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.



‘Let them eat resilience’: The genealogy of a vocabulary, and why it matters for public health

Nothing about the title of this post is original.  The main title imitates that  of an essay by historical sociologist Margaret Somers called ‘Let them eat social capital’, which appeared in 2005.  The subtitle and the idea of a genealogy of concepts that situates them in a larger political context draws on an essay by Nancy Fraser and Linda Gordon called ‘A Genealogy of Dependency’, published in 1994.  That essay dealt with a word that became current in debates leading up to US social policy changes signed into law in 1996 by then-President Clinton.  Those so-called reforms ended a decades-old guarantee of at least minimal income support to households with dependent children that was already among the least generous in the high-income world.  In many cases, the destructive effects, in particular those of draconian and arbitrary ‘sanctioning’ regimes, were uncannily similar to those that followed more recent changes to benefits eligibility in the UK.   I cannot achieve the depth or sophistication of Somers’ or Fraser and Gordon’s analyses.  But I do hope to stimulate critical thought about both the underlying, often unexamined assumptions of the public health vocabulary, and about the policy implications.

The concept of resilience is used in multiple ways and multiple contexts.  For public health, three are probably most relevant. The first involves disaster planning.  I won’t explore that further here, although important political dimensions that parallel the argument I will present are suggested by social scientists who have studied responses to events like the 1995 Chicago heat wave and Hurricane Katrina a decade later.  (In the words of an excellent book on the New Orleans experience of the hurricane, There Is No Such Thing as a Natural Disaster.) The definitions on which I will focus are, rather those put forward by psychologist Michael Rutter and by a Canadian research group on resilience in communities.

So, first, Michael Rutter:  ‘The term resilience is used to refer to the finding that some individuals have a relatively good psychological outcome despite suffering risk experiences that would be expected to bring about serious sequelae.  In other words, it implies relative resistance to environmental risk experiences, or the overcoming of stress or adversity’ (citations omitted).  There are similar definitions in the literature that are not restricted to psychological outcomes.

Then, second, the Canadian group’s take: ‘Resilience is the capability of individuals and systems to cope successfully in the face of significant adversity or risk. This capability develops and changes over time, and is enhanced by protective factors within the individual/system and the environment, and contributes to the maintenance or enhancement of health’.

Immediately we see why the conceptual unpacking that is essential is also so difficult.  Who would want individuals not to have good outcomes after risk experiences?  Who would not want communities to cope successfully, however that is defined, in the face of adversity?

My central argument – the take-home message, as the bureaucrats say – is about the need for political awareness and methodological self-consciousness.  A focus on resilience diverts attention from a more important question: the sources of risk experiences and adversities; the political choices that variously drive them, sustain them and magnify them; and the all-important question of who benefits from those choices.  In this, as in other work on the politics of health, I draw on an important analysis by Finn Diderichsen and colleagues, who argued the need to locate the origins of health inequalities with reference to ‘those central engines in society that generate and distribute power, wealth, and risks’.

I do not for a moment suggest that resilience is used in public health research in the way that dependency was used in the intellectual racketeering that infused the welfare reform debates.  I do think that the quest for sources of resilience, and the implicit ascription of responsibility that it entails, unavoidably shifts the focus of research, policy analysis and professional practice away from the ‘central engines’ referred to by Diderichsen and colleagues.  This is entirely congruent with a central element of the neoliberal ideological project and policy agenda.  Political scientist Jacob Hacker, writing in the US context, has called this The Great Risk Shift: whilst economic policy generates new forms and levels of insecurity, these are not understood as requiring public or collective responses of the kind exemplified in the United Kingdom by the creation of the National Health Service.  Rather, public policy and public understanding regard these risks as matters of individual or localized responsibility; risks are no longer to be shared, and cross-subsidies are anathema; they simply reward the undeserving.   In 1998, Anthony Giddens (in)famously wrote about replacing the welfare state with a social investment state, in order ‘to develop a society of “responsible risk takers”.’  For many people, this has meant replacing the welfare state with a no-second-chances state.   Social scientists should take the latter concept more seriously.

An example of the discursive shift I am talking about: one of several articles from a research programme organised around the concept of community-level resilience explored the characteristics of economically disadvantaged Parliamentary constituencies with relatively low mortality rates relative to other constituencies with similar levels of disadvantage.  The authors identified this policy implication: ‘If some areas can resist the translation of economic adversity into higher mortality, other areas can learn from their policies and approaches, so that they are better protected when economic recessions arrive’.

Note the language here: economic recessions ‘arrive’, like the swallows at Capistrano; there is no suggestion that recessions reflect either exercises of economic power or the consequences of past policy choices.  The article in question appeared in 2007, so this latter point is of special significance given what we learned shortly afterward about the inequitable global reach of negative externalities associated with financial deregulation in a few high-income countries.

