Tag Archives: austerity

COVID-19, state desertion and neoliberal epidemics

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

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

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

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

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

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

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

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

Marmot +10 and the grim prognosis for health equity

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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

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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 … 

Why no talk of an inequality emergency?

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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,  

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

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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.

Public finance and public health

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I have argued for many years that public finance is a public health issue.  Against the odds, this view appears to be gaining credence.  The Disease Control Priorities Project is a massive effort to identify the most ‘cost-effective’ options for improving health, funded by the Bill and Melinda Gates Foundation and organised by the World Bank.  The authors of a summary of its nine volumes of recommendations argued that ‘[i]n all likelihood, the finance ministry is the most important ministry (after health) for improving population health’.  Their argument related mainly to the options for taxing such health-destructive commodities as sugary drinks, while reducing subsidies on fossil fuels.  These are all laudable and important objectives, but we must go further.  Finance ministries are the most important ministries for improving population health – first, because they determine the budgets available to health ministries; second, because their policies determine the capacity of governments to meet health-related economic and social policy objectives (through taxation) and the distribution of the benefits of those policies (through their expenditure priorities).

In the United Kingdom, since 2010 we have witnessed an especially striking illustration of this point.  Tax and benefit policy changes have substantially reduced the incomes of those households near the bottom of the economic distribution, with minimal impact on those near the top.  Food bank use has increased sharply, and this is almost certainly only the tip of the health impact iceberg; the most deprived local authorities, which derive much of their income from central government, have been hit hardest by budget cuts and are closing libraries and preventive services like smoking cessation, even as the National Health Service simultaneously cuts back on stop-smoking prescriptions.  Indeed, the NHS as a whole is in a state of continued crisis because of government’s unwillingness to provide adequate funding from general tax revenues.  Meanwhile, corporate tax policy allows firms like Amazon to pay minimal taxes in the UK, even as their low operating costs – thanks to a perverse structure of business rates (taxes) – contributes to the destruction of high street retail.  This is likely to have at least indirect health consequences, for example as town centre dwellers whose age, abilities or finances mean they cannot hop in the car and drive to a suburban shopping park lose ‘control over destiny’.

Against this background, central government continues to commit tens of billions of pounds to megaprojects like high speed intercity rail lines and foreign-built atomic power stations.  (Since this posting was written, George Monbiot has pointed out in The Guardian that a motorway from Oxford to Cambridge is likely to be added to the craziness.)  If the World Health Organization’s important message of health in all policies had been taken seriously, at the very least we would have independent, peer-reviewed health impact assessments of these expenditures, including alternative uses of the funds committed and of the ‘do nothing’ option.  Based on decades of experience with environmental impact assessments, these are essential.  Such assessments are nowhere to be found; health economists’ ritual incantation that resources are limited so priorities must be set clearly does not apply here.

All this will be familiar even to casual observers of UK politics, and has parallels elsewhere, although the public health community has too often remained silent about them.  At the same time, once-radical perspectives on the revenue side of the fiscal policy equation are moving into the mainstream of policy analysis, if not yet of politics.  In 2013, the former head of Canada’s national public service and his son published a powerful edited volume called Tax is Not a Four-letter Word, and decried Canada’s ‘dangerously distorted tax conversation’ – sadly, to little effect.  In February 2018, The Economist warned that ‘[I]f Britons want good public services’ as an alternative to the current collapse, then ‘they will need to pay more’ and hinted at the need for some form of wealth taxation.  In August, it was more explicit.  A leader noted that ‘Amazon’s British subsidiary paid £1.7m ($2.2m) in tax last year, on profits of £72 m’ – an effective tax rate of less than three percent.  The leader also foregrounded the need to tax windfall gains from rising property values ‘in big, global cities’ – which without an effective inheritance tax regime will magnify economic inequalities across generations –  and to reform corporate tax regimes to address the ability of firms like Amazon to shift their revenues to low-tax jurisdictions.  Further, it noted that ‘[a]s the labour market continues to polarize between high earners and everyone else’, with labour’s share of national income in much of the world in a decades-long decline, ‘income taxes should be low or negative for the lowest earners’.  A briefing in the same issue explores one intriguing option – a land value tax, which would capture windfall gains in prosperous areas – in considerable detail.  (Today, taxes on residential property in England and Scotland are assessed on real or hypothetical value in 1991, with a capped ‘top band’ that corresponds to just a small fraction of today’s seven- and eight-figure prices.)

