least 70, in any given year, are now (across the rich world) twice as likely to die as are women of their age. Men react worse to competition. Men suffer far more than women from a prevailing belief that when they fail in competition no one will be there to help.23 Competition is greatest in the US where health and social care is so often found to be the worst among affluent nations. Competition and care are in many ways opposite ways of behaving, with very different outcomes as a result.
Every year around 100,000 people die prematurely in the US simply because of a lack of basic medical care, not care they did not seek, but care they were denied. This is three times the numbers who died there of AIDS in the early years of the current century. Those who revealed these facts found it hard to cope with the lack of interest they received. They wrote: ‘Any decent person should be outraged by this situation. How can we call the United States a civilised nation when it denies the basic human right of access to medical care in time of need? No other major capitalist country faces such a horrendous situation’.24 But no other capitalist country believes so ardently in competition. Rising competition not only causes more deaths but also helps prevent the efficient treatment of diseases that, if not treated, lead to early death. Competition is inefficient.
Some types of competition are more inefficient that others. Private medicine is found to be inefficient by every decent study carried out on it. The UN Research Institute for Social Development (based in Geneva) confirmed recently that it was the spending of a significantly higher proportion of money on state healthcare, rather than private healthcare, which marked out countries where life expectancy was high and infant mortality low. Spending on private or even charitable health services was counter-productive.25 It is even counter-productive for the rich.
Very wealthy people do not necessarily get good healthcare. When they are ill they become surrounded by people who have an interest in keeping them alive, but such an interest is not the same thing as providing good healthcare. The ideal patient from the point of view of private medicine is one who is very ill for a very long time, who requires constant treatment and the injection, inhalation and ingestion of very many expensive drugs. It makes sense for private physicians to scour the bodies of their most affluent patients particularly thoroughly in search of any malady that can be further investigated and treated, and then the side-effects of those treatments can also be treated. Ideal private patients are ones in a coma as they do not object to the way in which they are being used. As a result death is a very private thing in most of the US. In many states death records are not public, as they are in much of Europe, and the last years of the lives of the very rich are generally hidden from view, although they can be pieced together from their hospital receipts which detail every needle put in their carcass, every exploratory invasion of their bodies, every operation, even every meal they are sold.26
Private medicine may not improve the lives of the rich very much but it does deprive the poor from receiving some of the most basic of services from doctors because it diverts these doctors from doing their job. The wealthy in the US only receive the pampering that they mistake for a good health service because so many others there have no health service at all. Similarly, wealthy North Americans can only live in homes built and serviced by so many servants that they appear as palaces because so many other North Americans do not even have the right to have their rubbish collected by a government agency.27 Being surrounded by people paid to be sycophantic, to crawl or to otherwise suck up, does not add greatly to the well-being of the rich, but it does deprive others of the potentially useful labour of all these people. Amazingly it is often suggested in Britain that ideas on introducing markets, even health markets, be brought over from the US!
Introducing a little competition and a market-based system into state healthcare is dangerous. More competition is being introduced into the NHS, especially its variant in England. In England between 2002 and 2005 the number of GPs rose by an extra one for every 25,000 people. However, in the poorest fifth of areas an extra GP was only provided for every 35,700 people, whereas in the least deprived areas an extra GP was made available for every 18,500 people. The poorest areas had the lowest number of doctors per head to begin with, and the least poor areas had the most. Somehow the NHS administrators managed to further widen the inequality, despite having more resources to share out in the shape of some 2,000 extra doctors to be deployed in just these three years. In 2008 England’s Department of Health proudly published the graphs that these figures were derived from to show how well it was monitoring the situation as part of its evidence-based drive to reduce inequalities in health.28
Insecurity is not good. Being told you have to compete rather than work together is not good. Introducing private markets into state healthcare is not good. The ‘notion that market price is the only measure of value [is] “crass, offensive and contrary to human beliefs and actions”. Price based on scarcity does not reflect the value of a commodity to human life, as “the low valuation of water and the high valuation of diamonds” shows’.29 However, even ‘health and safety’ inspectors are now being told by their political masters that they must see making money as something they should encourage. If some form of making money is detrimental to health and safety why encourage it? The ‘economic progress’ seen as paramount in the US has in recent years been inflicted ever more forcibly on people in the UK to the point whereby British health and safety and other regulators are now told by Her Majesty’s Government that ‘… regulators should recognize that a key element of their activity will be to allow or even encourage economic progress’.30
Ultimately, if you want people to compete you have to keep them needy. Otherwise most people in rich countries come to realise that there is enough to go around. Over two centuries ago, among those with power who thought that there was too little to go around to cater for all, it was becoming widely recognised that: ‘[Slavery] ... is attended with too much trouble, violence, and noise, ... whereas hunger is not only a peaceable, silent, unremitted pressure, but as the most natural motive to industry, it calls forth the most powerful exertions.... Hunger will tame the fiercest animals, it will teach decency and civility, obedience and subjugation to the most brutish, the most obstinate, and the most perverse’.31 Just over a century ago in London, those again in positions of power had refined what kind of a wage they saw as needed: ‘The ideal wage, therefore, must be sufficient to persuade a man to offer his labour, but insufficient to allow him to withdraw it for more than a few days. Capitalism thus replaces the whip of the overseer with the lash of a more terrifying slave-driver - hunger’.32 Today we have the advertising of fast food that makes people hungry, and the results are obesity and heart disease. It is time to stop making people hungry.
