Natural disasters?

Jackson, the small capital city of the US state of Mississippi, is at this writing (4 September) without safe drinking water, and has only intermittent supplies of piped water of any quality.  Unfortunately, much of the best media coverage of this humanitarian emergency, in outlets like the Washington Post and The New York Times, appears to be paywalled, although readers with a university affiliation should be able to access it through Nexis.  (BBC News, which finds investigative journalism easier outside the UK, is a notable exception.)  The proximate cause is flooding of the Pearl River, which has disabled the city’s water treatment plant.  However, the New York Times’ coverage sums up the deeper problem of politically driven infrastructure neglect, one all too familiar in US cities: ‘For decades, the city’s population has been shrinking, an exodus propelled in large part by the flight of white residents — along with their tax dollars — to surrounding affluent suburbs where, by and large, the water on Tuesday was flowing just fine.’

Jackson’s situation brings to mind the title of what I think is still the best book on the politics of Hurricane Katrina and its aftermath, although numerous later journal articles provide added perspective: There Is No Such Thing as a Natural Disaster.  The same analytical point was made several years pre-Katrina by sociologist Eric Klinenberg, in a ‘social autopsy’ of the 1995 Chicago heat wave in which people in the city’s poorest and most African-American neighbourhoods, unable to afford air conditioning, barricaded themselves in their flats while an indifferent and under-resourced city government did not respond adequately.  Water quality and availability crises are in fact becoming all too routine in US cities, as pointed out in a superb 2019 doctoral thesis by anthropologist Nadia Gaber and a special issue of the journal Critical Sociology on the multi-year water crisis in deindustrialised Flint, Michigan.   

Although some such disasters may be triggered by extreme weather events, they are not in any meaningful sense natural.  Rather, they are traceable directly to the hegemony of neoliberal ideas and associated urban austerity – and, in the US case, to a history of systemic racism that goes back literally centuries.  Since such weather events are likely to occur with increasing frequency as the planet’s climate changes, it is worth reflecting carefully on what these observations mean for health inequalities.  For example, they not only add to the already formidable health case against austerity but also would appear to bolster the arguments for climate reparations, not only across national borders but also within them. Observer columnist Kenan Malik notes a broader pattern of purposive reductions in the capacity of states to help those they rule, tracing this (correctly in my view) to the infamous 1975 Trilateral Commission report on The Crisis of Democracy. Here, again, the resulting humanitarian emergencies are not natural.  They are features, not bugs in the neoliberal vision of the world.  Facing a cost of living crisis and a probable prime minister who rails against “the lens of redistribution,” millions of people in the UK are going to experience the sharp, sometimes deadly edge of that vision during the coming winter.  

New Year, New Lockdown: ‘The Great Deception’

Predictably, the New Year started in the United Kingdom with new lockdowns.  Given the negligent and cavalier stance of the Conservative central government towards basic public health principles since the start of the pandemic, and the consequent peril to the National Health Service, this was inevitable, although one may argue with some of the specifics.  It is important to remember, though, that both the parlous state of the NHS and the neglect and defunding of public health infrastructure are consequences of a homicidal decade of Conservative austerity, correctly described in 2017 by the editor of The Lancet, Richard Horton, as ‘a political choice that deepens the already open and bloody wounds of the poor and precarious’.     

One of the knock-on effects is that we are now living in a police state – so far, a non-violent one, but violence is not a necessary element of the definition.  Hyperbole, you say?  Well, what else would you call a polity in which the decision about what constitutes a ‘reasonable excuse’ for leaving home is decided, in the first instance, by police, who will be defended by Cabinet ministers?   I wish politicians and self-styled progressive colleagues alike would stop dissembling on this point.  They might well defend the situation as necessary, but they should stop lying about its nature.  Presumably some of these fines and arrests will be successfully contested by those with the time and money to do so, should government eventually permit courts to resume routine operation, which is far from certain.  

