Power and pandemics: A thought experiment

Imagine you’re a far-right government bent on a particular political project, whose lead minister for domestic affairs is on record as saying governments are not responsible for poverty, and you have to respond to a fast-moving contagious disease, after a decade of austerity has left the national health system overstretched even under normal circumstances and eviscerated local authorities’ ability to respond to public health crises. 

You are also committed to leaving the customs union whose members buy almost half your exports and supply about 30 percent of the nation’s food, in nine months, with or without a replacement set of arrangements[1] and despite the social and economic disruption that may ensue, including disruption of food supply chains whose precariousness the epidemic is already demonstrating. 

What might your sharpest-minded strategists do? 

Well, one approach would start by playing down the seriousness of the epidemic.  The Prime Minister might urge people to minimise social contact, whilst sometimes ignoring his own advice.  As the scale and speed of the epidemic became clearer, you might go ‘evidence-based,’ relying on a particularly apocalyptic set of model predictions that ignore the possible benefits of basic public health measures such as contact tracing, clinical observation, and testingperhaps to avoid drawing attention to austerity’s effects on the country’s ability to carry those out. 

Now invoking wartime imagery, you would close schools and most businesses and public facilities countrywide.  Within a few days, enabled by a hapless simpering Parliamentary opposition that did not oppose, you would enact a 348-page piece of legislation that centralises almost all power in the hands of the political executive for at least two years, and among many other extraordinary measures gives police the authority to use roadblocks and drones to prevent non-essential travel, indeed to define it, with criminal prosecution as a backstop. You would also, quite understandably, commit to massive borrowing and spending in order partially to compensate for lost jobs and business revenues, and to keep the economy from collapsing completely.

Oh, wait – the UK has such a government, and it just did all that.  Lancet editor Richard Horton has written that ‘basic principles of public health and infectious disease control were ignored, for reasons that remain opaque’; the following day, former Conservative Secretary of State Jeremy Hunt made a similar point, noting – about countries that tested early and intensively – that ‘[t]he restaurants are open in South Korea. You can go shopping in Taiwan. Offices are open in Singapore’. Abundant evidence now shows that permissible movements are now determined only by police acting on their interpretation of the orders of the political executive. When the other shoe drops, in the form of post-pandemic, post-Brexit austerity that will solemnly be defended on grounds of fiscal prudence, resistance may be difficult if not dangerous.  Methinks that far from blundering, the Conservative response to the pandemic has been extremely calculating and politically sophisticated.  I desperately hope I’m wrong.


[1]   Thanks to the US, the World Trade Organization now is nothing more than a talking shop, but that’s another story.

This post was updated on 31 March

Snapshots and casualties from the pandemic

On the morning of 18 March, Andrew Ross Sorkin’s indispensable Dealbook blog asked ‘what a “wartime” economy looks like’, pointing to the roughly US$2.5 billion in stimulus spending that the United States, the UK, France, Germany and Spain had offered as of yesterday; warning that it might not be enough; and calling the ‘spending plans unlike anything seen during peacetime’.

Actually he’s not quite correct on that last point.  The Bank of England pointed out in 2009 that in response to the financial crisis, the US and UK governments quickly mobilised an estimated US$14 trillion in cash and credit guarantees to rescue financial institutions, ‘equivalent to about 50% of annual GDP in those economies, although that does not equate to losses as in some cases these obligations were offset by holdings of assets’.  It is becoming clearer by the day that a commitment of that magnitude, if not larger, will be needed to avoid a depression.  And the blog points out that during the Second World War, the UK and the US ran budget deficits equivalent to more than a fifth of their respective GDPs.  By 20 March, The Economist was citing a figure of US$7.4 trillion (about 23 percent of GDP) as the combined commitment from the US, the UK, Germany, France and Italy; warning that conventional fiscal policy is likely to have limited impact; and observing that ‘new financial tools need to be deployed, and fast’. An optimistic view is that Green New Deals may achieve a breadth of political support unimaginable two weeks ago.

On the other hand, Toronto’s Globe and Mail offered an important commentary pointing out that many people already living paycheque to paycheque and now facing the probability of job losses cannot afford to stockpile a fortnight’s worth of food and will probably have trouble keeping a roof over their heads – an obvious point that seems to have escaped most of the mainstream media.  Both the New York Times, whose epidemic coverage is now out from behind its paywall, and the Guardian offered ominous frontline accounts calling into question the National Health Service’s ability to cope with increased caseloads after a decade of austerity-induced fragility. Similar accounts are now emerging from (among other places) the United States and Italy. And outspoken Lancet editor Richard Horton excoriated the British response as ‘a collective failure among politicians and perhaps even government experts to recognise the signals’ emanating from China and India.  He concluded that ‘when we have suppressed this epidemic, when life returns to some semblance of normality, difficult questions will have to be asked and answered’. 