Mental despair and the imagined need to consume more and more to try to avert it are greatest where politics is rendered most meaningless, where it has been captured by those with the most power and money. That sense of meaninglessness is enhanced when the news media is almost totally controlled by a small number of men, such as very rich businessmen in the US, or a few communist party bosses in China. As in both the US and China, the more advertising and other propaganda people are exposed to, the more they are told that individually they need to be wealthy and collectively they need to support economic growth. The more that public opinion and debate is almost totally controlled by a small elite with a tiny number of carefully vetted people allowed to speak, those drawn from the ‘top’ couple of universities, from the dominant party or party-pair, the more ‘positional competition and success are celebrated relentlessly’,33 then more and more the idea of being a loser will come to cross everyone’s mind.
Despite the recent heart attack striking their twin beating hearts, world finance continues to be utterly dominated by London and New York. The large majority of the world’s hedge funds were organised from these two cities in 2007, although some four fifths were registered in tax havens like the Cayman Islands. The derivative markets in these two centres were worth US$7 trillion a day by 2007; two days’ trading was the equivalent of the annual US GDP.34 And almost all commentators agreed by then that these excesses were harmful, that the speculators were harming rich countries as well as poor. In 2005 the Deputy Chancellor of Germany said of the London and New York-based speculators: ‘Some financial investors spare no thought for the people whose jobs they destroy. They remain anonymous, have no face, fall like a plague of locusts over our companies, devour everything, then fly on to the next one’.35 These words appeared in a German newspaper and resulted in the response in the Wall Street Journal from a hedge-funded chief executive who claimed that at least the North Americans and British bankers were ‘… bringing a measure of capitalism to Germany’.36 As a result of that particular little poisoned spoonful of capitalism, the GDP of Germany was reported to have fallen by 3.8% in just the first three months of 2009, the fastest collapse measured since modern records began.
The top one fifth of earners in Manhattan in 2000 earned 52 times more than the bottom quintile living there, a gap similar to that found only in countries as desperate as Namibia.37 An infant born on the poor side of the tracks in New York (Morningside Heights in Harlem, for example) has a 2% chance of dying in his or her first year of life, 12 times greater than the chance for infants born in the nearby salubrious Upper East Side.38 By 2004 unemployment rates for black men in Harlem were up to 50% worse than they had been even during the 1930s depression.39 By the start of this century, by age 15, US teenagers had only a 75%, a three in four, chance of reaching age 65, one of the lowest rates in the rich world. The chance is partly not higher because black teenagers in the US have only a 33%, a one in three, chance of seeing their 65th birthday.40
In the heart of London in the borough of Westminster a woman who has made it to age 65 living in the Church Street estate can expect on average to live roughly another 12 years. In contrast, a woman of the same age living in the opulent Little Venice enclave in the same borough can expect to live another 26 years41 (most thus living to at least age 91). On the streets outside their incredibly sumptuous and expensive homes are found more rough sleepers and more people who are officially counted as suffering serious mental illness and seeking housing than anywhere else in Britain. And just down the road are the women of Church Street who have had such different lives and whose prognosis beyond 65 is to live half as many more years as those in Little Venice.42
The convergence of people labelled as mentally ill on Westminster and Manhattan was an unforeseen outcome of the successful movement to close down asylums from the 1970s onwards, the failure of medicalisation in ‘the community’, including wider ‘care in the community’ and some strange attraction among those labelled as ‘mad’ towards these financial centres (Westminster borders the City).43 There was over-optimism in the 1970s that psychiatrists could cure mental illness with drugs. These drugs mostly suppressed symptoms rather than cured problems, so mentally ill patients usually never really felt better and were often reluctant to continue to take medication. Simultaneously, as banking hours became longer and longer the rumours that city traders could only keep going with artificial stimulants became more often the truth. It wasn’t just those sleeping rough on the streets outside the trading houses who were taking drugs.
Geographical divides come with varying degrees of contortion. Just as those supposed to be taking their drugs to calm them down (but not doing so) stumbled so close to those financiers supposed not to be taking drugs (but nevertheless partaking), so too were the living quarters of the very poor and very rich in these centres closely intertwined. It is hard to find social statistics as extreme and environments as different but so close together as are found within the hearts of London and New York. The intertwining of rich and poor neighbourhoods is far greater in the centres of these two cities than anywhere else in the rich world. The line separating rich and poor in the centres of these cities is most twisted at their hearts and less and less contorted further out. The lines that divide inner from outer London and New Jersey from Long Island are less convoluted to draw. Further out still they become straighter, or more smoothly curved. An outlying affluent suburb can be seen to be surrounded by slightly less affluent suburbs, and then by average places and only then do they touch on poorer districts. In Britain at the far commuting boundary of London the smoothest divide is now found, that which separates the south of England from the rest of the UK.
