Second of the reflections on CleanMed themes, this time on commodification,
production, and alternative models of ownership.
I’m fortunate enough not only to live in Sheffield, but to have grown up here.
With the highest ratio of trees to people of any city in Europe, 61% of my home
is what would currently be described as ‘urban green space’. Despite the cultural penetration of this vogueish terminology, the
tree-scattered knoll near where I used to live still goes by another, rather older, name; the Common.
It is unsurprising in an era of enclosure that the language of the commons is no longer fashionable. But much of the
discussion at the CleanMed Europe conference served to reinforce the principle that
central to creating a sustainable health system (and political economy) lies
the reinterpretation – or at least a pluralism of interpretations – of the
relationship between individuals, society, and the material resources of land and
labour.
There’s a standard economic taxonomy of resources according to which they may be: excludable or non-excludable (in the sense that individuals may be effectively prevented from accessing those resources); and rivalrous or non-rivalrous (in the sense that the use of the resource by one individual reduces the opportunity for resource use by another).This creates a fourfold classification - the private goods (excludable and rivalrous); the club goods (excludable but non-rivalrous); the common goods (excludable but non-rivalrous); and public goods (non-excludable and non-rivalrous). So, private goods are those that not everyone may use, and one person's use reduces the opportunities for another to use them, while public goods are those both enjoyed by all and such that one person's enjoyment of them does not impinge on others'. Common goods are those that may be depleted by use, but are nonetheless open to all; while club goods are those which some are prevented from accessing even though they cannot by used up.*
The rivalry condition is a function chiefly of the nature of the resource itself: the benefit of delicious sustenance I gained from my tea** could only be enjoyed by another if I were to cook up another portion, whereas the benefit of freedom from smallpox infection I've gained from effective international infection control policies in no way prevents others enjoying that self-same benefit (indeed, my enjoying it is part of the reason others do, and vice versa).***
Excludability, however, is unescapably a social construction; it relies on the institutions created for the purposes of enforcing it. Unsurprisingly, then, it permits of a rather finer graining than afforded above. Of particular import is the distinction that Jeremy Waldron observes in the category labelled previously as 'private goods' (that is, those resources that are both excludable and rivalrous), between private property and collective property. The former describes the regime of exclusion whereby individuals are assigned property rights over a given resource and have the power to do with them as they see fit. The latter, however, does not assign this authority to any such individual, but relies on the community as a whole to determine the appropriate use for the resources at its disposal. This remains an excludable form of good, since such determinations may prevent certain portions of the community from accessing those resources - an example would be prescription medications within the NHS, a collectively-owned resource to which access is nonetheless restricted on the basis of (at least nominally) democratic decisions made on a (plausible) ground of public interest. The distinction between these systems of property relies on the difference between decisional authority - having the effective ability to decide how resources are to be used; and use permission - being actually in the state of being able to use them. Private property elides the two, and assigns both to the individual; collective property, meanwhile places decisional authority in the hands of the community, who are then able to allot use permission in excludable (creating collectively-owned private goods) or non-excludable (common goods) ways.
It would be fair to say that the central motivation of the CleanMed Europe conference was provided by some important public goods - the prevention or mitigation of catastrophic climate change, and other environmental/ecological health threats. It's also reasonable to assert that our means of handling resources in the rivalrous category feature heavily in any explanation of how we got into this mess in the first place. At the very least, treating rivalrous goods as private property, traded on a market that separates use/accumulation of such goods from the externalities of their use and accumulation, is a large part of the problem. More deeply, there are powerful arguments to the effect that the material underpinnings of our consumption have shaped the very political economy that leads to their unsustainable exploitation.
Viewed in these terms, CleanMed Europe was a conference all about market failure. Market failure because markets have never been a viable way of managing public goods; market failure because the externalities of a crucial set of private goods (energy) violate the premises of efficiency; market failure because the accumulation of capital inevitably leads to loading the dice in favour of capital.