We must now confront the possibility that, if economic policy is mismanaged and some health services collapse, that return might take, not a few years, but a generation.

This post was updated on 20 March

COVID-19, state desertion and neoliberal epidemics

In these times of plague, at least as they are categorised by some, spilling more digital ink on COVID-19 smacks of either hubris or irrelevance, and many others are better qualified than I to comment on the outbreak’s epidemiological dimensions – although, interestingly enough, they don’t always agree, and media are stretching the category of ‘scientists’. In keeping with the blog’s theme, here are a few equity-related observations.

1.  In some jurisdictions, the outbreak is a neoliberal epidemic – the term Clare Bambra and I coined in 2015 – for at least two reasons.  The first of these is the lack of access to paid sick leave for literally millions of low-wage US workers in retail, hospitality, and grocery sectors who either have no entitlement to paid sick leave or do not think they do, as reported by The New York Times.   Of course, in the real world, for workers without a strong union this ‘entitlement’ is really at the employer’s discretion, regardless of what the law says.  In the UK, the fusion of executive and legislative power gives the government of the day the ability to remedy the comparable problem instantly, if it chooses to do so.   Will it?

The current outbreak is also a neoliberal epidemic because of reliance on a profit-motivated pharmaceutical industry for vaccine development.  A recent journal article points out that this model for vaccine development has systematically hindered the development of vaccines for so-called neglected diseases; it may now be doing so with regard to COVID-19.  In a long and important piece in The Guardian on 27 March, US researcher Peter Hotez described ‘a broken ecosystem for making vaccines’, and claimed that he might have had a COVID-19 vaccine to offer today if his team had been able to find funding for a clinical trial based on their previous (2011-2016) research on SARS. If we take seriously the broadly shared view in political theory that the most basic prerequisite for political legitimacy is a government’s ability to protect its subjects against basic threats to life and security, then the development of scientific capacity for developing diagnostics and vaccines from basic research through to production and free, not-for-profit distribution should be regarded as a national security imperative for countries able to support such initiatives, and as a development assistance priority. Will this lesson be learnt from COVID-19?

2.  Focussing on the UK context, we are now seeing the consequences of a decade of austerity during which the NHS was starved for resources and the budgets of the local authorities that since 2012 have had statutory responsibility for public health have been gutted.  It remains to be seen whether the NHS will be able to cope, and how high the casualty count will be both among those infected with COVID-19 and those whose care needs are displaced by COVID-19 patients in intensive care units.  Rest assured, there will be casualties.  In the United States, journalist Laurie Garrett has been warning for decades about the dangers of neglecting domestic public health infrastructure.  In January of this year, she broke the important story that President Trump had disbanded the country’s pandemic response capability.  Some mainstream media, although by no means all, have since picked up the story.  Clearly, this was regarded as less important than covering promises of building big, beautiful walls to keep out threats originating in deranged racist imaginaries.  Our media in the UK, and what has passed for a political opposition over the past decade, have not done a whole lot better.

3.  At this writing, one UK proposal is to respond to the outbreak by isolating people over 70 in their homes for up to 16 weeks, ‘for their own protection’, which among other shortcomings defies every principle of natural justice.  At this writing, it is unclear how draconian the restrictions would be, but if they are implemented, then one wonders how many deaths of despair will result not from COVID-19 infection, but from that isolation in the context of a care infrastructure that is completely unable to provide necessary support – again, after a decade of austerity.

Over the longer term, the economic impacts of the pandemic may prove to magnify health inequalities in ways that are as yet impossible to predict.  For example, what happens if lengthy school closures result in job losses for parents choosing between work and leaving their children home alone?  What happens to literally millions of workers in (initially) the transport, hospitality and retail sectors as their jobs disappear? What happens if, or more probably when, equity market declines mean that defined-contribution pension plans across the high-income world collapse in value and defined-benefit plans can no longer meet their obligations and face insolvency?

It is possible to envision creative and progressive (as the term is used in public finance) policy responses to all these questions, and other related ones.  An International Monetary Fund researcher has called for ‘substantial targeted fiscal, monetary, and financial market measures to help affected households and businesses’ (author’s emphasis).  Whether such policies will prove to be politically viable domestically and internationally given the sums involved – realistically, into trillions of US dollars – and the desirability of strongly progressive finance mechanisms is quite another question.  Within their own borders, both the United States and the United Kingdom have in recent years systematically and intentionally magnified inequality and redistributed resources and opportunity upward within their social structures. Time will tell.

This post was selectively updated on 29 March; many aspects have now been overtaken by events.

Starting a conversation: Evidence-informed polemic and the need for a new social movement

I am re-reading, not for the first time, some of the work of legal scholar Catharine MacKinnon.  (I used to refer to her as a feminist legal scholar; I don’t do this any more, since the adjective can be read as a qualifier, or a denigration.  Scholarship is scholarship, full stop.)  Her work has been an inspiration to me for a long time, since she combines impeccable, meticulously documented philosophical argumentation and legal reasoning with incandescent critique of injustice, gender inequality and misogyny.   