Figure 23 shows my attempt to provide a description of where the North–South divide runs through England. To say that it does not exist because the Midlands has its own identity is to miss both how divided the Midlands are, and how the identity which they did have has been chiselled down with the repeated decimation of manufacturing employment decade after decade. The North–South divide in England, drawn in Figure 23, is really the outermost boundary of London. It can be seen in how people vote, how they die, in their wealth, but even in things as mundane as how the fittings of pumps in pubs are altered so that a different head forms on pints of beer on either side of the border. You don’t really leave London until you’ve crossed this line; you can tell that you are still in the South not just from the cost of homes but from the taste of the drink. However, places both north and south are slowly losing their identities as what begins to matter more and more within the human geography of Britain is what the exact orbit of your locality is in relation to the capital. In other words, how well placed is your place to trade with, and in, that capital?
Divides are everywhere; they are the stuff of geography. They are found along country lanes in Lincolnshire, between regions in Europe and between countries worldwide. Divides are not there because of lack of interaction, but because over the borders things move in particular directions. Today the best health in the world is enjoyed in countries like Japan, Belgium and Norway, the worst in the Congo. There is both an indirect and a direct connection. The indirect connection is trade. Belgium and Norway both need things that come from the Congo – industrial diamonds for machine tools, minerals that make mobile phones function – and both countries pay a pittance for these. If they did not there would be much less of a divide. We don’t know exactly how these goods get from one place to another, but we know that they do, and that what matters more and more to how well you are likely to fare, is where you are to start off with, your orbit within the world trade system.
Note: This particular divide is the social, economic and political divide in England. Below the line people live about a year longer on average; identical houses cost much more; people in similar situations are more likely to vote Conservative below than above the line, and much more besides. For a more detailed description of the line and exactly where it is estimated to run see: www.sasi.group.shef.ac.uk/maps/nsdivide
Source: Drawn by the author with help from John Pritchard and derived from many sources.
The direct connection that explains why the Congo is poor and other places are rich is less well known. From around 1885 Europeans and later people in North America and then people in Japan began ‘… to live longer partly because people in other parts of the world were suffering deprivation and dying young’.44 The direct connection was that very soon after King Leopold the Second of Belgium took the Congo as his own private property in 1885, as well as instigating one of the first large-scale documented cases of genocide, his officers ensured that there was a rapid increase in the harvest of latex rubber, a proportion of which was exported to become condoms and diaphragms, resulting in smaller families in richer countries. Villagers who failed to meet their quota for producing rubber in a year could pay the remainder in baskets of severed hands cut from protesting fellow villagers, including children.45 It comes as a shock when you first learn that baskets of severed hands became the symbol of the Congo ‘Free’ State under colonial rule. But we quickly become anaesthetised. You probably know that there is at present a worldwide death toll of about two million young children from diarrhoea every year. This is equivalent to 15 per 1,000, a rate that matches that found in many English towns around a century ago, and diarrhoea is just as preventable abroad as it is in England today.46 You probably don’t think every day of these deaths as shocking. That is because they occur far away, and while it is kept at a distance it is a shock to which we can easily become anaesthetised.
International divides make local divisions often appear paltry, but not caring about poverty within rich countries is a precursor for not caring more widely. On Sunday, 15 March 2009 the Health Select Committee of the House of Commons released its report on health inequalities within Britain. The report had been produced because the government was set to fail to achieve the target on health inequalities that it had set in 2003. The target was, by 2010, to reduce inequalities in health outcomes by 10% as measured by infant mortality and life expectancy at birth. Success in Britain is still counted in the live bodies of babies. The report described this as perhaps one of the ‘toughest’ health targets in the world. However, other affluent countries did not need such tough targets because, apart from the US, they tended not to have such great health inequalities, inequalities that have such an impact on the overall health of their citizens.
There was a precedent for all this ‘tough’ talk. In 1985, when she signed up to the World Health Organization inequality targets, Margaret Thatcher had agreed to a tougher target of a 25% reduction in health inequalities by 2000. Britain spectacularly failed then, with health inequalities increasing dramatically instead of reducing. They continued to increase under New Labour, and even the most recent statistics show little sign of the widening gap abating. In the US in 2008, long before a single case of swine flu occurred, and for completely different reasons: ‘For the first time since the Spanish influenza of 1918, life expectancy is falling for a significant number of American women.… The phenomenon appears to be not only new but distinctly American’.47 The phenomenon being discussed was absolute rises of poverty in the poorest of US counties. Two years later, in January 2010, the charity Save the Children reported absolute rises in the numbers of children living in the worst states of poverty in the poorest areas of the UK.