A focus on resilience at the individual level diverts attention from the realities of life on a low and precarious income, and from the fact that in much of the high-income world – certainly in the United Kingdom – whatever opportunities for ‘overcoming stress or adversity’ people living in such circumstances might have are being cut away at the community level.  Far from reinforcing capacities that might sustain resilience, post-2010 public policy in the United Kingdom has systematically attacked them, notably draining resources from both local economies and local authority budgets.

For example, researchers at Sheffield Hallam University’s Centre for Regional Economic and Social Research (CRESR) have shown that  by 2021, post-2010 benefit reforms will be sucking close to £1000 per working-age person per year out of some of the poorest local authority areas in Britain.  That is an annual impact, on areas some of which are poorer than any regions elsewhere in northern Europe.  The impacts on households’ ability to pay the costs of daily living have been devastating, driving many deeper into debt and into reliance on food banks.  The effects have been exacerbated by cuts in central government funding to local authorities, crippling services that are disproportionately relied upon by those on low incomes whilst having little or no effect on affluent residents of leafy places.  Almost 30 years ago, former US politician Robert Reich characterised this pattern as the ‘secession of the successful’.

If one tried to design a strategy of undermining the ability of local areas or communities to resist the ‘translation of adversity into higher mortality’,  it would look quite a lot like post-2010 governments’ approach to providing social protection and financing local government.

I presented a less well developed version of this argument late in 2014, at a National Institute for Health Research School for Public Health Research annual scientific meeting.  (Its content may explain why I have not been invited back.)  Unbeknownst to me Public Health England, whose website describes it as ‘exist[ing] to protect and improve the nation’s health and wellbeing, and reduce health inequalities’, was then in the process of publishing a set of priorities that called for ‘developing local solutions that draw on all the assets and resources of an area, integrating public services and also building resilience in communities so that they take control and rely less on external support’.  This, after many years of debilitating policies that redistributed economic resources upward and to wealthier regions of the country.

What else is there to say?

To restate the point: the concept and vocabulary of resilience subtly but inexorably direct attention – and assign responsibility for ‘taking control’ –  to people and communities who suffer the consequences of choices made and policies adopted far away, over which they had little or no control.  In stage magic, this is called a misdirection: it distracts the audience from what is really going on.  That may not be the intention, but it most certainly is the effect.  Public health researchers and practitioners have a professional responsibility to see through the deception, and to help others to do the same.

What is this thing called neoliberalism? (With apologies, and gratitude, to Cole Porter)

In 2015, my colleague Clare Bambra and I published a book subtitled neoliberal epidemics. Since then, the destructive consequences of ‘austerity’ in the United Kingdom, where I live and work, have underscored the value of this critical perspective.  So, too has the extent to which austerity and tropes like ‘scarce resources’ have become normalised in the official and professional discourses of public health.  I put the terms in quotation marks to emphasise that the scarcities in question are highly selective; resources are abundant for the priorities of the powerful – think HS2, which is  at least in part a welfare programme for propertied money launderers along the planned route – among many other examples.  Yet at the same time, many public health researchers and practitioners are reluctant to engage with neoliberalism as a political phenomenon.  I recently participated in a workshop in which some accomplished researchers simply refused to talk about it.   Precarious employment status is one reason, but in various contexts I have observed a lack of familiarity with the term itself, and its core propositions.

Unlike some academic colleagues, I have argued that there is a set of core propositions that are relatively easy to identify, especially once we recognise that history matters and a trajectory can be observed leading (at least) from the establishment of the Mont-Pèlerin society in 1947, through the installation of the Pinochet dictatorship in Chile in 1973 and the election of Thatcher and Reagan at the end of that decade, to the current context of homicidal austerity in the UK and elsewhere.

Anyone who questions the use of the adjective ‘homicidal’ just has not been paying attention.  I will address this issue in more detail in a future posting.

There follows a list of sources for those interested in exploring neoliberalism further, building on a list developed for a doctoral candidate I advise.  Many of these sources have nothing directly to do with health.  Answering the ‘what’s all this got to do with health’ question relies on a much larger literature on social determinants of health,  Some of the sources draw on this literature, and WHO’s training manual on Health in All Policies is a valuable starting point.

Comments and suggestions for additions to the list are welcome!


Birch, K. (2015). Neoliberalism: The Whys and Wherefores – and Future Directions. Sociology Compass, 9, 571-584.

Brodie, J. (2015). Income Inequality and the Future of Global Governance. In S. Gill (Ed.), Critical Perspectives on the Crisis of Global Governance: Reimagining the Future (pp. 45-68). London: Palgrave Macmillan UK.