Speaking of lies, porkies* of Trumpian proportions have been emanating from central government.  We are told that, if we obey the rules and all goes well with vaccination, restrictions might be eased in ‘tulip season’ (May, in these parts) or ‘spring’ (technically, before 21 June).  If any reader believes that, then I can offer a really good deal on some oceanfront property in the Canadian province of Saskatchewan.  (Spoiler alert: there isn’t any.)  Given the government’s record of destroying any public health initiative it touches, the UK will be doing well to be out of the worst of lockdown by September.  In fact, more severe restrictions are threatened.  As John Harris observed in an important Guardian commentary: ‘The lack of alarm about these moves is remarkable’.

Disturbing manifestations of burnout can be anticipated by the end of a summer without holidays (I quote from the government guidance: ‘holidays in the UK and abroad are not allowed’).  Some of us would in theory have the attractive option of sitting on the local seafront and reading once the weather warms up … except that under current guidance this would not count as exercise, one of the ‘reasonable excuses’ to leave home, so would be a crime.  Such constraints weigh most heavily, of course, on those without gardens of their own or with caring responsibilities.  The incidence of deaths of despair is likely to soar, as is the number of employers using depression and anxiety as a pretext for forced redundancies.

All this means that the chances of a post-Soviet style economic and health collapse in the UK, lasting for a generation or longer, are considerably greater than they were when I first raised the possibility last summer.  It could be, of course, that vaccination will proceed more quickly and effectively than expected (pigs might fly, too) or that some other remarkable advance in prevention will be found.  Unfortunately, it is much more likely that the United Kingdom is over as a desirable place to live and work, for a very long time, except for those living in gated communities or behind castle walls. 

The ways in which the pandemic is magnifying inequality – on which I will expand in a subsequent posting, based on material from the postgraduate course in Advanced Social Determinants of Health that I lead – continue to be given limited attention.  Most of the ‘experts’ calling for even stricter lockdowns probably have gardens of their own, job security, and substantial savings, unlike many other Britons; they have generally been silent on inequality issues.  Still less often have they taken up Horton’s pre-pandemic injunction that: ‘The task of health professionals is to resist and to oppose the egregious economics of our times’.  One wishes that members of the government’s Scientific Advisory Group on Emergencies had to disclose their households’ incomes and net worth, along with their professorial titles and British Empire honours, as part of their declaration of interests.

Here is a thought experiment, keeping in mind two propositions.  First, people working in front-line occupations (think essential retail like supermarkets, delivery, driving those buses that continue to operate, Amazon warehouses, meat packing, care homes) cannot work from home, and especially if on zero-hours contracts or without union protection cannot afford to self-isolate after a positive test or if symptomatic.  (The jobs of many others, working in the sector broadly described as hospitality, have vanished under lockdown, possibly never to return.)  Second, as of 25 September almost nine out of ten deaths from Covid-19 involved people 65 or older (more recent figures are maddeningly hard to find on official web sites).  Most of these represented an actuarial boon for the UK treasury, no longer paying state pension, and many for defined-contribution pension plans.   

Now, if you wanted to design a pandemic response that pretended good intentions whilst concealing a subtextual agenda of culling the working class (potential claimants of state benefits, after all, and therefore intrinsically suspect for Conservatives) and the elderly, the current UK response is what it would look like.  The UK is hardly unique in this regard, but along with Canada and its charnel house care homes and even more calamitous vaccine rollout it is an especially egregious case. 

The title of this post refers to what I consider the greatest song by Irish troubadour Van Morrison, ‘The Great Deception’.  Part of the refrain goes like this:

‘I can’t stand it / Can’t stand it nohow / Livin’ in this / World of lies’.

Indeed.

* For those outside the UK: short for porky pies, rhyming slang for lies.

Epidemiology, history and heartbreak: Reflections from North Yorkshire

As any academic would, I took some work-related reading with me during a short holiday break in North Yorkshire.  Here are some reflections.

First up: Johan Mackenbach’s 2019 book Health Inequalities: Persistence and change in European welfare states.   This remarkable book displays not only the author’s formidable scholarship (there are 738 cited references) but also his laudable willingness to engage with multiple literatures, like those on theories of justice and the politics of responses to inequalities.