The cost in the US alone of the 2008 bail-out of banks was estimated to be greater in real terms, even in November 2008, than the combined sum of the costs of the Marshall Plan (US$155 billion), the Louisiana Purchase (US$217 billion), the Moon-shot (US$237 billion), the Savings and Loan Crisis (US$256 billion), the Korean War (US$454 billion), the New Deal (US$500 billion), the Iraq War (US$597 billion), Vietnam (US$698 billion) and the all-time budget of NASA (US$851 billion). When combined, all these nine giant expenses, at US$3.9 trillion, are dwarfed by the US$4.6 trillion bail-out price tag. And that was just the price as first announced.48
Something changed in 2008; this was not business as usual, not even crisis management as usual. It was the result of the most spectacular example of bird-brained thinking ever to have occurred in human history. Bird-brained thinking is a particular trait that humans have for not being able to think well ahead and for flocking in their behaviour in ways that can bring about catastrophe. It was bird-brained thinking, by bankers, businessmen (and a few businesswomen), politicians and consumers that led to the crash of 2008. Figure 24 shows just one of what will become thousands of similar graphs to be drawn of the crash. This one could be drawn early because the crash was initially most acute in the US.
Even early on the economic crash looked very unlike an economic recession. By August 2009 a tenth of the world’s merchant shipping was reported to be anchored up.49 And electricity consumption in countries like Britain fell in a year by a similar amount, mainly as so many industries shut down operations.50 A recession, such as that of the early 1980s, tends to see home borrowing fall as fewer houses are sold, but then borrowing increases again afterwards, as in the 122% rise in borrowing shown in Figure 24 that occurred in the US between 1983 and 1984. The recession in the early 1990s saw home borrowing slow down again, the rates of change go slightly negative, but then rise gently again in the late 1990s, then oscillate, then go higher, then peak at over a trillion dollars in 2005 and then come crashing down and down. Change in net lending did not just go negative, but exceeded (negative) 100% in 2007–08, when borrowing fell by US$698 billion, falling by 107% of what it had been in 2007. Recessions are not depicted by the plummeting figures seen in US mortgage lending. Recessions are slowdowns, not crash landings. It takes concerted bird-brained thinking to rise so high that the only way down is to crash.
The small groups of people who run corporations in the most profit-hungry of countries act most often with a kind of bird-brained thinking that is called hyperbolic discounting. That is because culturally they have evolved in a way that is similar to the way birds evolve biologically. Corporate bosses have not literally evolved to become bird-brained. Rather the modern corporation in unequal rich countries has evolved to favour promoting most often those individuals who demonstrate bird-brained behaviour.51 Whichever organisation was at the top under such a situation was going to look bad when the problems that were the product of believing so much in markets unravelled during 2008. Graduates of the Harvard Business School began to admit in 2009 that ‘There’s a certain self-consciousness now that we may be part of the problem’.52 The school’s graduates have, far more often than others, been running banks that crashed, heading security exchanges that failed to spot massive fraud (such as Bernard Madoff’s ‘Ponzi’ scheme), or have even been directly involved in fraud themselves. These stories were reported not in the obscure left-wing press, but on Bloomberg News, the television/internet channel of big business! But the greater fraud, not broadcast on Bloomberg, was the fraudulent message that the elevation of people with MBAs to such heights of reputation sent out. This was the message that bird-brained short-term thinking was somehow efficient.
Notes: Right-hand axis: net US$ billion additional borrowed in year shown by the bars in the graph. Left-hand axis: percentage change in that amount. Final percentage change unknown, but known to be based on a denominator of ‘just’ –46 US$ billion (the only negative bar). It is shown plummeting down off the scale. The 2009 mortgage debt to Quarter 3 was –370 US$ billion.
Figures for the fourth quarter of 2009 were not released at the time of going to press, but preliminary estimates suggest an even faster fall in 2009–10 than is shown in the graph above for 2008–09. There was no sign of a mortgage market recovery in spring 2010.
Source: Table 6, pp 231-2, this volume, first column of data (household home mortgage debt change); see footnotes to Table 6 for 2009 data.
Bird-brained thinking, of the kind corporate bosses recently engaged in (and still do so), was first recognised when it became clear through studying pigeons that an accounting method called ‘hyperbolic discounting’ could explain how birds choose to eat or store grain. Essentially, pigeons exhibit a huge appetite to consume now rather than save. Saving would allow them to be able to eat a little more evenly later. However, it is not that pigeons eat as much as they possibly can now, but they can be observed to discount the potential future value of grain according to a function that sees its value fall hyperbolically (very fast) with time.53 Clearly behaving in this way helped pigeons survive in the past, or at least the few that evolved into those we get to study in experiments now. These are the kinds of experiments in which the pigeons get to tap on a lever and receive grain now, or on another lever and get twice as much grain in one minute’s time. Which would you tap?
Currently it is still not legal to put business school MBA graduates into cages and to give them levers, one which gives them a treat now, and another that makes them wait, but get more later. What we can do instead is look to the past to see how their forebears behaved in these situations. The particular economics that people who take MBA courses are taught tells them that when a good becomes scarce its price rises, which both reduces consumption and increases the number of people trying to supply the good, so preserving its availability. This theory was, ironically, first tested on some cousins of those same pigeons whose behaviour taught us that hyperbolic discounting is natural, at least natural in birds.
