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Stress, domination and basic income: considering a citizens’ entitlement response to a public health crisis

Abstract and Figures

In 2015/16, stress was found psychologically to be responsible for 37% of all work-related illnesses and 45% of all working days lost due to illness in Great Britain. Stress has also been linked to long-term chronic health conditions—including heart disease, stroke, cancer, type 2 diabetes, arthritis and depression—responsible for 70% of NHS England spend, 50% of GP appointments, 64% of outpatient appointments and 70% of inpatient bed days. It is apparent that medical responses to stress-related illness contribute to the NHS funding crisis without resolving underlying causes. It is necessary to address the social bases of this public health issue. We argue that one of the primary causes of stress stems from a basic assumption of modern economics: that hierarchies are essential to organizational success. We argue that the combination of hierarchy and possibility of destitution inflicts domination on individuals. We then consider the potential contribution of universal basic income (UBI) to dealing causally with this public health problem. This marks a new development in both the public health and UBI literature studies. We conclude that future trials and studies of UBI ought to measure physiological effects on stress as part of a holistic evaluation of the policy.
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Stress, Domination and Basic Income: Considering a citizens’ entitlement response to a
public health crisis
Dr Matthew Johnson
m.johnson@lancaster.ac.uk
Elliott Johnson
ejohnsonresearch@gmail.com
This is an Author’s Original Manuscript (AOM) of an article published by Springer in Social
Theory & Health on 20 June 2018, available online: https://doi.org/10.1057/s41285-018-
0076-3
Abstract: In 2015/16, stress was found psychologically to be responsible for 37% of
work-related illnesses and 45% of working days lost due to illness in Great Britain.
Stress has also been linked to long-term chronic health conditions including heart
disease, stroke, cancer, type 2 diabetes, arthritis and depression – responsible for 70%
of NHS England spend, 50% of GP appointments, 64% of outpatient appointments
and 70% of inpatient bed days. It is apparent that medical responses to stress-related
illness contribute to the NHS funding crisis without resolving underlying causes. It is
necessary to address the social bases of this public health issue. We argue that one of
the primary causes of stress stems from a basic assumption of modern economics: that
hierarchies are essential to organizational success. We argue that the combination of
hierarchy and possibility of destitution inflicts domination on individuals. We then
consider the potential contribution of Universal Basic Income (UBI) to dealing
causally with this public health problem. This marks a new development in both the
public health and UBI literatures. We conclude that future trials and studies of UBI
ought to measure physiological effects on stress as part of an holistic evaluation of the
policy.
Keywords: Stress; domination; Universal Basic Income; public health
Introduction
In 2015/16, stress as a psychological phenomenon was found to be responsible for ‘37% of
all work related ill health cases and 45% of all working days lost due to ill health’ in Great
Britain (Health and Safety Executive, 2016, p. 2). The effect of stress on health and the
attendant burden on public finances is, though, much broader. In 2012, the Department of
Health estimated that a quarter of all people in England, some 15 million, suffered from long-
term chronic health conditions such as heart disease, stroke, cancer, type 2 diabetes, arthritis
and depression (2012, p. 5). The same Department of Health report suggests that caring for
patients with long-term conditions accounts for 70% of NHS England spend, representing
50% of all GP appointments, 64% of outpatient appointments and 70% of all inpatient bed
days (2012, p. 3). The medical literature strongly suggests that many such long-term
conditions are linked to stress as individuals respond first psychologically and then
biologically to threatening stimuli (see Cooper & Quick, 2017; Cohen et al., 2012;
Schneiderman, Ironson & Siegel, 2005; Dhabhar, 2009; Henderson & Baum, 2004; Everly Jr
& Lating, 2013; Thoits, 2010; Cf. Liu, et al., 2016).
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Increasingly, it is becoming apparent that medical responses to stress-related ill-health
fail adequately to promote health, while actively contributing to the NHS funding crisis. In
order to deal effectively with this issue, it is necessary to understand and address the social
bases of this public health issue. In what follows, we argue that one of the primary causes of
stress stems from a basic assumption in modern economic thinking: that hierarchies are
essential to organizational success (Kastelle, 2013). We draw upon the republican political
philosophical tradition and the epidemiological literature to argue that the combination of
hierarchy and the possibility of destitution inherent in modern, neo-liberal corporate
structures inflicts domination on individuals. We engage with a number of empirical studies,
including the Whitehall Study of UK Civil Servants (see Marmot et al., 1978) and the Labour
Force Survey (see Office for National Statistics, 2017), to contend that such domination
inflicts stress even on those who do not exist in absolute poverty. We examine the medical
literature to we outline the way in which stress responses to these experiences lead to illness
and disease. This enables us to assert that, in order to address the causes of the present
endemic, public health policy ought to be grounded in social and economic policy aimed at
minimizing sources of domination.
We consider the potential contribution of one socio-economic policy: Universal Basic
Income (UBI). UBI is a system of unconditional cash transfers to citizens that is typically
presented as an alternative to need-based welfare systems. UBI is subject to trials in a number
of contexts, with the Scottish government considering a proposal to give citizens up to £150
per week (Farrell, 2017). Historically, UBI has been justified as a means of promoting
citizens’ rights (Pettit, 2007) within a state (see discussion in Ferry, 1995), increasing
efficiency in welfare systems (Gordon, 2014) and promoting growth (Sheahan, 2012). The
notion of deploying UBI for reasons of public health, and grounding those reasons in the
medical literature, marks a key development within the field. At a time in which the UK
Government has a long-standing commitment to austerity, we argue that UBI may be an
efficient means of dealing causally, rather than symptomatically, with the problem of stress.