That said, there is much to disagree with here – for instance, Mackenbach’s privileging of epidemiology in assessing “what works” to reduce health inequalities, and the selection of relatively crude outcome measures as indicators of success or failure.  A more nuanced approach would better integrate findings from such disciplines as ethnography and programme evaluation, and – in particular – would unpack the fetishisation of “significance” as defined by a 95 percent level of confidence.

This is very different from what might be called colloquial, or more action-oriented, understandings of the term, and population health research and policy need urgently to rethink this definition.  To give a simple and provocative example, many of us individually would take, and are taking, protective measures against coronavirus infection on the basis of far lower than 95 percent probabilities that they would prevent infection.  Public health authorities should be guided by a similar insight.   The combination of privileging epidemiological findings and fetishisation of statistical significance can generate reluctance to infer probable causation that can be pernicious.  Those of us who cut our professional and activist teeth on environmental and occupational health issues learned this decades ago. “We don’t know what works” is a conclusion welcome to the rich and powerful.

Nevertheless, this book is a must-read and an essential resource for anyone seriously concerned with reducing health inequalities.

And then: an even more remarkable volume on Slavery’s Capitalism: A New History of America’s Economic Development, edited by Sven Beckert and Seth Rockman.  Historian Beckert’s previous book, Empire of Cotton, made a powerful case that the textile industry that developed in the early nineteenth century was the first truly globalised industrial production system, enabled by the combination of technological innovation in the UK and the possibilities for low-cost slave labour in the US South enabled by the transatlantic slave trade, with Liverpool as the epicentre first of the slave trade and then, after its abolition in the UK (1807), of the cotton trade.  The edited book is chilling in its documentation of such patterns as the routine use of torture – the lash and more devious instruments – as a way of increasing production, and the use by plantation managers of commercialised methods of scientific management decades before the routine was applied to manufacturing production by F.W. Taylor.

The volume is also a salutary reminder that history matters – a point neglected by Mackenbach, perhaps because of his European focus (there is no index entry for race).  Recent historical analysis indicates that the hard realities of African-American health deprivation in the US must be understood, and responded to, as a global health issue.  Analogously, outside the high-income world, global health research that neglects the destructive effects of decades of ‘structural adjustment’ conditionalities demanded by international financial institutions and driven by the priority of protecting creditor interests is intellectually irresponsible, even if still widespread.

Finally, heartbreak.  A 16 July Guardian article by LSHTM professor Val Curtis described a history of repeated delays in NHS diagnosis and treatment for her now probably terminal cancer.  Read it; any summary would do a disservice to its author, and her observation that she ‘still can’t get my head around the brutal fact that I’m dying’ at age 61.  She correctly notes that: ‘My story is only one of many thousands of people in England whose deaths can be linked to austerity.’  I have trouble containing my rage whilst reading this, and the scandal of almost four million people on NHS waiting lists for elective care has now hit The New York Times.  Like the fate of the Grenfell Tower casualties, Prof. Curtis’ situation demonstrates that policy choices made during the past decade of austerity, like the most recent knock-on effects on the coronavirus response, have been homicidal.  Let’s repeat that word, for emphasis: homicidal.

Whether the health research, policy and practice community are willing to use that word, and to call out those responsible, remains to be seen.

This post was updated on 20 July to add reference to the New York Times article.

Austerity, the homicidal present, and the probable Russian future

On 18 June, I presented a webinar with this deliberately provocative title as the inaugural event in Fuse’s Covid-19 seminar series.  I think the provocation is fully justified by the most recent summaries of the UK’s failed response to the pandemic, notably from The Economist, the Oxford Research Group and Reuters.  (A superb one from The New York Times unfortunately appears to be behind a paywall.) 

You can find an archived recording of the presentation here.  My particular focus, as in an earlier posting to this blog (in which I pointed out that the Adam Smith Institute and the leader of the Labour Party were agreed on the importance of a coherent post-lockdown economic strategy), was on what can be learned from the experience of Russia in the generation since the implosion of the Soviet Union about the possible health and health equity consequences of drastic economic collapse. 

Fuse have kindly collected the questions submitted by audience members, not all of which could be addressed in the available time, and I’ve provided brief answers in italics below, under several topic headings.