Soon after Europeans arrived in North America they observed staggering numbers of passenger pigeons, flocks said to be a mile wide and 300 miles long. These were hunted to extinction, the last one dying in 1914. They were killed for their meat, the price of which did not rise one blip as their numbers fell and scarcity rose.54 People simply ate other food, and ate pigeon when they could, to the very last bird. These hunters of passenger pigeons killed them at a rate explicable only if they were applying hyperbolic discounting to their value. A dead pigeon in the hand was worth so much more to a pigeon hunter in 1900 than two in the bush, even though two would breed more, more which he might be able to hunt in future.
Stories such as the passenger pigeons’ fate led those with imagination not curtailed by undertaking an MBA to worry that there is no reason why conventional economics should preserve oil supplies. The price of oil need not rise sky-high as the last marketable drops are squeezed out of the last well or from the last sands. If substitutes for oil are found, such as electric cars, organic fertilisers, paper instead of plastic, then as long as they provide short-term alternatives the last drops of oil can be sold cheaply. Corporate thinking is short-term thinking. It does not portray itself as such, of course, but it says that there is no alternative to the market, and the market works by a kind of magic to result in the best of all possible worlds. In 2008, just as the great crash had begun, the World Bank published its central argument on market magic; it suggested that:
Growth is not an end in itself. But it makes it possible to achieve other important objectives of individuals and societies. It can spare people en masse from poverty and drudgery. Nothing else ever has. It also creates the resources to support health care, education…. We do not know if limits to growth exist, or how generous those limits will be. The answer will depend on our ingenuity and technology, on finding new ways to create goods and services that people value on a finite foundation of natural resources. This is likely to be the ultimate challenge of the coming century. Growth and poverty reduction in the future will depend on our ability to meet it.…55
Technological innovation is the great trump card played in these arguments. In future we will be able to genetically engineer a new passenger pigeon, the MBA candidate may suggest at interview. But new technology causes as many problems as it solves. It is no great panacea. Being able to genetically engineer old species back into existence gives you the ability to create monsters. Being able to create new sources of power allows you to burn up even more of some other resource to carry out an activity that you perhaps do not need to undertake. Worldwide it has been the very opposite of growth that has spared people from poverty and drudgery. It has been through curtailing growth and greed that most people who have been spared from poverty have seen their parents brought out of it. Trade unions curtailed profiteering by bosses and argued wages up. Governments nationalised health services and freed their citizens from fear by curtailing the greed of private physicians. In Britain they told those physicians that if most wanted to work they would have to treat all those who were sick, not just the wealthy. Much earlier the French rebelled against the excesses of a king in a revolution partly inspired to reduce poverty; the North Americans had a revolution to overcome the greed of the English; the English reduced poverty in England by exploiting others but also partly by occasionally voting down the power of the aristocracy between 1906 and 1974 to distribute wealth better within England. The world bankers are unfortunately being selected for their bird brain-like attributes. They appear to remember little and either know or accept nothing of most of the history of actual human progress. Bird-brained economic thinking requires almost no memory.
Most mammals do not undertake hyperbolic discounting; many even store food excessively. Presumably there were at times some particularly severe winters in the past and those cautious few prudent savers prevailed. A few humans are not so prudent but have been found to behave in predatory reptilian ways towards others, sometimes due to being a little brain damaged. The evidence for this is found in abnormalities in the prefrontal cortex and the potentially criminal-like disregard of some psychopaths who have been well educated and have found agreeable work in business.56 Fortunately, most humans behave in mammalian rather than reptilian or bird-brained ways; they save and store, including for others. We are not doomed to greed or vicious selfishness. However, humans did not collectively plan the world systems they came to live in: these systems came about because we did not plan. Like passenger pigeons flocking across the North American plains, we mostly follow our nearest neighbours, and do what they do. The nearest neighbours of world bankers are other economists, and especially elite MBA graduates.