As such, we conclude that there are good reasons to measure physiologically the effect of
UBI on stress, including, and especially, among the employed, in future studies. Broader
prospective arguments for and against the costs and benefits, that have been discussed in
length elsewhere (see, for example, Martinelli, 2017; OECD, 2017; Standing, 2017), are
beyond the scope of this article. We begin by tracing the relationship between social
structures, stress and health.
The stress response and health consequences
Homeostasis the state of near constant biological regulation is the existential foundation
of all living organisms (see Maslow, 1970, pp. 35-36; Chrousos & Gold, 1992, pp. 1245).
Stress consists in the perception of, and response to, a threat to homeostasis. Stress
represents, therefore, the most fundamental challenge an individual being can experience (see
Cannon, 1932). It effects a cascade of biological changes that prime the body to respond to
physical and existential harm (see Currie & Symmington, 1955). In normal circumstances, in
which a healthy individual faces only occasional threats, this response is considered adaptive
(Smith & Vale 2006, p. 383; Schneiderman, Ironson & Siegel, 2005, p. 612; Henderson &
Baum, 2004, p. 72). Through a process of nervous and endocrine activation (Chrousos &
Gold, 1992, pp. 1245-1246; Hartzell, Dodd, & Gatchel, 2017, p. 211; Henderson & Baum,
2004, p. 72), physiological changes are effected including ‘increased cardiovascular tone,
respiratory rate, and intermediate metabolism, along with inhibition of general vegetative
functions such as feeding, digestion, growth, reproduction’ (Smith & Vale, 2006, p. 383; see
also Henderson & Baum, 2004, p. 72). Acute stress can also enhance innate and adaptive
immune responses to ‘prepare the immune system for challenges (e.g. wounding or infection)
2
that may be imposed by a stressor (e.g. predator or surgical procedure)’ (Dhabhar, 2009, p.
300).
Following appraisal of a stimulus as a threat, there is an initial fast, but short-lived,
response from the sympathetic nervous system (SNS) using direct synaptic transmission that
increases, among other things, heart and respiratory rate, followed with stimulation of the
endocrine system to maintain this response and activate longer-term support mechanisms
(Hartzell, Dodd, & Gatchel, 2017, p. 211; Henderson & Baum, 2004, p. 72). Two systems, in
particular, drive this secondary response: the sympathoadrenal medullary (SAM) system,
which releases catecholamines, including adrenaline (Everly Jr. & Lating, 2013, p. 34;
Carrasco & Van de Kar, 2003, p. 237; Schneiderman, Ironson & Siegel 2005, pp. 612-613) to
augment and support direct SNS effects (Henderson & Baum, 2004, p. 72); and the
hypothalamic pituitary adrenal (HPA) axis that, following a chain of hormonal causation,
releases corticosteroids, including cortisol a glucocorticoid –, which effects metabolism,
inflammation (Henderson & Baum, 2004, p. 72; Hartzell, Dodd, & Gatchel, 2017, p. 211)
and, crucially, short-term innate immune system activation involving macrophages and
natural killer cells to respond to unknown pathogens (Schneiderman, Ironson & Siegel 2005,
p. 613; Dhabhar, 2009, p. 300). These effects are usually self-limiting by natural feedback
inhibition (Chrousos & Gold, 1992, pp. 1249; Dhabhar, 2009, p. 310). Glucocorticoids, such
as cortisol, inhibit corticotropin-releasing hormone (Carrasco & Van de Kar, 2003, p. 237-
238; Smith & Vale, 2006, p. 384), which usually acts to cause the secretion of
Adrenocorticotropic hormone (ACTH) (Henderson & Baum, 2004, p. 72; Smith & Vale
2006, p. 384). This stimulates the secretion of glucocorticoids, such as cortisol (Smith & Vale
2006, pp. 386-387; Carrasco & Van de Kar, 2003, p. 237; Henderson & Baum, 2004, p. 72).
A more direct feedback system exists in the SAM system, with the adrenal medulla sensitive
to the effects of adrenaline through ‘α2-Adrenoceptors on central and sympathetic axon
terminals and on the chromaffin cells’ (Fagerholm, Haaparanta & Scheinin 2011, p. 365).
When these feedback systems are disrupted, the effects on health can be deleterious
(Dhabhar, 2009, p. 301; Henderson & Baum, 2004, p. 72; Everly Jr & Lating, 2013, pp. 40-
43; Schneiderman, Ironson & Siegel 2005, pp. 616-617). Chronic psychological stress is
‘associated with a greater risk of depression, cardiovascular disease (CVD), diabetes,
autoimmune diseases, upper respiratory infections (URIs), and poorer wound healing’ (Cohen
et al., 2012, p. 5995; see also Henderson & Baum, 2004, p. 73). It was formerly believed that
this association resulted simply and directly from long-term (over)activation of the SAM and
HPA systems, especially through excessive secretion of cortisol. Proponents contended that
this causes ‘allostatic load’: ‘wear and tear’ that undermines the capacity to achieve allostasis
‘the ability to achieve stability through change’ (McEwen, 1998, pp. 171-172; see also
Cohen, Gianaros and Manuck, 2016, p. 457). It was speculated that this ‘allostatic load over a
lifetime may cause the allostatic systems to wear out or become exhausted’ (McEwen, 1998,
p. 173) leading to reduced secretion of, for example, cortisol, responsible for an increase of
inflammatory cytokines (p. 173) – proteins released by cells to communicate with each other.