(This post was updated on 30 June to add a reference to the excellent Reuters report on the UK’s coronavirus response.)

Economic inequalities and uncertainties

Just an observation- what to do about inequality is known, what we lack is the political will to act.

On the other hand… I think we have a generation who will no longer stand for inequalities and injustice. In the words of the late Whitney- I believe the children are our future…

I am also concerned about this issue being compounded by the uncertainty of Brexit when the economy was already in jeopardy pre-Covid 19

A perfect storm – austerity, Covid and Brexit

Agreed that much of what to do about inequality is known … as a small example, researchers at the University of Warwick recently showed that just requiring everyone earning more than £100,000 a year to pay an alternative minimum income tax rate of 35 percent would raise around £11 billion per year, without changing the ‘headline’ tax rate.  Raising the rate on high-income earners would further increase fiscal capacity, as would such measures as a one-off wealth tax of the kind proposed by Thomas Piketty as a way of paying off Europe’s rising debts after the 2008 financial crisis … and, of course, curbing tax avoidance by transnational corporations.

Agreed as well about the added uncertainties associated with Brexit.  For example, what happens to the economy of the North-East if the Nissan plant in Sunderland cannot remain viable?  The one bright spot may be what could be done, but probably won’t be, in terms of national economic redevelopment once EU rules on state aid no longer apply.

What we need to do is convince those in power that the health of the poor actually has implications for their wealth and wellbeing.

Ah, but does it?  COVID-19 would appear to prove the point, but consider how much easier it has been for Mr. and Mrs. Range Rover with a house, a garden, high-speed broadband and professional occupations to work from home and reduce exposure risk … meanwhile, the poor and marginalised in service sector occupations that require in-person work and presonal contact are obviously unable to work from home, whilst in many cases more vulnerable to the various comorbidities that appear to increase the severity of infection.

A Basic Universal Income … a ‘healthy response’ to economic and social sustainability?   

Maybe, if it is not seen as a substitute for investment in in-kind social provision (e.g. social housing, public transport, public health programming).  If used as a substitute, a Basic Universal Income could function as a subsidy for private landlords and dodgy second-hand car dealers, with recipients acting as the intermediaries.  I believe a better response is a basic living income floor, delivered to those eligible by way of a refundable tax credit. 

Do we have economic evidence to argue the case for tackling inequality? For example if we introduced a Basic Universal Income does this have a cost benefit analysis that could convince the rich that it is a good idea?

Here, the answer is an emphatic yes – as the OECD, for example, pointed out in 2015 in a report called In It Together: Why Less Inequality Benefits All.  Researchers at the International Monetary Fund have made a similar point about the need for inclusive growth.  The political problem, as economist Branko Milanovic has shown, is that ‘the rich’ may have much more to gain from promoting policies that redistribute income upward, of the kind we have seen in the UK post-2010, than from promoting economy-wide growth.  Building coalitions around the idea of inclusive growth will be absolutely essential if the pandemic is not to have the effect of ratcheting up inequality.

How many gold-plated Lear jets can one have?

Can’t speak to private aircraft, which is not a market in which I window-shop, but readers who love the sea and want to get really frustrated may want to check out the 200 largest yachts in the world.

Rebuilding economy and society: ‘Building back better’

The areas hardest hit economically seem to be in the North, Midlands, coastal areas etc.  Do you have any insights on the impact of governance structures on preparation for and response to the pandemic?  Do countries with more genuinely devolved powers respond better?

A very good question; I’m sure PhD dissertations will be written in the years to come on precisely that topic. 

I think we can only depend upon the local communities. Take Grenfell: Government stood back, community rushed in to support.

The third sector have traditionally always stepped in when the statutory sectors have cut back support/resources.  I’m interested to know what it is that enables the third sector to do this and what are the barriers that prevent the government.

I would agree that a communitarian approach is key. Hoping to appeal to the conscience of the rich seems wasted energy. For those of us in the academy could we try to make the case to our HE [higher education] institutions that working with charities, mutual aid groups and the third sector is part of our civic duty? There are groups, such as APLE and ATD Fourth World, pushing and campaigning hard against the worst effects of inequality.