Before asking why all the passenger pigeons were wiped out, ask first why there were so many. Passenger pigeons, it is thought in some quarters, expanded to such huge populations partly due to the decimation of competitors when Europeans first arrived and so altered the ecology of the North American continent. Just as we are not sure why there were so many pigeons, neither are we sure why there were suddenly so many extra humans available to come to the Americas. We do not have much of an idea as to why human populations rose rapidly when they did, to spread out around the world from Europe. What we do know is that the latest rise coincided with a new order of thinking, a new leniency over profiteering becoming permissible. The two are coincident. Something did enable population growth and it may well have been that population growth which spared us from drudgery, resulting (among much else)in those French and then American revolutions. Profiteering, however, is not a magic solution, but a monster: ‘Capitalism is a machine programmed to do one thing – make profit. That is its great strength. There is no morality, no sentiment, just a never-ending quest to increase profits, locally, nationally and ultimately globally.… Enough is never enough. Capitalism always ends up eating itself. It’s like a shark that has its stomach cut open and briefly feeds on itself’.57
For 64 years, between 1926, the end of the last gilded age, and 1990, the beginning of the end of our current gilded age of wealth, gross national product (GNP) in the US rose by an average of 3% a year. The return rate on the shares of all corporations trading on the New York Stock Exchange over the same period rose by some 8.6% a year on average. While it could be argued that technical growth and education may partly account for the GNP rise, the same argument cannot be used to account for the much higher share price increase. The researchers who highlighted this discrepancy favour the suggestion that shares rose faster in price through the increased exploitation over time of people and parts of people’s lives which were not part of the market system in 1926, but which had been incorporated into it by 1990, not just within the US, but also from abroad.58
The rises in share prices relative to GNP were a measure of how much was being sucked out of the rest of humanity and out of the planet’s resources. This blood sucking fell for a short time after 1926 and it is falling again now, but between economic crashes it was rife. Many argue that, in the 1930s and 1940s, economic recovery began because of the marketing of consumer goods and then services to people in poorer countries of the world. This eventually turned depression into growth. Today there is no new poor world to exploit. And it is because there isn’t an extra planet waiting to have its surplus extracted that we have to start planning for a more frugal future now.59 This frugality is required not because we consume so much more in rich countries than is consumed in poor countries, but because we consume so much more than even our parents did. We consume more mostly because we are offered so many more things that our parents never had, things that are made from materials that are not sustainable and, to a much lesser extent, because there are more of us. Those of us living in the rich world, the rich fifth of global society, consume on average six times more oil, minerals, water, food and energy than did our parents.60 It is not that we literally eat six times as much as they did, but we waste so much food and eat so much meat. We do not drink six times as much water, but more water is used in the production of many of the extra things we now consume that our parents did not.
The way corporations create food today and the way in which we consume it is responsible for almost a third of carbon emissions from rich nations.61 Far more food is created than we can healthily eat (and than we do eat), far more meat is produced to be eaten than is healthy, and is produced in ways that certainly are not healthy. We throw away a huge amount of food, but it is estimated that we throw away five times as much food packaging in weight each day as even the food we throw out. Of the food that we do eat, its nutritional value has been falling as its sugar and fat content has been increased to sell it more easily. The worldwide redistribution of fat and oil production over the course of the last third of a century, coincident with the industrialisation of food production, has been staggering, as the rich in the richer countries progressively consume healthier olive oils while most people in the poorer countries consume more of the least healthy of fats.62 Food poisoning is becoming more common, especially as we eat out more, eating in restaurants whose core interest is not necessarily to serve good food, but to make profit. Our food system is essentially unhealthy, both globally and locally.
The idea that economic growth is essential is based on the belief that human beings cannot escape their bird-brained tendencies, the belief that we will always be greedy and stuff our faces given the opportunity. This is a counsel of despair that fails to recognise how simple it would be to eat more healthily. The first step is to eat less or no meat and much less fish. Meat is simply not very good for us and hugely expensive to rear, let alone dangerous in indirect ways, from promoting new strains of disease to making the industrial treatment of animals a norm that is easily transferred to people. The health benefits of eating fish have luckily recently been found to be over-rated. Medical reviews have found that evidence of reduction in cardiovascular events and mortality from eating fish is less conclusive than was recently thought.63 This is lucky because fish stocks are now so depleted that we cannot substitute fish for meat.
Eating more healthily is not just good for individuals, but for social groups and the environment. Consuming both less and more healthily, and spending more time on pursuits that involve exercise rather than purchasing, also has far wider social and environmental benefits. Most of the rise in pollution from poorer countries such as China has been due to the generation of the power needed to run factories to make things for people in rich countries to buy. The levels of lead in the blood of people who live in cities in China are now recorded to be at twice what is considered a dangerous level and certain to harm the mental development of huge numbers of children in China.64 Occasionally, high lead levels are found in the paint on toys made in China, but we rarely wonder why it is in the paint in the first place. People in China have had to live under a regime of having far fewer children than almost anywhere else in the world partly to allow their factories to be built so quickly and staffed so fully by adults not occupied in childrearing. The epidemic of lead poisoning among children in China is just one of many cruel and largely unforeseen consequences of those policies. More factories and power stations in China will not raise levels of health in China in future. It would be a bird-brained response to continue to add to that pollution, to produce goods for others overseas just in order to have growth at home.
When you are no longer in control of your life you live in fear. The most extreme case of losing control is imprisonment. At the start of the 1990s it was reported that more sedatives, tranquillisers and other such drugs were being dispensed per inmate in British prisons than in its psychiatric institutions. The highest recorded ‘doping’ was of an average of 941 doses per woman per year in Holloway women’s prison in London.65 Worldwide, at the same time, a single company was making a billion US dollars a year just from selling Valium.66 By the end of the 1990s some 11 million children in the US alone were being prescribed Ritalin to calm them down and 83 million adults were being prescribed Prozac or its equivalents.67 It is being reported more and more often that to stabilise populations ‘… mass treatment options are not far off’.68 These could include anything from over-the-counter sales of former prescription drugs, to more sinister suggestions which would begin with compulsory medicating in prisons.