Such market failure can be interpreted in a narrow sense, of real markets' inefficiency due to defined deviations from the premises of market efficiency. This narrow perspective suggests an approach based on refinement of market mechanisms; fiddling with the settings to compensate for each deviation. Such suggestions were to be found at CleanMed - whether in David Pencheon's call to externalise the costs of unsustainable behaviour, or in the arguments about carbon valuation and the 'carbon QALY' (a rather catchy phrase coined from the floor during a session on how to visualise resource usage). I am open to the possibility (largely due to my verging-on-nonexistent knowledge of economics) that such tinkering may produce results (even if the record isn't looking too great on that score). But it would be a shame if it were to be the sole focus, when more radical answers have the potential to produce a more profound transition to a sustainable society.
Exploring this latter type of answer requires that we interpret market failure in broader sense, not just as a breakdown of certain subroutines within market mechanisms, but as more fundamental conceptual shortcomings. The possibilities explored and interventions imagined (or in some cases, already enacted) at the conference that most excited me were those that attempted to do just this, working to achieve better health and more sustainable healthcare through new models of ownership and production.
I first encountered such options being entertained while listening to plenary speaker Tim Helweg-Larsen, CEO of EnergyBank. He envisioned a future where the means of energy production were reclaimed from the hands of the "energy landlords" - the big energy companies who have accumulated the rights to the vast majority of energy supply in the UK - through user-ownership of 100% renewable energy infrastructure (and yes, 100% renewable does add up). While EnergyBank's current work, through focusing on large corporate bodies, might seem to take power from the hands of one elite only to place it in another, its long-term plan is structured so as to mitigate the damages of a new energy market (through price controls and trade restrictions - anathema to libertarian free-marketeers). Furthermore, in a national context such as the UK's, where major energy users with significant purchasing power are also public sector bodies - speaking here, of course, of the NHS - EnergyBank's plans propose little short of a return of energy production to collective ownership.
But it is hardly only such major investors who have the potential to reclaim the power; collective ownership on a direct, community level is happening across the world, with resounding success. A central role for energy co-operatives lies at the heart of Denmark and Germany's successes in renewable energy, and similar co-ops (wind, solar, and hydro) are developing across the UK. Furthermore, evidence suggests that such collective ownership schemes have exert a positive political and psychological feedback - community ownership correlates with increased support for renewable energy infrastructure.
The possibilities for a reimagining of property and production were not, however, restrained to energy production or co-op ownership. Projects already underway highlighted the potential of the rejection of private property to enhance both sustainability and health - whether through open reversal of enclosure of the commons, or subversive attempts to resist the logic of enclosure.
The first of these came in the form of the NHS Forest. While co-opting the language of neoliberalism by presenting the creators as 'greenspace entrepreneurs', their recent work would be better described as re-establishing a greenspace commons from enclosed land. A crowd-funded effort to create an environment open to all that is enabling of healthier lifestyles should be proud to consider itself an exercise in refashioning private goods into common goods (for the common good!) The Coventry Hospitals team, meanwhile, described their NHS Forest-related efforts in terms of removing exclusionary boundaries from access to green space; furthermore, in doing so they hoped to break down other, psychological, boundaries between community and hospital - to re-engage their community in exercising their decisional authority over the collective property of our health service (which is still just about, pace PFIs and the Circles/Sercos/Care UKs of this world, the collective property of every user, current attempts to dismantle it notwithstanding).
Exploring this latter type of answer requires that we interpret market failure in broader sense, not just as a breakdown of certain subroutines within market mechanisms, but as more fundamental conceptual shortcomings. The possibilities explored and interventions imagined (or in some cases, already enacted) at the conference that most excited me were those that attempted to do just this, working to achieve better health and more sustainable healthcare through new models of ownership and production.