But MacKinnon is much more than a hyper-accomplished academic.  Among a host of other achievements, she was co-counsel in the first US Supreme Court case that recognised workplace sexual harassment as a form of discrimination; contributed to the development of Canadian equality law under the country’s Charter of Rights and Freedoms; was co-counsel in the suit that won a landmark US damage award against Serbian warlord Radovan Karadzic, establishing rape as an act of genocide in the context of ‘ethnic cleansing’; and subsequently served as the first gender adviser to the International Criminal Court.  MacKinnon’s advocacy played an important role in generating what is now widespread recognition of rape as a weapon and crime of war.  She has written extensively about these experiences, and much else, in a style I think of as evidence-informed polemic. [1]

The literature on health inequity includes at least a few examples of this style.  For example, in 2013 David Stuckler and Sanjay Basu argued (in The Body Economic) that: ‘The price of austerity is calculated in human lives.  And these lost lives won’t return when the stock market bounces back’.  Immodestly, in 2015 Clare Bambra and I put forward (in How Politics Makes Us Sick) the idea of neoliberal epidemics, specifying neoliberalism as a fundamental cause of health inequalities.  And in 2017, Lancet editor Richard Horton memorably described austerity as ‘a political choice that deepens the already open and bloody wounds of the poor and precarious’.   Outside the academic bubble of citation counts, these interventions (we) have had approximately zero impact in the real world. This post is an effort to start a conversation about how to change that.

One obvious observation is that MacKinnon’s impact results from a combination of advocacy and creative litigation using existing bodies of statute and doctrine.  One of the researchers interviewed by Katherine Smith characterised health inequalities as ‘the most fundamental abuse of human rights in the developed world. [I]f you imagine locking up a substantial proportion of your population for the last five or ten years of their life without any justification at all, well actually this is worse than that, it’s like executing them arbitrarily’.  Stated thus, the point seems obvious, but it’s hard to see avenues for turning it into a basis for litigation.  Maybe concerned academics have simply not connected with the right litigators, but issues of causation might present formidable barriers to success, given courts’ (and many epidemiologists’) tendency to set standards of proof that are often inappropriately high

At least in the UK, the deliberate corruption of universities by organising priorities and career paths around generating research income means fewer and fewer academics – mainly those near the end of their working lives, without dependents or with independent wealth – can engage in evidence-informed polemic rather than forelock-tugging before funders without fear of reprisal.  Professionals working in public health in government are likely to be even more limited in their ability to speak out, however sophisticated their private understandings of the origins and politics of health inequality (and in many cases, again in the UK at least, these are very sophisticated indeed).  The tendency of too many health promoters to acquiesce in the popular conception of poor health as somehow the fault of the individual affected does not help. 

Perhaps the most important issue is suggested by Sir Michael Marmot’s call, after the release of the 2008 WHO Commission report, for ‘a social movement, based on evidence, to reduce inequalities in health’.  That movement has yet to materialise.  Writing about women’s resistance to workplace sexual harassment in the United States, Carrie Baker defines social movements as ‘a mixture of informal networks and formal organizations outside of conventional politics that make clear demands for fundamental social, political, or economic change and utilize unconventional or protest tactics’.  Crucially, many coalitions that formed to fight sexual harassment connected women who were not otherwise similarly situated in socioeconomic terms.   Another, much more recent manifestation of such a coalition is the powerful anti-violence performance ‘A rapist in your path’, which originated in last autumn’s Chilean protests against inequality and has now gone viral in much of the world.  

Here’s the rub.  As I wrote a decade ago in the Canadian context, effective social movements need not only evidence and coalitions, but also rage, hopelessness, desperation, hope, shared passion, shared vulnerabilities, or some combination of these.  That’s where their energy comes from.  If one adopts a suitably precautionary standard of proof, as suggested by the human rights frame, there is no shortage of evidence – certainly not of the damage done by the past decade’s systematic upward redistribution of resources and opportunity.  What possible coalitions could move the health equity agenda forward, and how can the necessary emotional energy be mobilised?  Let the conversation begin.


[1] A selection of MacKinnon’s earlier work appears in Feminism, Unmodified (1988); somewhat later work in Are Women Human? (2007); and her landmark explication of feminism as political theory in Toward a Feminist Theory of the State (1991).  A very recent open access introduction to her perspective is available here.

