Work, Health and Control

A few weeks ago the World Health Organization’s Commission on Social Determinants of Health released its long-awaited report on the ways in which social, economic and political factors affect population health outcomes across the globe. The report’s punchline certainly has punch: “Social injustice is killing people on a grand scale.”

http://www.who.int/social_determinants/final_report/en/index.html

Despite its length, the report offers a compelling read with contributions from some extraordinary researchers and writers including Michael Marmot and Amartya Sen.

Chapter 7 makes the case that employment arrangements and workplace conditions can have both positive and negative effects on health. Not unexpectedly, working in unsafe conditions can have negative consequences for health. Less obvious, but no less significant, are the ways by which the nature of the employment contract and the organization of work themselves can have negative consequences for health outcomes. The authors found that health outcomes (e.g., mortality and mental health) are significantly worse for the precariously employed (e.g., those with informal work, non-fixed term temporary contracts, and part-time work) than permanent, full-time workers. At the same time, the authors found evidence that “high job demand, low control, and effort-reward imbalance are risk factors for mental and physical health problems” (72-3).

While accepting all of those findings, I think there may be reason to give special emphasis to the element of control. (And control in two senses). Many of us know individuals whose work in the knowledge economy consists of precisely those informal, non-fixed temporary contracts and part-time work arrangements that WHO associates with poor health outcomes. But these individuals do not face the adverse health outcomes that we would expect of people on lower rungs of the socio-economic ladder.

My sense is that the health effects of these types of arrangements depend as much, if not more, on the forces which drive people into those kinds of employment than the contract types themselves. An individual who takes on any contract position due to economic need has less control over her fate than someone who takes on contract work because, for example, she finds the nature of that particular contract intellectually stimulating. This is the first sense of control: Control over the conditions which constrain and motivate work-related choices. The less one needs any particular position, the less likely there will be adverse health consequences of temporary work.

The second sense of control involves the organization of work itself. The more control one has over how and when to fulfill the obligations of any temporary position, the less likely one is to suffer negative health outcomes by being employed in that way. In short, if you can always walk out the door, you're less likely to tolerate work conditions and employers who should not be tolerated. These hypotheses would require testing (and I don't think I've made the distinction as clear as I'd like), but I suspect that something like this is the case.

But this brings us back to the question of why we work and why the question matters: Those of us who have the luxury of working (at least in part) for some non-financial purpose, rather than just for money, are likely to lead healthier lives than those who don’t have that opportunity. And in that case, maybe H.L. Mencken – whom the Commission quotes sympathetically – captures a part, but only a part, of our moral intuitions about work:

It is an absurdity to call a country civilized in which a decent and industrious man, laboriously mastering a trade which is valuable and necessary to the common weal, has no assurance that it will sustain him while he stands ready to practice it, or keep him out of the poorhouse when illness or age makes him idle.

In addition to sustainable and fairly paid work, we might also need secure conditions from which to make genuinely free choices and a set of options which have or could facilitate meaningful activity.