However, recent studies have demonstrated that levels of cortisol are a poor predictor
of disease risk (Cohen et al., 2012, p. 5997; see also Edwards et al., 2003). Instead,
psychobiological evidence has suggested that the effect of chronic stress and excessive
release of cortisol is ‘compensatory downregulation of glucocorticoid receptor (GR)
expression and functioning’ (Miller, et al., 2009, p. 824; see also Cohen et al., 2012, p. 5997).
Such ‘glucocorticoid resistance’ renders anti-inflammatory instructions from glucocorticoids
to (immune) cells insufficient (Cohen et al., 2012, p. 5995; Miller, Cohen & Ritchey, 2002, p.
538) and likely impedes function of the hypothalamic-pituitary-adrenal feedback loop
(Marques, Silverman & Sternberg, 2009, p. 6; see also Miller, Cohen & Ritchey, 2002, p.
539). This (indirect) process can increase inflammation and autoimmunity, leading to
3
increased risk of disease (Cohen et al., 2012, p. 5997; Cohen, Gianaros & Manuck, 2016, p.
460). Cohen, Gianaros & Manuck provide a simplified representation of the primary potential
pathways for stress to induce or increase ill-health seeks to unify what have often been
distinct epidemiological (environmental trigger-focused), psychological and biological
models. The figure outlines potential feedback loop effects, especially from levels four, five
and six to one, two and three:
Figure 1: A heuristic model of the stress process illustrating potential integration of
environmental, psychological, and biological definitions
Source: Cohen, Gianaros, & Manuck, 2016, p. 460
These illnesses associated with stress include ‘seven of the ten leading causes of death in the
United States, United Kingdom and all developed nations’: heart disease, cancer, stroke,
4
Environmental Demands
(Stressful Life Events)
Demands Appraised as
Stressful (Perceived Stress)
Negave Emoonal Response
Disease Related
Physiological Changes
(e.g., immune, cardiovascular)
Increased Risk of Disease
Onset or Disease Progression
Poor Health
Decisions &
Behaviour
Acvaon
of SAM &
HPA
injuries, suicide/homicide, chronic liver disease and emphysema or chronic bronchitis
(Cooper & Quick, 2017, p.1).
The causes of stress are many, but work often and increasingly features centrally. For
example, in a survey by Mind (2013), significantly more respondents (34%) reported that
their work life was either very or quite stressful than did financial problems (30%) or health
(17%). The existential reasons to regard such phenomena as stress-inducing are evident in the
abstract. Today, however, there are many structural socio-economic reasons that link these
causes harmfully.
Domination and work-related stress
The UK Health and Safety Executive defines stress as ‘a harmful reaction… to undue
pressures and demands placed on them at work’ (2016, p. 2). It has identified six key factors
involved in work-related stress: excessive demands; a lack of control over performance of
tasks; a lack of support from colleagues and superiors; damaging relationships, including
unacceptable behaviour and bullying; lack of clarity in role or responsibility, and a lack of
engagement and consultation during organizational change (Health and Safety Executive,
2017). At least five of these are inherent in modern corporate structures: excessive demands
from employees are a natural consequence of the drive for per capita productivity (Standing,
2011, p. 49-50); a lack of real control over workload and performance can stem from belief in
the need for decisive management and competition both between managers within a company
(see Rajan & Zingales, 2001, pp. 808-809) and between companies (see Syverson, 2011);
unacceptable behaviour and bullying can stem from individuals needing to uphold their status
and authority within a competitive system that emphasizes the importance of hierarchy (see
Hales, 2001, pp. 24-38; 120, and implications of Fast, Halevy & Galinsky, 2012); worker
consultation and input during times of change is regarded as contrary to organizational
prioritization of efficiency (see van Elteren, 2017, pp. 6; 158, etc.), and job losses and
diminution of work conditions and pay reflect the need for flexibility (see Gordon, 1996).
This ‘corporate experience’ renders employees, in Guy Standing’s terms, ‘denizens’:
‘partial insider[s]’ with some economic, but few or no political rights, subject to
‘“unaccountable domination”’ (2011, pp. 7-8; 9). Domination in this context is often
misunderstood. Republican (the tradition, not the party) political thinkers, such as Philip
Pettit, have argued that domination consists in being subject to ‘arbitrary interference’, in
which individuals are at the mercy of ‘the arbitrium, the decision or judgment, of the agent’.
The ‘agent’, in this case, is the manager or employer, who is ‘in a position to choose… or not
choose…, at their pleasure’, with choices made ‘without reference to the interests, or the
opinions, of those affected’, in this case the employees. An arbitrary choice is one that is ‘not
forced to track what the interests of those others require according to their own judgments’
(Pettit, 2006, p. 225). The consequence is that individuals are perpetually in a state of
preparedness for threat; always at risk of having their existential interests undermined (see
Howard, 2005, pp. 621-622). Individuals who are dominated cannot ever relax their guard;
they must always adopt tactics to uphold their interests, no matter how demeaning or
unnatural those tactics may appear.