Marmot +10 and the grim prognosis for health equity

Most readers will now be aware of the release on 25 February of the ten-year followup to the 2010 ‘Marmot review’ of health inequalities in England.  To say that the report makes depressing reading is putting it mildly.  Despite the epidemiologist’s caution expressed in Sir Michael Marmot’s foreword – ‘We were reluctant to attribute the slowdown in health improvement to years of austerity because of difficulty in establishing cause and effect – we cannot repeat years without austerity just to test a hypothesis’ – the report as a whole offers a devastating portfolio of evidence of the human damage done by a decade of austerity.  Its accumulation of graphs and charts makes a compelling case for the point I try to bring home to postgraduate students at every opportunity: public finance is a public health issue.  An especially bitter irony, of course, is the emerging recognition across much of the political spectrum, and of the economics profession, that the decade was not only unnecessary but even counterproductive in macroeconomic terms.

Unfortunately, that kind of evidence is not relevant to the broader post-2010 project of redistributing income, wealth, and opportunity upward within British society.  (The brilliant and iconoclastic economist Branko Milanovic has pointed out that the rich have much more to gain from such upward redistribution than from stimulating growth across an entire national economy; their ready access to tax avoidance opportunities unavailable to the rest of us further distorts the incentive structure.)  Neither does evidence of macroeconomic (in)effectivess bear on what might be called the micro-level attack on the poor, marginalised and precarious.  The day after the release of Marmot +10, The Independent reported that the Department of Work and Pensions had shredded ‘up to 49’ internal reviews of suicides that occurred after people’s benefits had been cut off.  This followed an earlier report of 69 suicides among benefit claimants in the past five years, which is almost certainly a low figure. 

Just a few items from the report deserve flagging.  Fewer than 200,000 workers in the UK were on zero hours contracts in 2010; by late 2018 the figure was close to 900,000.  For the poorest tenth of English households, eating healthily would require three-quarters of all their disposable income after housing costs.  And the targeted financial destruction of local government has led (for example) to an England-wide reduction of 42 percent in local spending on transport and a 52 percent cut in housing.  As the report points out, ‘councils have used reserves, sold assets and reduced spending on the non-statutory services they are not legally required to deliver’.

None of this matters to Mr. and Mrs. Range Rover, of course.  An Arizonan interviewed by US journalist Ken Silverstein captured the underlying political economy a decade ago: ‘People who have swimming pools don’t need state parks. If you buy your books at Borders you don’t need libraries. If your kids are in private school, you don’t need K-12. The people here, or at least those who vote, don’t see the need for government.’  And The Times recently reported that residents in some of London’s ultra-wealthy boroughs pay less than £1 in council tax for every £1,000 of property value, whilst those in ten poor local authorities in the Midlands and the North such as Hartlepool, Middlesbrough, Gateshead and Stockton-on-Tees pay between ten and fourteen times as much (unfortunately behind a paywall; contact me if you would like the figures.)

 It is hard to know how to respond to such situations, beyond despair and resignation.  These responses are heightened by the fact that many of the new report’s ‘case studies,’ seemingly intended as success stories, are at best sticking plasters, doing little to address the critical upstream drivers of inequality – the ‘toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics’ correctly targeted by the 2008 Commission on Social Determinants of Health.  I have to remind myself more and more often that the last word in Albert Camus’ famous essay on suicide is hope.  One hope is that public health researchers and practitioners might disengage themselves from producing yet more systematic reviews of the evidence, organised around impossibly and inappropriately high epidemiological standards of proof, and turn attention, energy and pedagogy to more practical questions such as what to do when government adopts homicidal social policies and then destroys the evidence.  

Strange days, strange priorities

The news of the day sometimes throws up events that combine to highlight the absurdity, and the perversity, of today’s policies of selective market fundamentalism.

Tuesday, 14 January was one of those days.  The Guardian reported that councillors in the last county in England without a Burger King, Kentucky Fried Chicken or McDonald’s restaurant (if that is really the appropriate word) had approved a 24-hour McDonald’s drive-through in the town of Oakham.  This happened even though 55 of the 78 representations submitted to planning officers opposed the planning permission.

In a spirit of rough and ready critical discourse analysis, it is worth considering the language of the news report.  Damien Gayle and Kevin Rawlinson wrote that many people they interviewed were ‘hopeful that the new restaurant would give the town’s young people somewhere to go and create local jobs’ (my italics), and ‘[p]arents … said they would welcome not having to drive to neighbouring counties to “treat” their children to McDonald’s food’ (my italics again). 

So this is what market fundamentalism hath wrought, and obeisance before the deity of (private sector) job creation is only part of the picture.  Silly me; I would never have thought of McDonald’s on a list of places for young people to go.  Oakham’s library is still functioning, unlike the 343 libraries across the UK that closed between 2010 and 2015, although admittedly it is only open during the day Monday to Saturday.  Rutland County’s web site offers numerous links to parking information, but no mention of parks; I’m not certain what to make of that.  And these are strange days indeed when parents feel compelled to drive substantial to feed their children a McDonald’s meal.  The industry, of course, is not just a passive bystander.  It targets children in its advertising, as McDonald’s did in Chile; this was pointed out in the web summary of a September 2011 Euromonitor report that is no longer online, but I have it on file. 