Evans, P. B. & Sewell, W. H. (2013). Neoliberalism: Policy Regimes, International Regimes, and Social Effects. In P. A. Hall & M. Lamont (Eds.), Social Resilience in the Neoliberal Era (pp. 35-68). Cambridge: Cambridge University Press.

Farnsworth, K. & Irving, Z. (2018). Austerity: Neoliberal dreams come true? Critical Social Policy, 38, 461-481.

Fraser, N. (2017). From Progressive Neoliberalism to Trump—and Beyond. American Affairs, 1, 46-64.

Fudge, J. & Cossman, B. (2002). Introduction: Privatization, Law, and the Challenge to Feminism. In B. Cossman & J. Fudge (Eds.), Privatization, Law, and the Challenge to Feminism (pp. 3-40). Toronto: University of Toronto Press (important source on the multiple dimensions of ‘privatisation’).

Goodman, P.S. (2018, May 28). In Britain, Austerity Is Changing Everything. New York Times.  Retrieved from:

Harvey, D. (2006). Neo-liberalism and the restoration of class power. In his Spaces of Global Capitalism (pp. 9-68). London: Verso.  (This is the most succinct and least over-theorised of Harvey’s several works on this topic.)

Horton, R. (2017). Offline: Not one day more. The Lancet, 390, 110 (eloquent must-read critique by the editor of The Lancet).

Jones, D.S. (2012).  Masters of the Universe: Hayek, Friedman, and the Birth of Neoliberal Politics.  Princeton: Princeton University Press.

Kentikelenis, A. E. (2017). Structural adjustment and health: A conceptual framework and evidence on pathways. Social Science & Medicine, 187, 296-305.

MacLean, N. (2017). Democracy in Chains: The Deep History of the Radical Right’s Stealth Plan for America. New York: Viking.

Marchak, P. (1991). The Integrated Circus: The New Right and the Restructuring of Global Markets. Montreal: McGill-Queen’s University Press (indispensable historical source on the early policy initiatives that advanced neoliberal globalisation).

Metcalf, S. (2017, August 18). Neoliberalism: the idea that changed the world. Guardian.  Retrieved from:

Phillips-Fein, K. (2009). Business Conservativees and the Mont Pèlerin Society. In P. Mirowski & D. Plehwe (Eds.), The Road from Mont Pèlerin: The Making of the Neoliberal Thought Collective (pp. 280-304). Cambridge, MA: Harvard University Press.

Powell, L. F. (1971). Attack on American Free Enterprise System. Washington, DC: US Chamber of Commerce. Retrieved from: (a key historical turning point; Powell was later appointed to the US Supreme Court by Richard Nixon).

Schmidt, V. A. (1995). The New World Order, Incorporated: The Rise of Business and the Decline of the Nation State. Daedalus, 124, 75-106.

Schmidt, V. A. & Thatcher, M. (2014). Why are neoliberal ideas so resilient in Europe’s political economy? Critical Policy Studies, 8, 340-347.

Schrecker, T. (2016). ‘Neoliberal epidemics’ and public health: sometimes the world is less complicated than it appears. Critical Public Health, 26, 477-480.

Spooner, M. (2018). Qualitative Research and the Global Audit Culture. In N. K. Denzin & Y. S. Lincoln (Eds.), Sage Handbook of Qualitative Research (5th ed.). Los Angeles: Sage.

Springer, S. (2013). Neoliberalism.   In K. Dodds, M. Juus & J. Sharp (Eds.) The Ashgate Research Companion to Critical Geopolitics.  Farnham: Ashgate.

Steger, M.B., & Roy, R.K. (2010). Neoliberalism: A Very Short Introduction.  Oxford: Oxford University Press (very useful road map).

Stuckler, D., & Basu, S. (2013).  The Body Economic: Why Austerity Kills.  London: Allen Lane (now a classic).

Stuckler, D., Reeves, A., Loopstra, R., Karanikolos, M., & McKee, M. (2017). Austerity and health: the impact in the UK and Europe. European Journal of Public Health, 27, 18-21.

Wacquant, L. (2010). Crafting the Neoliberal State: Workfare, Prisonfare, and Social Insecurity. Sociological Forum, 25, 197-220.

Wacquant, L. (2012). Three steps to a historical anthropology of actually existing neoliberalism. Social Anthropology, 20, 66-79.

Ward, K. & England, K. (2007). Introduction: Reading Neoliberalization. In K. England & K. Ward (Eds.), Neoliberalization: States, Networks, People (pp. 1-22). Oxford: Blackwell.  Online:  


Mobility and invisibility: As we age, time for a policy phase change

(This article was originally published by the International Network for Critical Gerontology; republished here with their kind permission)

As we get old, unless we have the glow of money about us, we gradually become invisible.  This is nowhere more the case than in transport policy and planning.