As Standing demonstrates, experience of domination advances in accordance with
neoliberal reform aimed at promoting labour force flexibility and productivity. Employees,
like asylum seekers or other denizens, often ‘lack the capacity to claim or enforce rights, or
fear that the act of asserting a claim right would have a high probability of retributive
consequences or disastrous costs’ (2011, p. 9). For example, although an employee subject to
arbitrary and harmful management decisions has the right to appeal to a tribunal, this is a
lengthy, costly and uncertain means of upholding interests (Hirsch, 2017). In the UK, if an
employee is dismissed on the grounds of alleged ‘misconduct’, they will be subject to a
5
benefits sanction, preventing them from claiming Jobseekers Allowance, the primary
unemployment benefit, for a minimum of 13 weeks (Department for Work and Pensions,
2016). Until a recent Supreme Court judgment ruled it unlawful (Marsh and Elgot, 2017),
there was a cost attached to filing a claim to an employment tribunal to appeal against
dismissal, with financial assistance provided in a relatively opaque and discretionary manner
(Gov.uk, 2017). If employees are not sacked for resisting domination, they may instead be
subject to workplace retaliation, having contractual terms enforced more strictly or being
overlooked for promotions (see Vodanovich & Piotrowski, 2014).
Because of this and because of the expansion of low-paid, precarious positions, there
are genuine costs attached to seeking and sustaining paid employment. As Standing puts it,
the old recipe of job creation “work is the best route out of poverty” is
increasingly wrong and counter-productive. Governments may be able to boost the
number of jobs by rolling back labour protections in order to make labour markets
more flexible, but in doing so they make many more people more economically
insecure. (Standing, 2017, p. 74)
Often, there are good reasons, such as the ‘marginal tax rate’ attached to entering low paid
employment and the increased possibility of domination, to remain economically inactive and
to retain the security of whatever ‘needs-based’ welfare payments that still exist (see
Standing, 2017, p. 76-77). The response of Government to reduce those needs-based forms of
security merely fosters domination in the name of economic ends that are increasingly
unrelated, even rhetorically, to the interests of the population.
Domination, as an institutionalized, inter-subjective phenomenon, can occur within
any deeply hierarchical socio-economic structure. There are, clearly, opportunities for, and
examples of, domination in slave, feudal, capitalist (Marx and Engels, 1967, pp. 222-224)
and state capitalist societies. The majority of forms faced in the present are clearly often less
egregious than those in other contexts, but the effect is real and felt nonetheless. This effect is
clarified through reference to the epidemiological and evolutionary psychological literatures.
In effect, domination serves as a cue for ‘extrinsic mortality’ by invoking two existential
threats – resource scarcity and unpredictability. Being dominated lowers anticipated lifespan
and raises anticipation of imminent harm. The consequence is two-fold: people face stress
and associated illness and adopt ‘adaptively patterned shifts in behaviour, which then become
propagated through social transmission’ (Pepper and Nettle, 2014, pp. 236-237). These
patterns focus on short-term interests, increasing impulsive, sensory and hedonistic behaviour
(see Frankenhuis, Panchanathan and Nettle, 2016, p. 76; Páal, Carpenter and Nettle, 2015).
Adams et al., for example, found that ‘Greater anticipated survival was cross-sectionally
associated with lower likelihood of smoking, and higher physical activity levels’, while
‘Lower anticipated survival was associated with decreased probability of adopting healthier
patterns of physical activity, and increased probability of becoming a smoker at follow up’
(2015, p. 1). Even those raised in affluent circumstances are only partially protected against
the effects in adulthood (Nettle and Bateson, 2017). Whatever the source and structure
through which domination emerges, its effect on the body is the same: the epidemiological
and evolutionary psychological literatures indicate that domination is deleterious.
Domination and hierarchy
Thinking about domination as a cluster of related cues for ‘extrinsic mortality’ is important
insofar as it helps us to understand data indicating a relationship between hierarchy status and
health outcomes, even when phenomenological studies do not identify the cause as
domination explicitly. The data on stress indicates that the causes stem from hierarchical
6
relationships. Respondents to the 2009/10-2011/12 Labour Force Survey, for example,
reported workload, then lack of clarity and support, then violence, threats or bullying as the
three leading causes of stress (Health and Safety Executive, 2016, p. 8). Workload stems
from a worker’s inability to control their activities, either because they cannot resist their
manager’s demands or because they take on increased workloads that they regard as
unreasonable in order to advance professionally (see Galinsky, et al., 2004; Standing 2011, p.
20); lack of clarity and role uncertainty speak to individuals’ being trapped in conditions of
stress response, unable to feel secure against arbitrary interference from their superiors, while
violence, threats and bullying are explicit means of demonstrating domination.
The hierarchical source of stress is apparent within research such as The Whitehall
Study of Civil Servants. The study, which covers a broad range of social and health topics,
revealed that health followed a social gradient (Marmot, Shipley & Rose, 1984): ‘the lower
the position in the social hierarchy, the higher the mortality from cardiovascular disease and
from a range of other major causes of death’ (Marmot and Steptoe, 2008, p. 42). This
confounds received opinion on ‘executive stress’, in which those at the top are deemed to
deserve enhanced remuneration due to the exceptional stress associated with responsibility.
Whitehall demonstrated that Civil Servants at every level experienced greater stress than
those above them in the hierarchy, including those one step away from the top level of
management (Marmot, 2006, p. 1304). These deputies are endowed with significant status
and power and are remunerated accordingly. However, they remain subject to domination by
those occupying the one remaining ‘superior’ tier.