In an attempt to prevent what may become seen as necessary mass treatment, governments are turning to behaviour therapies that involve talking more than ‘doping’. In Britain alone an extra 3,500 cognitive behaviour therapists were recruited in 2008, trained to talk to people and to suggest ways in which their clients could become more optimistic; the patients do at least get someone to listen to them, a government-provided substitute for having a friend who is good at listening and who is upbeat. These therapists will be organised around ‘happy centres’ and it has not gone unnoticed that ‘… the idea of 250 happiness centres to promote rose-tinted bubbles of positive illusions is faintly sinister…’.69 The problem is that in many cases the real reasons for people’s mental distress are genuine and cannot be talked away that easily. This may partly be because an underlying reason for rising mental ill health is that much of the way we are living in the rich world is mentally unhealthy. To see what treatments for distress are now advocated and why, we need to take a short journey through the history of the medication revolution.
Governments respond to rising distress by trying to treat the symptoms. The UK government has been employing health trainers for our bodies as well as more therapists for our minds. The Department of Health in England reported in 2008 on what its 1,200 new health trainers were doing. Its assessment was undertaken by recounting the anecdotal case of Tammy and Jane (using fictional names). In its report, the Department suggests it is doing well because its employees have found a ‘service user’ (a person) who is grateful for their help. ‘Tammy’ for instance, talking of her trainer ‘Jane’, says: ‘Jane has supported me from the beginning of my referral programme. Without Jane’s presence and guidance, I would have felt unable to attend to begin with because of my low self-esteem. With her help I feel able to reach my goals of improved health and fitness’.70 Why was Tammy’s esteem so low? How have human beings been able to be mentally healthy and physically fit for generations without personalised health trainers? What could Jane be doing more usefully in a society in which people like Tammy were not so crushed? Do people really talk with such near perfect English as this, or was the conversation as fictional as the names?
At least ‘Tammy’ can talk of her esteem being low and ‘Jane’ can talk of not giving Tammy a pill (as Jane isn’t allowed to give pills). Tammy and Jane’s grandparents lived in a world where mental ill health was less common but just as greatly feared (see discussion on page 273), and there was not much that could be done about it. Since then we have developed many drugs, and not all drugs are bad for us. Some work, especially for severe mental illness (psychosis) and severe depression. The first anti-psychotic drug, Chlorpromazine, was marketed in Europe as Largactil and in the US as Thorazine. It was synthesised in 1950 and began to be widely used to treat schizophrenia by 1954. Chlorpromazine belongs to a group of drugs called phenothiazines, and their use was a major factor in the halving of the population in old-fashioned lunatic asylums in Britain to stand at some 75,000 by 197571 (the majority by then being inpatients rather than imprisoned). Phenothiazines suppress hallucinations, delusions and violence and thereby allowed so many to be released, but many were reluctant to keep taking the pills.
The first effective anti-depressant drug was Imipramine (Tofranil), first licensed in 1956. It belongs to a class called tricyclic anti-depressants, the most effective probably being Amitriptyline (Tryptizol), licensed in 1961. These drugs changed a situation where seriously depressed patients were admitted to psychiatric hospitals often for six to twelve months before recovering well enough to cope, to a situation where many were getting better within a month. However, partly because of the danger of overdoses from taking too many of these tricyclic anti-depressants developed during the 1950s and 1960s, older drugs such as barbiturates continued to be used and other new drugs were introduced, many of which turned out to have other particularly harmful side effects.
Largactil, Tofranil and Tryptizol were breakthroughs that had their problems but worked well in particular situations. But both before and after them there have been other drugs that in retrospect it would have been better never to use in many of the situations for which they were prescribed. In Victorian times Laudanum, a solution of opium in alcohol, was used to help sleeping problems as well as to relieve pain. It was, of course, a very addictive drug. The first sleeping ‘tablet’ was not licensed until 1903, the barbiturate Veronal (which was initially used to put dogs to sleep). Ten year later, in 1913, another barbiturate, Luminal, was licensed, a sedative used to treat tension and anxiety. It was one of the first of many which were lethal in overdose and also contributed to depression. The First World War saw demand for this and other barbiturates explode. The Second World War saw a similar explosion in the demand for another set of the newly marketed drugs, amphetamines, which were first put in tablet form in 1937.