‘McDonald’s arrived in Chile targeting the segment of children, but over time, the customer base has expanded from not just children to also their parents, as well as young people. This strategy has allowed this brand to claim an important part of the category, and it has established itself amongst consumers of fast food ’ (Euromonitor, 2011; photo from Santiago city centre: T. Schrecker)

It’s as if no one had heard of the epidemic of child and adolescent obesity, or the massive revenues, profits and marketing budgets of the ultra-processed food and fast food industries that contribute to it.  Encouragingly, the public health community is slowly coming to grips with the importance of commercial determinants of health, but it will be a long hard slog, with deep-pocketed adversaries.

On, then, to the second news item of the day.  Short-haul airline Flybe, which serves 56 locations in the UK and continental Europe, received a bailout from its major shareholders that may be accompanied by sweeteners from the magic public money tree including deferred tax payments and a reduction in air passenger duty on domestic flights.  Entirely understandable expressions of outrage, not least from its commercial competitors, seem likely to have no effect, yet as Nils Pratley pointed out in The Guardian: ‘Increased trading losses? Higher fuel costs after sterling’s decline last summer?  Brexit uncertainty?  None of those risks were unimaginable 12 months ago’.   This is a case of bad management, or more accurately bad accounting, pure and simple.  Management is surely what was lacking. 

It’s as if no one had heard of climate change, or the aviation industry’s contribution to greenhouse gas emissions.

Many forms of infrastructure are essential for modern life, and in the UK many have been dismembered by a decade of austerity. In a carbon-conscious age when, as economists never cease to remind us, resources are limited, a failing regional airline is not one of those essentials. The idea of letting markets work never seems to play very well in the commercial aviation industry, or with its political protectors. 

Now, please don’t take what I am about to write the wrong way.  All of us concerned with health inequalities recognise that governments must get in the way of markets, in all kinds of ways and for all kinds of reasons.  But here are two modest proposals, with apologies to Jonathan Swift, for how a creative, environment- and health-friendly government might use markets to move towards a healthier, less inequitable and greener world. 

First: let airlines, like your local drycleaner, price their services at a level that will ensure an adequate return on investment, whatever that may be, or go bust.  By all means subsidise transport, but concentrate on options that generate the fewest negative health impacts:  low-carbon rail and bus services, active transport, and reducing the need for travel.  Conversely, massively dis-incentivise polluting and carbon-intensive transport.  The British Heart Foundation have just launched an important campaign on air pollution, as has The Times; more power to them both, even though The Times’s proposals are modest, perhaps in deference to its Range Rover readership.

Second:  if planning permission for fast food franchises must be allowed, why can’t central government legislate a quota of such permissions for the entire country, or for each region (say, in the English case, each NHS footprint area); auction opportunities to apply for them to the highest bidders, with periodic renewal required; and gradually shrink the quota at each successive auction?  The tidy bit of revenue generated could be ring-fenced to reopen libraries and activity centres, restore parks, use traffic calming to improve the activity-friendliness of neighbourhoods, and perhaps subsidise the cost of healthy food.

Just asking … 

What now for trade and health politics post-Brexit?

With the election over and the United Kingdom’s exit from the European Union on some terms or other now a certainty, it is useful to reflect on the trade negotiations that will follow.  I offer these  initial observations.

First, there has been much talk of the option of reverting to World Trade Organization (WTO) rules in trade relations if ‘deals’ to replace the agreements to which the UK was party by virtue of its EU membership cannot be negotiated by the end of 2020.  However, thanks to the United States’ refusal to agree to appointing new members of the WTO Appellate Body, effectively there will be no WTO rules going forward, until and unless a future US government changes this position in 2021 or thereafter.  Once out of the EU, the UK is effectively unprotected in a trade policy jungle, not having been able to negotiate independently of the EU, so pressure quickly to negotiate new agreements will be intense.  Domestic proponents of a deregulated, ultra-liberal future, including (for example) further privatisation in the NHS and opening the country’s arms even wider to dodgy flight capital, will make use of this opportunity. The government’s announced intent to legislate an exit from the EU at the end of 2020, whether or not an agreement has been reached, is a first step in this process.

Second, in this process the UK will be at a substantial disadvantage as it negotiates with entities like the United States (an economy more than six times larger, based on GDP at purchasing power parity) and the comparably large European Union.  It will have to offer more, in terms of market access and other considerations, to get less.  And when anyone in an official capacity says that a particular service or health protection measure, such as the NHS or food safety standards, ‘will not be on the table’, we have to ask what else will be on the table instead.  That is the reality of asymmetrical trade negotiations, as countries throughout the Global South have found out.