Civil Servants, in general, are not subject to objective levels of poverty, so could not
suffer from resource scarcity, while standard risk factors for mortality (cholesterol, smoking,
systolic blood pressure, glucose intolerance and diabetes) explain only a third of social
gradient’s predictive power (van Rossum et al., 2000). A follow-up study, Whitehall II,
examined the likely psychosocial factors at play (Marmot and Steptoe, 2008, p. 42). The
results indicated that, in general, the magnitude of psychobiological stress response to tasks
was not strongly related to the social gradient. Rather, those of lower socioeconomic status
(SES) experienced delayed recovery and prolonged activation of stress markers after the task
had ended (Steptoe, et al., 2002; Marmot and Steptoe, 2008, p. 48). The levels of other
markers were greater for those in lower occupational grades on workday mornings. Markers
included those for ambulatory blood pressure (Steptoe, et al., 2003), which has been
associated with increased risk of cardiac events (Giles, 2006), and cortisol awakening
response (Kunz-Ebrecht, et al., 2004), which has been found in those experiencing depressive
symptoms and work and financial stress (Pruessner, et al., 2003) and appears to be an
indicator of stress-related hypothalamic-pituitary-adrenal dysfunction (Chida & Steptoe,
2009). Both an excessive secretion of cortisol in response to stress and a slow recovery from
its effects after repeated exposure are consistent with Cohen’s model of the development of
glucocorticoid resistance.
While executives experience unpredictability, they do so without the exposure to
domination as described above: unpredictability more often stems from circumstance or from
the actions of those without direct control over their lives, such as executives in other
companies and organizations (see Worrall and Cooper, 1995, p. 10). Moreover, executives
are the first to receive information, have power to dismiss requests and to delegate tasks to
respond to changing circumstances (see discussion in Wulf, 2012, p. 6). Those operating at
lower levels of the hierarchy operate under conditions of domination, even when they are
relatively well-remunerated. Individuals may have experienced domination for much of their
lives, meaning that they are in a continuous state of preparedness for unpredictable demands.
As the epidemiological and evolutionary psychological literatures suggest, this experience of
firefighting or short-term survival thinking, rather than long-term planning, renders
7
individuals, on a psychobiological level, less able to progress professionally, which is
especially unfortunate given that such progress up a hierarchy has been shown to improve
health (see Marmot 2004b, p. 152).
The burden that dominated individuals face has been explored by Mullainathan and
Shafir (2014), who have coined the notion of the ‘psychological bandwidth tax’. In common
with even a modern, high-powered computer, every individual has a limited capacity for
dealing with tasks, especially those inducing stress. When overloaded with tasks, the mind
lacks the necessary psychological resources by which to function. To substantiate their thesis,
Mullainathan and Shafir presented participants with a scenario in which their car required
maintenance, but their insurance would cover only half the cost of a $300 service. The
service is an objective benefit in which future damage, and further costs for repair, could be
avoided, but with an up-front cost. Participants were asked to consider whether they would
pay for the service or hope that it lasted longer and risk doubling the prospective $150 deficit.
They were also questioned how, and with what difficulty, they would go about making such a
decision. Others were asked the same question but with a $3,000 service cost. The authors
followed this with a series of Raven’s Matrices problems, which are used to measure fluid
intelligence and are common in IQ tests, and divided participants into rich and poor cohorts
based on median income. Those required to find $150 were relatively unaffected by the
scenario. However, when faced with a $1,500 deficit, those with lower incomes were
significantly less able to respond to Raven’s Matrices problems by virtue of their
psychological bandwidth tax (2014, pp. 48-51).
Mullainathan and Shafir focus on the effect of resource scarcity on cognitive
functioning (see also Mani et al. 2013). However, their approach is compatible with concern
for domination insofar as domination works by threatening resource scarcity as the
consequence of employees’ actions or inactions. Indeed, they accept relativity of scarcity,
suggesting that even those above the poverty line can be burdened by the tax. While wealthier
individuals may not be impaired by the scenario above, they may be burdened by a scenario
in which they are faced with a deficit of $15,000 (see Mullainathan and Shafir, 2014, p. 11).
The point is that resources insure us against extrinsic threats to our survival. Those on higher
wages may be more protected, but domination still triggers the stress response on account of
threatening destitution or an intolerable quality of life. As such, the work of Marmot (2004a)
shows that absolute poverty is only part of the problem. Relative position within hierarchies,
indicated in part by relative wealth, has the capacity to inflict absolute deprivation in health.
As Marmot (2004b, p.153) puts it,
A way to stress an animal, of the human or non-human variety, is to remove control.
This is true whether the animal or person is high status or low status, but low control
is more common the lower down the pile you find yourself. Low grade chronic stress,
acting through the brain, mobilises hormones – cortisol and adrenaline and
noradrenaline – that lead to profound biological changes. Among these is likely to be
the metabolic syndrome, linked to insulin resistance that increases risk of diabetes and
heart disease.
The consequences of the subjective activation of stress response according to social
status have been mapped in a meta-analysis by Tang, et al. (2016), who contend that low
Subjective Social Status (SSS), or an individual’s perceived position in the social hierarchy,
significantly increases odds of coronary artery disease, hypertension, diabetes and
dyslipidaemia, with a trend toward increased odds of obesity (p. 1). This builds on the
findings of Whitehall II, confirming that the gradient follows more objective measures of
SES within whatever hierarchy individuals inhabit, but highlighting that ‘increasing evidence
8
suggests that low SSS may have adverse effects on health due to internalization of
perceptions of inferiority resulting in activation of stress-related neuroendocrine mechanisms,
and increased tendency to participate in behaviours that may negatively influence health’
(Tang, et al., 2016, p. 2). The psychobiological effect, therefore, is not just the result of one’s
objective position in a hierarchy, but an individual’s perception of that position in the
hierarchy: hierarchies create scope for domination and perception of hierarchies influences
the extent to which domination is deployed perniciously.