I first encountered such options being entertained while listening to plenary speaker Tim Helweg-Larsen, CEO of EnergyBank. He envisioned a future where the means of energy production were reclaimed from the hands of the "energy landlords" - the big energy companies who have accumulated the rights to the vast majority of energy supply in the UK - through user-ownership of 100% renewable energy infrastructure (and yes, 100% renewable does add up). While EnergyBank's current work, through focusing on large corporate bodies, might seem to take power from the hands of one elite only to place it in another, its long-term plan is structured so as to mitigate the damages of a new energy market (through price controls and trade restrictions - anathema to libertarian free-marketeers). Furthermore, in a national context such as the UK's, where major energy users with significant purchasing power are also public sector bodies - speaking here, of course, of the NHS - EnergyBank's plans propose little short of a return of energy production to collective ownership.
But it is hardly only such major investors who have the potential to reclaim the power; collective ownership on a direct, community level is happening across the world, with resounding success. A central role for energy co-operatives lies at the heart of Denmark and Germany's successes in renewable energy, and similar co-ops (wind, solar, and hydro) are developing across the UK. Furthermore, evidence suggests that such collective ownership schemes have exert a positive political and psychological feedback - community ownership correlates with increased support for renewable energy infrastructure.
The possibilities for a reimagining of property and production were not, however, restrained to energy production or co-op ownership. Projects already underway highlighted the potential of the rejection of private property to enhance both sustainability and health - whether through open reversal of enclosure of the commons, or subversive attempts to resist the logic of enclosure.
The first of these came in the form of the NHS Forest. While co-opting the language of neoliberalism by presenting the creators as 'greenspace entrepreneurs', their recent work would be better described as re-establishing a greenspace commons from enclosed land. A crowd-funded effort to create an environment open to all that is enabling of healthier lifestyles should be proud to consider itself an exercise in refashioning private goods into common goods (for the common good!) The Coventry Hospitals team, meanwhile, described their NHS Forest-related efforts in terms of removing exclusionary boundaries from access to green space; furthermore, in doing so they hoped to break down other, psychological, boundaries between community and hospital - to re-engage their community in exercising their decisional authority over the collective property of our health service (which is still just about, pace PFIs and the Circles/Sercos/Care UKs of this world, the collective property of every user, current attempts to dismantle it notwithstanding).
Where groups lacked the legal authority to repurpose private property, however, there was evidence of attempts nonetheless to subvert it to work towards a more sustainable system. In contrast to the inertia of alienation - exemplified by the comment quoted in the last post that health workers "desperately want someone [else] to handle" the creation of a more sustainable health system - the work of Health4Healthcare represented an attempt to force an exploration of collective ownership by advocating that workers seize decisional authority over a work environment that is not supposed to be theirs to own. Frustrated at the inaction of those given decisional authority under the private property regime, Health4Healthcare advocate 'positive deviance' - worker-led, grassroots action to restructure the material resources of their work into more sustainable models. In doing so, they transform a de jure private property (the hospital) into a de facto collective property, by helping workers to assert decisional authority over the products of their labour. (Alternatively, in the setting of NHS healthcare, they reclaim the de facto power of decisional authority over a resource that always should have been subject to collective ownership - the facilities and estates of our NHS).
So, might the answer to a crisis born of market failure be a reinterpretation of the relationship between society and the material resources on which we depend - a transition to new models of ownership and production? What the CleanMed conference showed us was that, at the very least, such an answer is neither implausibly radical nor inaccessibly utopian - that transition is happening already (even while simultaneously our society is being failed and our lives threatened by a resurgent drive to privatisation), and is proving ever-more successful.
* The non-rivalry condition, particularly of club goods, may be complicated by their being positional goods; but since that category isn't of much relevance hereafter, and the very idea of positional goods provokes some rather pressing ethical concerns, I'll leave that aside for now.
** For any non-Northern readers that's 'evening meal', not 'stewed-leaf beverage'.
*** Infection control as a public good was the topic I cut my bioethics teeth on (Paywall-free here).
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