Third, the House of Commons will be largely irrelevant.  A former Canadian cabinet minister pointed out decades ago that: ‘Under our parliamentary system, a Prime Minister or a Premier with a majority has immense power …. [In] 1688 we traded the divine right of kings for the divine right of a Premier or a Prime Minister with a majority at his or her back for a period of five years’.  The new Conservative government has a large enough majority that even with a unanimous opposition, close to 40 defections would be necessary in order to defeat whatever legislation the government proposed, and that is all but unthinkable.  Advocates for health equity concerned with the implications of post-Brexit trade policy will have to look elsewhere for points of influence.  There may not be many.

Thus, fourth, a final irony. The campaign to leave the EU was waged using the mantra of taking back control. During the process of leaving and after its completion, influences and actors outside the UK’s border will probably be more important in terms of shaping the direction of the economy, society and everyday life than they were during the country’s EU membership.

Why no talk of an inequality emergency?

We hear much talk now of a climate emergency.  As I was revising a talk I give frequently on ‘global health in an unequal world’, I realised that there is no talk of an inequality emergency, either globally or close to home, although the same macroeconomic trends and political choices driving increased inequality within national borders and on a variety of smaller scales are often involved wherever on the map one happens to look.  (On these inequalities at metropolitan scale, I cannot recommend too highly photographer Johnny Miller’s compelling aerial images.)

Why is there no talk of such an emergency?  Many manifestations of climate change occur on a scale that makes them fodder for our spectacle-hungry visual media: think Californian and Australian wildfires; collapsing glaciers; and catastrophic damage from hurricanes and floods.  The casualties of inequality tend to be smaller in scale and less visible: the lives ended sooner and more painfully than they should have been because of the accumulated damage done by relying on food banks and fearing the ‘brown envelope’ that initiates the vicious privatised process of fitness-for-work assessments here in the UK, or the estimated 300,000 women per year who die in pregnancy or childbirth from causes that are routinely avoided in the high-income world.   Academically, it may be effective to compare the annual toll from death in pregnancy and childbirth to the crash of two or three airliners every day of the year, as a colleague and I have done, but such comparisons have little salience in the broader, media-corrupted world of political priorities.

Relatively vast resources have been devoted to climate science – the Intergovernmental Panel on Climate Change is the world’s largest-ever scientific collaboration – and climate researchers  long ago realised that just generating more evidence was never going to be enough to generate the change needed.   So many became advocates, for example tracing 63 percent of cumulative worldwide emissions of carbon dioxide and methane between 1751 and 2010 to just 90 massive state- and investor-owned corporations (and their customers, of course).  More recently, another group of authors (supported by more than 11,000 signatories) argued that ‘Scientists have a moral obligation to clearly warn humanity of any catastrophic threat’.  Researchers on health inequalities, in particular, have generally been more circumspect.  In the UK, advocacy that looks far enough ‘upstream’ at the economic and political substrates of health inequalities – more on that point later – is unlikely to be acceptable to agencies of the capitalist state and the trustees of billionaires’ fortunes whose funding priorities shape the direction of academic research and the career paths of academics.  And the health inequalities of greatest concern, by definition, do not affect ‘all of us’.  Whether the consequences of climate change will genuinely do so is too complex a question to be investigated here, but the question is well worth asking.  Certainly, its effects will be felt first and worst by those least implicated in its origins.

Another issue is the decades-long rhetorical and ideological Thatcherite drumbeat that ‘there is no alternative’ to rising inequality and the policies that drive it.  This problem is particularly acute with regard to the austerity that has been thoroughly discredited in terms of the macroeconomic objectives of sustaining growth that it was supposed to achieve, whether in the era of World Bank and IMF-mandated structural adjustment or, more recently, in post-2010 responses to the financial crisis.  As Nobel prize-winning economist Paul Krugman commented in the run-up to the 2015 UK election: ‘All of the economic research that allegedly supported the austerity push has been discredited. On the other side of the ledger, the benefits of improved confidence failed to make their promised appearance. Since the global turn to austerity in 2010, every country that introduced significant austerity has seen its economy suffer, with the depth of the suffering closely related to the harshness of the austerity’.  Post-2015, of course, austerity in the UK became harsher still, demonstrably redistributing income and resources upward within British society, through both tax and benefit ‘reforms’ and savagely destructive cuts to local authority budgets.

Now, austerity has become normalised; it is part of the quotidian policy landscape to the extent that we are almost no longer capable of rage when the strutting, glossy Home Secretary straightfacedly claims that poverty is not the government’s problem, when the evidence is overwhelming that post-2010 public policy has systematically and premeditatedly made the problem worse.  Despite the best efforts of the fossil fuel industry, we can imagine a decarbonised economy, even though we may not be able to specify its details.  Too many of us now have difficulty imagining economic systems that do not operate as what Serge Halimi, the editor of Le Monde Diplomatique, has called an ‘inequality machine’.  A powerful antidote to this well-funded intellectual cauterisation is the United Nations Conference on Trade and Development’s 2017 blueprint for a global new deal.  How many global health researchers have read it, I wonder?  How many medical or MPH students have been asked to do so?