What does the best response to avoid the potential Russian pitfalls more specifically look like at a local level?

Surely we created a North of Tyne Combined Authority and Northern Powerhouse to take control of our assets and our future. 

Again, all important points.  There are at least two different issues here: (a) local control over priorities for building back, which is essential, and (b) local resources for building back, which are hopelessly inadequate thanks in part to the fiscal evisceration of local government under post-2010 austerity. 

Local governments and entities like NTCA simply did not have the revenue streams or revenue-raising capabilities they needed even before the pandemic, as I pointed out in the presentation. 

I am convinced that the most likely approach to succeed at the national level is a national development bank, with a multi-billion pound initial capitalisation, empowered to lend on concessional (nowadays,  zero-interest) terms and offer direct grants to private businesses and, especially, local authorities for green rebuilding projects, under a streamlined planning process.  (Such rebuilding in war-ravaged Europe was, in fact, the original mission of the World Bank.)  Think what such an institution could achieve with the resources that would otherwise have been committed to HS2 and the road infrastructure necessitated by the third Heathrow runway …

At the international level, a remarkable pre-pandemic blueprint for a global New Deal was produced in 2017 by the United Nations Conference on Trade and Development.  Good ideas are not thin on the ground.

Age and ageing

How do we challenge the ‘othering’ of the elderly and those with pre-existing health conditions? There seems to be a tacit agreement that this is an expendable group.

Do you think ageing populations and care homes being in the spotlight during the pandemic will change how our society sees ageing?

Yes please to an ageing and Covid webinar!

Why have we [collectively] allowed the crisis in the care homes to accumulate over the past few decades?

There’s a cultural ‘groupthink’ that only other people grow old and get ill – ageing is ‘nothing to do with us’. How can we influence people to make the connection to the fact that it’s their own future care that’s in jeopardy?

All excellent points, and it is hard to avoid the conclusion that the elderly have been regarded as expendable, whether infected in care homes (and this has been a scandal throughout most of the high-income world) or effectively, in some countries like the UK, placed under house arrest.  In Canada’s two largest provinces, Ontario and Québec, no one familiar with the long-term care sector’s decades of underfunding, patchwork public/private provision, casualisation of personal support workers and under-regulation was surprised when some facilities turned into charnel houses.  Will this change?  I am sceptical, although encouraged by the creative response of organisations like the International Longevity Centre here in the UK. 

Fighting back, building ahead

How can we ensure that the public health community don’t shy away from the inherently political nature of inequality and its impacts?

How can we come together as a PH community – and bring about change in a meaningful impactful way without falling into a purely political debate which is a distraction from the key debate?

Public health is everyone’s business it will take all sectors working together.

Good questions, although I can’t agree that ‘purely political’ debates are necessarily a distraction.  Choices about who gets how much of a society’s resources, and on what terms, are at the core of politics, and public health risks irrelevance by ignoring them. 

Are we hindered because the Public Health community does not have a collective voice? This completely reduces our influence in the system.

I think the fact that we separate health from public health is part of this problem.  All health is public health. It is a sleight of hand to suggest otherwise.

I’m not sure that the public health community lacks a collective voice.  It has, in the UK, both the Faculty of Public Health and the Royal Society for Public Health.  The problem seems to me rather that highly accomplished public health professionals have been deeply divided about such issues as the unequal distribution of health damage and long-term economic risk associated with the lockdown … which has meant that the political executive can cherry-pick the ‘science’ it wants.  COVID-19 is hardly unique in this respect!  But in the course of spending far too much time reading media coverage of the pandemic, I’ve been struck by the extent to which The Telegraph ‘got’ the issue of unequal damage from lockdown, and The Guardian didn’t. 

I have a question following on from above – what do you see as the key points and forms of resistance to this?  Especially given the positions of many governments, not least in the UK.

I’m very concerned that these stark inequalities are fuelling reactionary far right wing populism / nationalism / patriotism – and the current government are happy to let this narrative run. Any ideas of how this can be challenged?