Throughout the Anglo-American world, pedestrians and public transport users of any age are second-class citizens.  Cars and those who can afford to own and run them rule, often with substantial public subsidy for the fossil fuels they consume, and sometimes more direct subsidies as well.  (Good green Germany, for example, subsidized each company car to the tune of 2,500 euros per year a few years ago.)  In much of the low- and middle-income world, the situation is even worse, with motorways and high-speed commuter lines claiming scarce resources that could serve the mobility needs of the disenfranchised majority.

For older people, the problems posed by this transport apartheid can be especially serious, because of reduced physical mobility (we can’t walk as fast as we used to); limitations on driving; and, often, the difficulty of running a car on a fixed income.

Here’s a simple example: crossing the street to Newcastle’s Royal Victoria Infirmary (above), where my office is located, the signal transitions from ‘walk’ to ‘wait’ after six seconds, and the overall length of the crossing time is 14 seconds – hardly enough for someone with reduced mobility, of any age, to cross safely.  The junction itself is thoroughly confusing, even for those of us who use it regularly.  Illustration 2 shows an especially hazardous traffic sewer in downtown Ottawa, Canada, where I lived and worked before moving to the United Kingdom.  Predictably, several pedestrian fatalities occurred within a few hundred metres of this location in the years before I left.  Many suburban junctions are even worse.

Like so many other determinants of health, the problems are socioeconomically patterned:  my former Ottawa colleague Theresa Grant has done splendid work on how high-income neighbourhoods are much more ‘walkable’.   Although her focus was on older people, the health and safety benefits accrue to every age group.

The situation is similarly grim for bus users.  US-owned Greyhound Lines recently cancelled all long-distance bus services in Canada’s western provinces, stranding a large number of rural residents and raising the question of why the provision of non-automotive mobility should be left exclusively to the private marketplace.  (Even asking the question is difficult in today’s climate of market fundamentalism.)  The isolation of rural residents without access to a car can be soul-destroying.  In the United Kingdom, several years of savage cuts to local authority budgets, which come largely from central government, have led to widespread reductions in subsidies for bus transport, higher fares, and the cancellation of many services.  Older residents of many local authority areas are eligible for free bus service, but this means little when the service isn’t there.  A bus no longer runs from the neighbourhood where I lived until December, 2018 to the local hospital.  For those who don’t drive, the options are taxis, finding a ride with a friend or neighbour, or a one-kilometre walk to a bus stand in the town centre.

Some researchers have long recognized the problem.  Karen Lucas, of the University of Leeds, is perhaps the world’s leading authority on (and advocate for) inclusive transport; her work on ‘transport poverty’ and the need for inclusive transport policy is inspirational.  She writes with typical British understatement that: ‘What is still severely lacking in terms of progress in this research domain … is its transfer into policy and practice’.  If anything, policy and practice in many jurisdictions are moving in the opposite direction, probably reflecting growing inequality in the distribution of money and political influence.

An equity-oriented phase change (in physics, the transition between states of matter) is overdue.  Some short-term remedies are simple and inexpensive.  Pedestrian crossing times at junctions can be lengthened.  Zebra crossings (crosswalks) can be made more numerous, and better marked. Speed limits in residential areas can be reduced to 20 mph (32 km/h); this change has already been widely adopted in the United Kingdom, based on strong evidence for improvements in child safety).  Once enacted into law, prohibitions on blocking pedestrian crossings (see below), like pedestrian right of way in crosswalks, can be enforced using traffic cameras and automatic fines for vehicle owners.  Other remedies, like de-subsidizing fossil fuel and company cars and using road tolls to fund public transport, will take longer if they ever happen.  They will require fundamental reorientation of transport policy away from the convenience of drivers, and therefore be politically conflictual.  The challenges are formidable, to say the least, but population aging could make for a more receptive audience.

Health professionals who care about such matters can help by insisting on the vocabulary of ‘road violence’, and foregrounding the uneven distribution of its consequences.  (For example, of 408 pedestrians killed in the United Kingdom in 2015, more than half were over the age of 60, although this age group makes up just 24 percent of the total population.)  In New York City, pedestrian death investigation remains a low priority.

I first wrote about transport equity as a human rights issue more than 20 years ago.  Although international human rights instruments make no specific reference to mobility, the overarching human rights norm of antidiscrimination is clearly relevant, as is the right to the highest attainable standard of physical and mental health – which for many is daily threatened by car-centred transport planning.  To raise the visibility of non-inclusive transport, the United Nations Human Rights Council would do well to consider establishing a special procedure related to mobility in the context of the antidiscrimination norm and the economic, social and cultural rights to which most of the world’s countries have committed themselves.