Back to the view looking upstream.  Failure to understand and declare an inequality emergency reflects the success of neoliberalism or ‘market fundamentalism’ as a global class project of restoring inequality and the privileges of the rich to the levels that prevailed before what has been called the ‘great compression’ that reduced inequality after World War II in much of the high-income world, and inspired egalitarian visions far outside it.  The evidence on this point can’t even be summarised here – I am glad to provide key sources – but in the context of the work that academics do, two decades of marketisation in British universities must be understood as part of the project.  Centrally funded institutions that served a public educational and scholarly purpose were dismantled, replaced by corporate-style enterprises organised around generating income from deep-pocketed funders and indebted students, with careers often ended by failure to put out salable products.   

Isn’t this a form of conspiracy theory, you ask?  Empirically, the best rejoinders come from the work of journalists like Jane Mayer and historians like Stefan Collini and Nancy MacLean.  Conceptually, an especially apposite riposte comes from the brilliant legal historian Douglas Hay, who established himself in the field with the research that underpinned the following conclusion: ‘The private manipulation of the law by the wealthy and powerful’ in eighteenth-century England ‘was in truth a ruling-class conspiracy, in the most exact meaning of the word. …. The legal definition of conspiracy does not require explicit agreement; those party to it need not even all know one another, provided they are working together for the same ends.  In this case, the common assumptions of the conspirators lay so deep that they were never questioned, and rarely made explicit’ (1).  Enough said.

(1)  Hay, D.  Property, Authority, and the Criminal Law. In D. Hay et al., Albion’s Fatal Tree: Crime and Society in Eighteenth-Century England (pp. 17-64). New York: Pantheon, 1975,  

Revelation! The International Monetary Fund discovers tax avoidance and capital flight

Capital flight – in which actors with liquid assets shift them out of their country in order to earn higher returns, avoid currency depreciation and escape regulation – has been recognised as an important constraint on development prospects for decades.[1]  Before I moved from Canada to the UK, I was often dismissed and sometimes ridiculed by colleagues (millionaire physicians in particular, but not only they) for suggesting that discussions of ‘global health governance’ must not ignore capital flight and the mechanisms that facilitate it, for example by creating opportunities for tax avoidance or evasion.

Recent developments have underscored the issue’s importance.  Notably, a 2014 Chatham House report on how to finance the transition to universal health coverage that has now been endorsed as a target for the United Nations’ Sustainable Development Goals highlighted ‘[e]nsuring good tax compliance by taking steps to reduce tax avoidance and evasion, particularly by high net worth individuals, high-profit companies and transnationals’. And the September, 2019 issue of the International Monetary Fund’s quarterly Finance & Development focuses on tax avoidance, under the rubric ‘Hidden corners of the global economy’.

The magnitudes involved are staggering.  In the lead article, the acting managing director of the IMF cites an estimate of US$ 7 trillion (yes, trillion) as the amount of private wealth hidden in tax havens.  The annual tax revenue losses to governments, amounting to US$ 1 trillion on one estimate (or roughly 1.5 times the United States’ bloated military budget) are just a part of the overall loss related to such mechanisms as mispricing in cross-border trade within global production networks dominated by transnational corporations, and purchase of nationality by ultra-rich individuals (see Figure 1, a screenshot from a consulting firm that describes itself as ‘The Leader in Residence and Citizenship Planning’).  The latter process at least is entirely legal, indeed entrenched in many national ‘golden visa’ policies, and the legalities of transfer pricing remain the topic of extensive and inconclusive litigation using the limited options that are now available.

Figure 1

The IMF’s belated discovery of tax avoidance, and its engagement with leading researchers like Nicholas Shaxson, is therefore welcome.  Perhaps, to quote Tracy Chapman, ‘finally the tables are starting to turn’, even though this possibility requires temporary suspension of disbelief with regard to the IMF’s historic role in expanding global predatory capitalism under US leadership.  In an alternative universe, IMF conditionalities would for decades have included performance requirements related to national policies aimed at reducing tax avoidance and capital flight.

Meanwhile, public health protagonists working within national contexts where it is safe to do so (a shrinking universe) must foreground how a global economic order that enables ultra-wealthy individuals and transnational corporations to avoid tax liabilities limits the ability of well-intentioned national and sub-national governments (yes, there still are some) to reduce health inequalities, whether directly through equitable provision of health services or indirectly through poverty reduction, addressing place-related dangers, and other strategies.

Public finance is a global health issue.  This message must be communicated as widely and forcefully as possible. I am glad to provide more extensive reference lists to those interested in advancing this understanding. .