I wish I had better answers; hopefully the important dialogue that Fuse has initiated will contribute to developing them, as will a revival of critical thinking in UK universities.  As a political scientist, I have to observe that one of the undesirable characteristics of Westminster-style parliamentary systems is that a government with a legislative majority is so impermeable that it functions as an elective monarchy, in this case with a term of office that runs until the end of 2024. 

What can universities contribute to the resistance of this future in terms of our teaching?

Education has been commodified and is not about transformation. We need to address who can access education and what is provided when they get there … thinking Pedagogy of the Oppressed.

These are of course critically important questions, about which (in particular) Stefan Collini and Lawrence Busch have written brilliantly.  More recently another Canadian (like myself), retired legal scholar Philip Slayton, had this to say:

‘A curious and well-informed mind is a free mind, and a person with a free mind is a free person; creating this free person is what education, particularly postsecondary education, is meant to do. Universities need to reject a corporate consumer-driven model; a student is not a “client.” Universities must eschew misguided vocationalism, emphasize the development of critical thinking – in particular, the ability to distinguish between a good argument and a bad argument – and recognize that society needs dreamers at least as much as technicians. They need a fee structure that makes postsecondary education available to all without career-distorting long-term debt. And they need to welcome the expression of all views, even extreme ones.’

Realism versus Monbiot: Thoughts on possible worlds of post-pandemic reconstruction

George Monbiot is only one of many commentators who have argued the need for a post-pandemic programme of economic reconstruction that will address environmental concerns as well as the imperative of restoring and securing the livelihoods of literally hundreds of millions of people. The importance of this latter imperative cannot be overstated. In the US alone, unemployment by the end of April quadrupled to 14.7 percent, with 20.5 million jobs lost.  In the UK, the Bank of England has warned of a doubling of unemployment to nine percent and a shrinkage of the economy’s overall output to a 300-year low.   The UK unemployment figures are less horrific than they otherwise would be because of a massive debt-financed programme of wage and salary compensation that the Chancellor of the Exchequer has correctly characterised as unsustainable. 

Against this background, Monbiot (and I am not picking on him here; he is rather the most articulate and best informed proponent of this perspective, and therefore the most difficult target) argues that ‘[g]overnments should provide financial support to company workers while refashioning the economy to provide new jobs’ outside the automobile, fossil fuel and airline industries.  It is now a commonplace that after the financial crisis of 2008, governments bailed out many of the financial institutions that had caused the crisis – that is, their shareholders, managers and workers – rather than those who bore the worst consequences.  Monbiot argues that: ‘This is our second great chance to do things differently’.  But with government debt and expenditure levels relative to GDP already approaching twentieth-century wartime levels, just to finance short-term remediation, the unavoidable question is:  do things differently with what? And where will the investment necessary for such new jobs, and the financing needed to support workers’ transition to them, come from?

It is nice to envision, as a team of luminaries including Nobel laureate economist Joseph Stiglitz and climate economics authority Sir Nicholas Stern has recently argued based on an expert survey, that post-pandemic reconstruction can contribute to reducing climate impacts through investment  in ‘clean physical infrastructure, building efficiency retrofits, investment in education and training, natural capital investment, and clean R&D’, whatever that is.  The authors do not explain where the money will come from, in a world where the estimated US$2.5 trillion annual investment needed to meet the Sustainable Development Goals before the pandemic was nowhere in sight.

It is possible, in theory, to envision mobilising the needed resources by way of income and wealth tax rates that were prevalent after the Second World War, responding to wartime government debt and expenditure levels.  Many of these are now probably infeasible because of the concentration of ultra-wealth in financial instruments and tax haven real estate, and because of possibilities for capital flight that can best be limited through transnational cooperation in a world where a corporate-financed US Congressional candidate has claimed that ‘[f]reedom and democracy are best secured when banking secrecy and tax havens exist’.