This pushes back at the social Darwinian notion of status as health selection (see
Marmot 2004a, pp. 58-60). In this account, ill-health determines social position, not the other
way round: good health leads to winning the Oscar’ (Marmot 2004b, p. 152). Rather, capacity
emerges, in part, by virtue of inhabiting a particular social position, whether that position is
reached through systemic advantage or otherwise (see Marmot 2004b, p. 152). The benefits
of holding and retaining a position of domination within hierarchies has been demonstrated in
a more practical context by Knight and Mehta (2017) who suggest that high social status
confers benefit in reducing experience of stress when challenged by a social stressor (a mock
job interview), but improves performance only in a stable hierarchy. There is no such benefit
in an unstable hierarchy. Those in higher positions in the hierarchy, therefore, have both a
strong material and physiological interest in maintaining domination, locking those below
them in perpetual conditions of stress.
A social approach to tackling the social health gradient
At present, the approach adopted to dealing with stress-related illness and disease is to treat
medically individual patients as they present themselves symptomatically. This either
neglects and fails adequately to deal with the social bases of the health crisis or reflects a
neoliberal assumption, with social Darwinian implications, that stress and ill-health are
inevitable consequences of employment to be addressed individually by sufferers themselves.
We argue that, on health grounds alone, there is good reason to reject this approach and to
consider means of reducing domination.
In order to promote health, we need to promote what the republican thinker, Philip
Pettit, has termed ‘freedom as nondomination’ (2006, p. 225), in which no individual has ‘the
capacity to interfere in another’s ‘affairs on an arbitrary basis’ (1999, p. 165). The state may
still interfere in people’s lives, through compelling taxation, for example, but only within a
resilient institutional framework that precludes partial acts ‘that worsen the agent’s situation –
or at least worsen it significantly either by reducing the alternatives available in choice, or
by raising the actual or expected costs associated with some of the alternatives’ (2006, p.
225). The point, here, is that republicans distinguish between conditions in which two
individuals experience similar levels of non-interference: one is a dominated slave who relies
upon the grace and favour of their master; the other is a non-dominated citizen who exists
within a resilient institutional structure that guarantees liberty. The slave is subject to
contingent non-interference, while the citizen experiences resilient non-interference. As
Widerquist (2013, p. 27) puts it, in order to secure real freedom for individuals, they must
have ‘the power to say no’. Workplace stress stems from the absence of the power to say no,
even when there is no interference. It is the ever-increasing lack of resilient non-interference
that renders them unwell.
Pettit specifically identifies means of challenging such forms of domination ‘by
introducing a form of social security that would make the prospect of losing a job less than
wholly intolerable’ (1993, p. 26). More recently, discussion has shifted toward the
introduction of UBI (see, for example, Taylor, 2017, pp. 22; 54), which is one of a range of
approaches aimed at ensuring that all citizens receive a minimum income. In UBI, the
government provides an unconditional monthly stipend to all adult citizens. There are no
9
forms of means testing, work requirements or potential sanctions (Wright, 2006, p. 5). The
approach seeks to ensure that no citizen falls below the poverty line and that all are free from
interference to engage, or not engage, in economic activity suited to their circumstances,
talents or interests (Wright, 2006, p. 6). In so doing, proponents such as Standing (2011, pp.
171-173) argue that UBI is pragmatic: it does not seek fundamentally to challenge capitalism;
instead, it eliminates the onerous administrative exercise and expense of means-tested welfare
and is grounded in rights-based liberal thinking. However, there is reason to believe that the
policy has scope for significant impact: it releases or relieves workers from workplace
domination, such that employees can refuse to acknowledge arbitrary managerial demands
and resign from positions safe in the knowledge that their basic needs will be satisfied (see
Pettit, 2007, p. 6). Although Birnbaum and De Wispelaere (2016), among others, argue that
capacity for exit is less clear cut insofar as resignation imposes other costs, those costs are
greatly reduced in comparison to existing welfare systems that actively punish workers who
resign. This all suggests scope for reducing stress, expanding psychological bandwidth and
improving health.
Evidence drawn from trials indicates a positive effect on health. The 1974-1979 trial
of MINCOME, a Canadian Guaranteed Annual Income (GAI) was conducted in the province
of Manitoba. Unlike UBI, MINCOME included a means testing element with a tapered
payment based on other sources of income. The study ‘found a significant reduction in
hospitalization, especially for admissions related to mental health and to accidents and
injuries, relative to the matched comparison group. Physician contacts for mental health
diagnoses fell relative to the comparison group’ (Forget 2011, p. 0). Some such pilots have
included evaluation of psychological benefits, including stress as a psychological state.
Indeed, phenomenological data from Finland indicate a reduction in stress (Independent Staff
2017). Psychologists are increasingly making a public health case for UBI on account of its
effect on mental health, calling for UK trials ‘incorporating psychological impact
measurements, including the healthy social indicators of sense of agency and control;
uncertainty and security; connections with others; sense of meaning and purpose in life; and
social trust and cohesion’ (Psychologists for Social Change 2017, p. 3). We argue that the
medical literature on the effect of stress on health give good grounds for exploring such
impacts more clearly, specifically with regard to psychobiological effects. Indeed, medical
and social researchers have begun to use findings from investigations into the socio-economic
contribution to inflammatory biomarkers (see Davillas, Benzeval, & Kumari, 2017) to
develop policies by which to reduce their impact, recommending, for example, early
retirement for those in more stressful positions (see Arney, 2017).