[1] For an early discussion in the Latin American context, see D. Lessard and J. Williamson, eds., Capital Flight and Third World Debt (Washington, DC: Institute for International Economics, 1987).  For a summary of later work by the leaders in research on capital flight from sub-Saharan Africa, see Boyce and Ndikumana (2012).

Learning from Canada: What politicians’ egos, and the casualties left behind, have to do with public health

The polite fiction disseminated in too many sixth-form classes is that political leaders enter public life to further a vision of what is best for their society, or at least the segments of that society they care most about and whose interests they claim to advance.  Why, then, do we see many politicians following their egos down paths that are thoroughly destructive of those interests?  Since the origins of so many health inequalities lie outside the health sector, and specifically in political choices made outside that sector, public health researchers and practitioners need at least to think about such questions.

Two examples from Canada, where I lived for most of my life before moving to the UK, come to mind.  In early 2018 Kathleen Wynne, the Liberal party premier of Ontario, Canada’s largest province, hung on as party leader in the face of opinion polls placing her party in a distant third place behind the Conservatives and the (mildly) social democratic New Democratic Party (NDP).  Her unpopularity had many sources, most tied to the performance of her Liberal predecessor’s government (in which she had held a Cabinet post unrelated to the sources of unpopularity).

Who knows whether another leader could have overcome this barrier?  Even before the June, 2018 election, Wynne conceded that she could not.  The election decimated Wynne’s Liberals, depriving them of official party status in the provincial Legislature.  The winner was a retrograde Conservative party led by Doug Ford, who sometimes acts like a Trump clone and has already been buffeted by multiple scandals.  His government has among other actions cancelled Ontario’s participation in a cap-and-trade programme to reduce greenhouse gas emissions, whilst opposing a national carbon tax; cancelled a pilot guaranteed income scheme in three Ontario communities; and cut education and public health budgets.  This happened despite the fact that Ford’s Conservatives won just 40 percent of the popular vote, against more than 53 percent for the Liberals and NDP, running on essentially identical left-of-centre platforms.  (There is a lesson here about the perniciousness of first-past-the-post electoral systems, but that is another post.)

Canada’s multimillionaire prime minister Justin Trudeau (son of a former prime minister revered by some and reviled by others) faces a tight re-election battle in October after having been found by an official ethics overseer to have violated conflict-of-interest guidelines by pressuring former Attorney General Jody Wilson-Raybould to offer the engineering transnational SNC-Lavalin, based in Trudeau’s home province of Québec, a deferred prosecution agreement.  Federal prosecutors, backed by Wilson-Raybould, wanted to pursue criminal charges on multiple bribery counts involving the corporation’s attempt to win foreign contracts.  Wilson-Raybould and another high-profile cabinet minister, Jane Philpott, eventually resigned from cabinet and were expelled from the Liberal caucus, taking with them much of the gloss that brought Trudeau’s Liberals to power in 2015 after a decade of increasingly inward-looking and parochial Conservative government.  Trudeau’s chief of staff and the head of Canada’s public service also quit; Trudeau is unrepentant.

Should Trudeau step aside?  There have been no calls for him to do so, and it remains to be seen whether he can win re-election, in a multi-party context made more complicated (that issue of electoral systems, again) by a surging Green party and a far-right People’s Party started by a breakaway Conservative legislator and climate change denier.  Pollsters are not (yet) asking, but it is certainly conceivable that a senior member of Trudeau’s cabinet like foreign affairs minister Chrystia Freeland would stand a better chance.

Now we come, of course, to Brexit and its (mostly negative) potential implications for public health, even if the worst short-term calamities of a ‘no-deal’ Brexit can be avoided.  A majority of British parliamentarians and almost half the British population are opposed to the megalomaniac no-deal Brexit trajectory of Boris Johnson and his crew.  Just as clearly, a parliamentary coalition backing any government led by Labour leader Jeremy Corbyn as a way of avoiding a no-deal Brexit is highly improbable, and would be widely unpopular.  The relevance of this observation could change within hours, of course.  Meanwhile, it may be too provocative to compare the independent accomplishments of Chrystia Freeland and Sir Keir Starmer (among others) to those of the heads of their respective parties, neither of whom has many, but in a time of crisis I’ll do it anyway.

The analytical point is: today’s brinkmanship is like long-ago outlaw hot rodders’ game of chicken, with a crucial difference: in that game only direct participants are at risk.  In the event of a no-deal Brexit, as in post-Wynne Ontario, negative externalities and casualties will spread across the entire jurisdiction and will be concentrated amongst those without protective coatings of money and class privilege.  Those actually making the decisions will not be left hungry, sick or homeless whatever happens.  With the clock ticking, will the relevant political protagonists rise to the occasion? If they do not, another polite fiction – that those in power care about the harm they do – will be demolished.  Will a sense of overarching public purpose, analogous to that associated with wartime, kick in?  All of us concerned with public health and health inequalities must worry about the outcome if it does not.