If the ultra-rich are probably beyond the reach of national public policy, then the menu of policy options shrinks considerably.  When many dividends have already been cancelled, whose income does Monbiot propose to reduce, whose assets to tax or seize, and how?  What happens to firms that cancel dividend payouts when investors flee their shares, making it impossible for them to raise new capital in response to lockdown-created shortfalls?  How can green jobs be created by seizing foreign oligarchs’ London property holdings, their financial assets having long ago been safely shifted elsewhere?  How many of the Russell Group universities’ 508 senior staff who were paid more than the prime minister in 2018-19 will agree to salary cuts or marginal tax rate increases for the greater good?  Will their response be representative of their broader posh demographic?  Will clinicians who own second homes be content with strongly progressive taxation of their increased value over the years?  What are the legalities of much-needed retrospective wealth taxation?

In short: How are these dreams to be paid for? 

These are not rhetorical questions, and they should be the starting point for conversations that substitute serious consideration of political economy for cheerleading. Even in high-income countries, the post-pandemic menu of policy options is likely to be circumscribed by the International Monetary Fund’s role as a gatekeeper to financial markets – a role that low- and middle-income countries (LMICs) have experienced with often bitter consequences over the past decades, with the impacts compounded by capital flight.  Given the dire situation of LMICs, what justification can the high-income world offer to the world’s majority outside its borders for not taking advantage of fossil fuel prices that have sunk to the pre-1973 levels that enabled today’s rich to get that way, unless its development assistance agencies and investors are willing to increase their commitments by at least an order of magnitude?   Such conversations may have begun, but I am not hearing them. 

Virus reads from around the web

Intriguing looks at the Swedish approach to pandemic response from Vanity Fair and Nature

An argument that the pandemic is revealing varieties of ‘structural violence’ by government including the UK’s neglect of its health services under austerity, by two professors at Queen Mary University London (this is from Counterpunch, which has provided numerous valuable commentaries on the politics of the pandemic)

A debunking of the idea that UK government is ‘following the science’, pointing out that this claim doesn’t even make sense in the uncertain world of public health policy

And a fine, plain-language guide to the wonderful world of World Health Organization decision-making and finance

Against Covid-19 fetishism, and other musings

Herewith a few equity- and policy-oriented musings about the latest state of the pandemic world.

1.  Media, and many researchers who should know better, seem obsessed with the number of deaths from Covid-19, or associated with Covid-19.  Good reasons exist to want to know this over the short term, for purposes of tracking the spread of the virus, but apart from the fact that in most countries the current chaos makes it impossible accurately to determine this number, it is largely irrelevant in terms of the overall health impacts of the pandemic.

The most basic indicator that matters is the all-cause mortality rate (age-adjusted or not, and both figures should be presented), and the inequalities in this indicator amongst various age, class, gender, race/ethnicity and regional demographics. Over time, all-cause mortality rates will reflect not only the short-term health system dislocations and dysfunctions associated with the pandemic, but also the longer-term impacts on social determinants of health of the depression that will follow the lockdown. In a few years, those of us still alive will be able to compare the effectiveness of various national responses … and to restate a point it is all-cause mortality, and not the number of deaths directly attributable to Covid-19 or among people tested positive, that matters. Dead is dead, whatever the cause.

2.  In the UK, I continue to be baffled by the utter lack of comprehension among people professing a concern for equity of what economic downturns of the magnitude now apparently envisioned by Treasury – and of course these anticipations are all dependent on the assumed length of the lockdown, the nature of the exit strategy, and the economy’s subsequent response – will mean for everyday life and for the economic substrates of health inequalities.  The cynical me suspects that most people in a position to prognosticate with anyone paying attention have gardens and can comfortably work from home, unlike much of the rest of the population.

Let me suggest just one example of probable impacts:

Concern about the fate of high street commerce has long been unmatched by meaningful policy response.  Mr. and Mrs. Range Rover, who matter most in political terms, usually shop online or in the suburbs.   Post-pandemic, for hard financial reasons, it is likely that local authorities will simply cease providing services to low-occupancy commercial high streets, and utilities will be released from whatever obligations they have to provide services in those areas.  There will be few users, and fewer still who are able to pay their bills or council taxes. 