At present, evaluation of UBI focuses, understandably, on its effect on poverty as an
independent variable in determining health outcomes. Forget (2011, p. 2) contends that the
health benefits of MINCOME were secured via a reduction in poverty, while The Public
Health Agency of Canada (2016) notes the importance of ‘upstream investments’, addressing
‘social, economic and environmental conditions’. Others have noted the social health gradient
and recognized the importance of promoting policy based on reducing ‘health inequalities,
the structural conditions that put people “at risk of risks”’: ‘discrimination, poverty,
residential segregation, inadequate schools, unemployment’ (Thoits, 2010, S47). Domination
presents each of these factors as threats that constitute extrinsic mortality cues. As such,
proponents of UBI would be better served examining the broader effect of UBI in minimizing
domination as the basis of its effect on health.
Public cost and public benefit
The debate on UBI is broad and considers many prospective costs and benefits that are
beyond the scope of this paper and discussed in depth elsewhere (see OECD, 2017;
10
Martinelli, 2017; Standing 2017). Most clearly, though, that debate has often returned to
concern for financial feasibility (see Lewis, Pressman, & Widerquist, 2005). Abstracted from
progressive revisions to income tax rates and comparison with existing costs associated with
current welfare arrangements, the notion of allocating a monthly stipend even to the richest
seems absurd. However, there are grounds for regarding the scheme as part of a broader
redistributive regime with concomitant deployment of increased tax rates for higher earners
(see discussion in, for example, Pelzer, 1999) and/or the introduction of a Land Value Tax
(see Robertson, 1999) or the imposition of a flat income tax rate of 30-50% that is
progressively negated by UBI for lower earners (Atkinson, 1995, esp. pp. 24-46; Straubhaar,
2017). Whatever the model, it is clear that the system offers prospective benefits to those
significantly above the poverty line (see OECD, 2017).
The benefit to more affluent citizens in terms of reducing their exposure to stress has
seldom been granted sufficient attention. This is of particular justificatory importance in
affluent countries, such as the UK, in which the average rate of poverty ranges between
around a quarter to a fifth of the population and those at risk of persistent poverty around one
in 15, compared to 1 in 10 in the EU (Office for National Statistics, 2016a). In such contexts,
concern for addressing the poverty of the 6.5% of the UK population at risk of persistent
poverty, can be supplemented by concern for the 15 million people affected by long-term
stress-related illness (Department of Health 2012, p. 5).
Promoting health among such a large proportion of the population offers potential
means of reducing the burden on the NHS and increasing workplace productivity. The policy
would substitute a single payment administered by a streamlined Department for Work and
Pensions for existing welfare spending, which accounted for £258bn of UK public spending
in 2014/15, including £108bn on pensions, £44bn on family benefits, income support and tax
credits, £41bn on incapacity, disability and injury benefits and £27bn on housing benefits and
just £3bn on unemployment benefits (Office for National Statistics, 2016c). Martin Farley
(2016) has demonstrated how a UBI of £7,200 for all adult citizens in the UK and pensioners
living abroad, some 53 million people, would be feasible fiscally with the introduction of a
flat tax rate of 35% on all income that would, in effect, cancel out income tax for the lowest
45% of earners. His calculations include additional ‘spare’ income for the Government to be
spent on benefits for those who require further assistance, such as those with disabilities,
housing needs and contribution-based pensions.
There are, though, several reasons to revise such an approach and qualify its potential
benefits. Firstly, the level of UBI hardly stands as a viable alternative to well-remunerated
employment with domination. Beyond mere survival, the level of income at which a life
becomes liveable has a subjective element high earners may regard even median earnings
insufficient (Bamfield, & Horton, 2009). In this regard, adjustments to the formula, which
does not include the substantial savings to be made from streamlined administration, could be
made to increase the UBI to a level of around £10,000-£15,000 at which basic needs can be
met. Secondly, calculations of cost do not account for the possibility of reducing health and
social care spending, which amounted to approximately £170bn in 2015/16 (Luchinskaya,
Simpson, & Stoye, 2017, p. 142), and improving productivity, given that 139 million work
days are estimated to have been lost to sickness absences in 2015, with 15 million the direct
result of stress, anxiety and depression (Office for National Statistics 2016b). However,
judging savings to the NHS and welfare spending overall is extremely complicated, not least
insofar as improving public health means increasing life spans which, in turn, increases the
length of time in which individuals require the greatest number of medical interventions.
Thirdly, retaining any needs-based monetary element may sustain elements of the benefits
trap insofar as individuals lose income as they become healthy, subjecting individuals to
domination by virtue of health assessments. As such, there is good reason to favour a system
11
based solely on a single, unconditional payment combined with increased investment in
public health and care services for those in medical need that confer no monetary advantage
on recipients. The investment in institutions is especially important insofar as, as the Nordic
Model has demonstrated (see Arnesen, & Lindahl, 2006), there is need for institutionalization
of norms to encourage citizenly participation in work once domination has been challenged.
Finally, UBI may serve to challenge domination in work, but would not deal with other
sources of stress that are commonly implicated in physical and psychological ill health, not
least traumatic life events (van der Kolk 2014).
However, even with these qualifications, at a time in which UK public support for tax
and spending is at its highest in over a decade (see Harding 2017, pp. 3-5), there is potential
political will for trials which evaluate a contribution to health that has been neglected by UBI
proponents.
Conclusion
UBI is gaining traction on both the left and right of the political spectrum for a range of
reasons, including increasing precariatization and automation of work and inefficiencies in
needs-based welfare systems. If we accept the validity of the literature on the
psychobiological effect of stress, the insights gleaned from Whitehall II provide good
grounds for examination of the effect of UBI on domination and, in consequence, health. We
contend that it is this specific contribution that offers the most significant potential impact of
the policy and argue that proponents ought to draw more clearly and heavily upon the
medical literature in order to advance the case.