By 1970 barbiturates were rarely prescribed in Britain as sleeping tablets because of their dire side effects, and because a new set of drugs had been developed, the benzodiazepines. Diazepam, the form of Valium that made its owners over a billion US dollars a year by the 1990s, was licensed in 1963, Mogadon in 1965, then Temazepam (a later favourite of addicts). These drugs turned out to have numerous harmful side effects including depression. Lithium was given to manic depressives from the 1960s onwards, and reduced manic episodes, but also took the spice out of life. There were no magic pills, but given the profits that could be made through claiming to have found one, there was no slowdown in the search for that magic, nor any great profit to be made in looking for the underlying causes, rather than for potential treatments.72
In the 1970s, a new class of anti-depressant was developed, the selective serotonin re-uptake inhibitors (SSRIs). They were based on theories that depression was caused by a shortage of serotonin in the brain. There is still very little evidence that this is actually the case. The best known is Fluoxetine (Prozac), approved in 1988. It became very widely used and very widely criticised: ‘Prozac is the emblematic anti-depressant, and the fact that is has become as common a household name as “aspirin” illustrates the extent of the phenomenon … that allow[s] depressed subjects to work on their inner selves so as to “feel better”, or even “better than themselves” … [but] it is becoming difficult to tell which is the self and which is the artificially reworked self’.73 Prozac’s one great advantage is that overdose on SSRIs is rarely fatal and you can take it for months, or years and years and years. In contrast, for children there was also the development of the amphetamine derivative Methylphenidate, marketed as Ritalin, which, by 2008, turned out to be so harmful that it had a health warning put out against its continued use in Britain.74
SSRIs became the mass medication drugs of the 1990s. They had the effect of stopping people complaining, which caused speculation that this was a large part of the reason why so many GPs were willing to prescribe them so often. This was despite repeated stories such as that blazoned on the front page of The Guardian on 26 February 2008 that read: ‘Prozac, used by 40 million people, does not work say scientists’. A year earlier, in 2007, the BBC had reported(as a national news story) the fact that in Scotland anti-depressant use had risen more than four-fold, 85 daily doses of anti-depressant drugs being prescribed by 2006 per 1,000 people in the general population as compared with ‘just’ 19 doses per 1,000 in 1992. The report itself showed that it was between the ages of 25 and 44 that use peaked. Across the whole of Greater Glasgow around 10% of people aged 15 or over were taking daily doses, the implication being that in poorer parts of Glasgow rates would be far higher. Mass medication had arrived; the targets (which the 2007 report announced) were simply to try to stop these high rates rising further.75 Then came the economic crash of 2008 and the rise in mass joblessness across Britain, concentrated in places like Glasgow. Figure 25 shows just how rapid the rise in prescriptions across all of Scotland had been. It shows how policy, and possibly market saturation, was having the effect of a slight curtailment in that rise after 2004. But for that curtailment to continue would require a remarkable change in Scotland given the most recent rise in economic distress, and given so little curtailment of the underlying causes of mass despair; the underlying causes being that despair is often rational, given the life that so many people now find they have to live.76
The adults (and children aged 15, 16 and 17) being prescribed anti-depressants, almost always now SSRIs, include the parents of the girls who had recorded such sharp increases in depression in the study undertaken around Glasgow with which this chapter began (when describing the rise in anxiety among children in unequal countries in Section 7.1). It will also include some of the girls themselves. There are many reasons for expecting to see despair and the treatment of its symptoms rising in years to come. Almost all the legalised medical drugs we have to treat despair with were inventions of the last century. We are only now beginning to fully discover the long-term detrimental side effects of many prescription drugs. This is because they are such recent inventions, because of the reluctance to accept that there is not a pill for every problem, and because of the manufacturers’ wish to suppress any information that might have a bad effect on sales. There are also those drugs for which you do not need a prescription. We still turn to alcohol more than to any other drug to try to deal with our despair, with hugely detrimental results for both our physical and mental health.
Despair reaches across social classes. Rates were a little higher in Glasgow by 2006, at 10%, than in the least affected part of Scotland, Grampian, where the Royal Family goes on holiday, and where ‘just’ 7% of adults are currently taking anti-depressants daily. For children, rates of anxiety and depression are now found to be higher in higher social classes in Scotland. Wealth does not shelter you or those you love from despair. Should you be rich and live in a rich unequal country, your children are far more likely to suffer from mental illness than you were. Should they escape the worst effects, around them huge proportions of other people will be zoned out, behaving in placid ways, artificially ‘enhanced’ not to complain. Your children will grow up in a world where they will listen to others talk about their therapists, their anxieties, their pills, repeatedly, if current trends are allowed to continue. At the extreme, just prior to the 2008 presidential election, those suggesting new ways to imprison people more effectively in maximum security jails in the US were quietly implying that inducing a coma in inmates might be an option. Mass medication is no real cure. If any reason were needed as to why injustice is harmful it is the effects that we now know the resulting inequalities have on our general mental health. Material wealth offers no protection, when, after all and ultimately, ‘… all rewards are in the mind’.77
Notes: The NHS uses financial years when reporting on prescribing rates because costs are still mainly counted in terms of money rather than human misery. The measure shown is what is called standardised defined daily doses per 1,000 people aged 15+.
Source: NHS Quality Improvement Scotland (2007) NHS quality improvement Scotland: Clinical indicators 2007, Glasgow: NHS Quality Improvement Scotland, Table 1.1, p 12.