A fantasy?  Not at all.  A variant of this policy was partially adopted as “planned shrinkage” in New York City in the 1980s, and much more recently in post-bankruptcy Detroit.  There will be no-go high street wastelands of abandonment, at least until some far distant future when they will become attractive for reinvestment (beyond the lifetimes of many of us).

Alternatives can be imagined, in abundance (and will be the topic of a future post), but it is hard to think that any UK government will pursue them in the near future, especially as the country’s post-pandemic economic policy may well be managed jointly by the International Monetary Fund, as gatekeeper, and China, as the only external actor with the resources necessary to provide direct investment on the scale necessary.

3.  Even if the UK’s post-Brexit departure from the single market and customs union is delayed, as it should be, the full scope of the dislocations will become clear at the start of next winter, when it becomes clear how many Britons simply cannot afford to heat their homes.  Watch the all-cause mortality rate carefully as that happens. 

This post was updated on 15 April.

The Sounds of Silence: Lack of concern for post-pandemic economic and equity impacts

Like many colleagues, I have spent the past decade and a half mainly investigating the way in which macro-scale economic and social conditions and policies affect health by way of the unequal distribution of exposures, vulnerabilities and opportunities – the social determinants of health.  The way in which authorities in the UK and elsewhere have responded to the coronavirus pandemic cries out for analysis from this perspective.  Yet most colleagues’ silence has been deafening.  Why?

After all, to stay with the UK situation for the moment, the best post-pandemic outcome that can be anticipated is a prolonged recession, the consequences of which will be distributed unequally.  Despite temporary assistance, many small businesses will not reopen, and many workers will exhaust temporary supports as their employers fail.  After a decade of austerity local authorities are, to put it mildly, ill situated to provide necessary assistance.  Such predictions are necessarily cast in general terms.  Modelling the behaviour of economies is even more difficult than modelling epidemics of communicable disease, not least because external influences outside the control of even the best intentioned national policy-makers are more significant.  Yet the population health community in the UK has been almost completely silent on these issues. 

I suspect that part of the answer has to do with apprehensions about being identified with arguments for cautiously restarting the economy that mainly originate from the political right, like Gerard Lyons’ piece in The Telegraph or President Trump’s (in)famous statement that the cure cannot be worse than the disease – which, taken at face value without regard for its deranged originator, is unexceptionable.  In the political arena, such an apprehension may be behind newly anointed Labour leader Sir Keir Starmer’s inexplicable and seemingly reflexive support for the Health Secretary’s threat on 5 April to ban all outdoor exercise if lockdown rules are not followed – a threat that probably has no basis in statute, and if carried out certainly could undermine the rule of law and citizens’ faith in it.  There are sound arguments and important research questions here, about who will bear the financial costs of a prolonged lockdown and their health consequences, which have not been taken seriously enough by colleagues.

Quite apart from the material deprivation that can be anticipated as a consequence of potential economic collapse, there is the ‘loss of control over destiny’ about which Dame Margaret Whitehead and colleagues have convincingly written.  Their important analysis operates on multiple scales, with the paradigmatic example of ‘pathways from traumatic social transition to poorer population health’ being the implosion of the former Soviet Union.  An implosion of comparable severity, with oligarchs the primary beneficiaries, can be envisioned in the UK if both the pandemic and the retreat from lockdown are mismanaged.  ‘Save lives at any cost’ is an emotionally appealing mantra, but no society anywhere, ever, has operationalised this at a population level. Destroying an economy itself has health consequences, the distribution of which will be highly unequal. An Institute for Fiscal Studies briefing shows that the lockdown will hit young workers, low-income workers and women the hardest. Impacts will also be spatially differentiated: Important research by Elena Magrini at the Centre for Cities identifies dramatic differences among cities in how many workers can adapt to work-from-home routines – or, alternatively, are vulnerable to job loss or disease exposure if they work in the essential sectors that are the unsung heroes of the pandemic. The credibility of all researchers concerned with health inequality will be defined in the coming months and years by how seriously we took these differences, and their implications for equity-oriented health, social, and economic policy – in the first instance, the design of exit strategies from the lockdown that is today in place. Those of us who did not take them seriously will no longer deserve an audience.

This post was updated on 6 April 2020.

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