Long-held opposition to UBI on account of cost and disincentive to work needs to be
evaluated within this broader public health context, since the full effect on public finances
beyond welfare spending abstracted from amendments to tax codes has seldom been
considered. Moreover, cost-based opposition has often been grounded ideologically in
neoliberal dogma, holding that corporate hierarchies are essential to delivering efficiency and
that cliff edges are important means of incentivizing success. Non-manager-based enterprises,
including Ricardo Semler’s Semco Partners and the Mondragon Corporation, have
demonstrated the power of flat organization (see Herr, 2009, p. 14; Kastelle, 2016), with
workers contributing to decision making and possessing the capacity to move between
projects. Such organizations have experienced enhanced productivity and growth precisely
because they minimize domination. In other words, even according to their own standards,
neoliberals propound inefficient systems. As such, given the potential contribution to health,
pragmatic governments have every reason to evaluate UBI with regard to public health. To
this end, we call for all trials and studies of UBI to measure physiological indicators of stress
responses among all participants, whether in work or not.
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... In addition, several studies have reported that the health sector suffers the most from this type of problem [13][14][15]. In line with this data, occupational stress has become one of the most relevant problems for public and occupational health [16][17][18]. ...
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... Haagh, 2019;Pettit, 2007;Sheahan 2012;Standing, 2011). However, as Labour recognised in requesting a summary of the health case for UBI (see Johnson & Johnson 2019), the public-health case for UBI is under-explored (Johnson & Johnson, 2018;cf Forget, 2011;Haagh & Rohregger, 2019). In that light, we wish to investigate the extent to which UBI may mitigate the ICL by ensuring that citizens in a range of 'precarious' circumstances have health-promoting relationships with the NHS. ...
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Background A large body of evidence indicates the importance of upstream determinants to health. Universal Basic Income (UBI) has been suggested as an upstream intervention capable of promoting health by affecting material, biopsychosocial and behavioural determinants. Calls are emerging across the political spectrum to introduce an emergency UBI to address socioeconomic insecurity. However, although existing studies indicate effects on health through cash transfers, UBI schemes have not previously been designed specifically to promote health. Methods In this article, we scope the existing literature to set out a set of interdisciplinary research challenges to address in designing a trial of the effectiveness of UBI as a population health measure. Results We present a theoretical model of impact that identifies three pathways to health impact, before identifying open questions related to regularity, size of payment, needs-based supplements, personality and behaviour, conditionality and duration. Conclusions These results set, for the first time, a set of research activities required in order to maximize health impact in UBI programmes.
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Background In the context of the UK Government’s ‘prevention agenda’, Laura Webber and colleagues have called for a ‘health in all policies’ approach. Universal Basic Income (UBI) is a system of cash transfers to citizens. Recent research suggests it could significantly benefit population health, including via reducing stress. However, a Finnish trial of a policy with similarities to UBI has influenced debate. This was reported as a failure due to a policy objective of reducing unemployment, despite demonstrating significant benefits to well-being. Aims and objectives In this piece, we seek to advance the debate about the cost-benefit of UBI by identifying knowledge gaps and proposing a means of designing effective trials. Methods We review UBI trial design and findings in comparison with social gradient in health literature and biopsychosocial theory to identify knowledge gaps. Findings We highlight a need to refocus UBI trials on improved health, including via reduced stress, to provide policy makers the means of producing accurate cost-benefit analysis. Previous trials have either not reflected likely UBI policy or failed to measure impacts that enable accurate analysis. We contend that interdisciplinary work is required to establish trials that observe factors known to drive the social health gradient. Finally, we argue that statistical modelling is needed to extrapolate shorter-term findings to long-term population-level outcomes. Discussion and conclusions Resource allocation by Government and/or major funders is required to produce evidence that enables accurate analysis of UBI. Such trials would provide a platform for interdisciplinary work resulting in joined-up evidence and policy.
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In the context of the UK Government's 'prevention agenda', Laura Webber and colleagues have called for a 'health in all policies' approach. Universal Basic Income (UBI) is a system of cash transfers to citizens and recent research suggests it may have a significant impact on health, including via an underexplored role in reduced stress. However, debate has been influenced by a recent Finnish trial of a policy with similarities to UBI. This was reported as a failure due to a policy objective of reducing unemployment, despite demonstrating significant benefits to wellbeing. In this article, we advance this debate by exploring the current evidence and proposing a practical way forward. We propose a need to refocus evidence collection in UBI trials on improved health-via reduced stress-to provide policymakers with the means of producing an accurate cost-benefit analysis. We argue that previous trials have either not reflected likely UBI policy or have not measured a sufficient range of impacts to enable accurate analysis of its cost-benefit. We contend that interdisciplinary work is needed in order to establish trials that observe key factors driving the social health gradient. Finally, we argue that statistical modelling is needed to extrapolate short-term findings to long-term population-level outcomes. One implication is that substantial allocation of resource is required from Government and/or major research funders. On the other hand, this presents an opportunity to pioneer an interdisciplinary approach resulting in joined-up evidence and policy for UBI and 'upstream' interventions.
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Chapter
In the first chapter, we provided the following working definition of the stress response: “Stress is a physiological response that serves as a mechanism of mediation linking any given stressor to its target-organ effect.” By viewing the phenomenology of stress within the context of a “linking” mechanism, we can answer one of the most critical questions in psychosomatic medicine, that is, through what mechanisms can stressor stimuli, such as life events, lead to disease and dysfunction? The response to that query will be addressed within the next three chapters.
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