Unfortunately, The Economist did not extend its analysis to such policy options as comprehensive wealth taxation or higher marginal tax rates and alternative minimum taxes on high-income individuals.  Nevertheless, its critical attention to public finance offers the possibility that ‘distorted tax conversations’ may become less so – offering prospects for reducing health inequalities by way of their essential economic substrate.  In these grim and disturbing times, we must seek faint hope where we can.

This posting appears as well on Policies for Equitable Access to Health.

Through the looking glass … in the spirit of Eduardo Galeano

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The remarkable Uruguayan essayist and journalist Eduardo Galeano was a relentless dissector of what Serge Halimi of Le Monde Diplomatique has called ‘the inequality machine [that] is reshaping the planet’.  Here is an example, written about Caracas circa 1971.  Even before the 1973 quadrupling of oil prices, Venezuela’s oil production had made it one of the least poor economies in Latin America.  However, most of the revenues were extracted by transnational corporations like Exxon, Gulf Oil and Royal Dutch Shell, and what wealth remained in the country was highly concentrated.  ‘While the latest models flash like lightning down Caracas’s golden avenues’, wrote Galeano, ‘more than half a million people contemplate the wasteful extravagance of others from huts made of garbage’.  The relation between automobiles and social exclusion, both symbolically and by way of transport infrastructure choices that are literally cast in concrete, was a consistent theme in Galeano’s work.  ‘[T]he city is ruled by Mercedes-Benzes and Mustangs’, he wrote.  ‘In Caracas, enormous and expensive machines abound for producing pleasure or speed or sound or light. Like poor frightened ants we face these machines and wonder: “Jesus, is each of these really worth more than me?”’

This sounds like a rhetorical question, but decades later, it provides a useful window into twenty-first century inequalities.  At the start of this decade, the best available research suggests that the median household wealth of the UK population was around £80,000.  In other words, half of all UK households ‘were worth’ less than that.  A knowledgeable petrolhead can stand on a kerb in London, and many other major British cities, and in ten minutes or so point out numerous cars and SUVs that cost more than £80,000.  (Non-petrolhead readers who doubt this should pick up a copy of Evo or Octane at their local newsagent’s.)  So the answer to Galeano’s question, in the UK context, is clearly affirmative.  Such grounded comparisons arguably tell us more about the real world of inequality than abstractions like Gini coefficients.

Galeano’s Open Veins of Latin America appeared in English in 1973, just before the US-supported coup d’état that turned Chile into a bloody showcase for neoliberal policies.  It was a text in the undergraduate development studies course that forever transformed my provincial outlook on world affairs.  I have been re-reading his more recent Upside Down: A Primer for the Looking-Glass World, which appeared 20 years ago – and, chillingly, reminds us that a 1997 New York Times article praised the coup as beginning ‘Chile’s transformation from a backwater banana republic to the economic star of Latin America’.  The book swings between savagery and satire (on the media and Monica Lewinsky: ‘I think something else happened in 1998, but I can’t remember what’) and I find myself wondering how Galeano – who died in 2015 – would regard the era of Brexit, Trump, and a decade-long retreat from the always fragile institutions of democracy into the authoritarianism that repeatedly forced him into exile.   

He noted that Saudi Arabia’s role as one of the world’s largest customers for the arms trade appeared to confer immunity from criticism of its deplorable human rights record.  Plus ça change … Already, Galeano was concerned about the spread of surveillance. ‘Is there an eye hidden in the TV remote control?  Ears listening from the ashtray?’ What would he make of Alexa?  Or of the fact that it is possible to access detailed personal information about almost 300,000 people (contacts of contacts) through a single Facebook account, as the New York Times has shown, and few users seem to care?

Galeano memorably described globalisation as ‘a magic galleon that spirits factories away to poor countries’, noting that the resulting ‘[f]ear of unemployment allows a mockery to be made of labour rights.  The eight-hour day no longer belongs to the realm of law but to literature, where it shines among other works of surrealist poetry,’ as ‘the fruits of two centuries of labour struggles get raffled off before you can say good-bye’.  Here is one of several sobering reminders that key understandings of how the inequality machine operates were in place two decades (or more) ago; many social scientific advances since then involve refinement and body counting.

Galeano was similarly eloquent about  the dangers of finance capitalism, as it shifted power and accountability towards ‘the markets’ that often dictate terms to national governments, and spawned a proliferation of tax havens and obliging facilitators seeking to protect kleptocrats’ looted billions.  How would he now regard the revelations in the Panama Papers and Paradise Papers?  Or look back on the financial crisis starting in 2007 that turned into a US$14 trillion hostage taking that debilitated many national economies, ratcheted up inequality and created the political opening for the destructive post-2010 trajectory of UK austerity?  Galeano correctly notes that Margaret Thatcher ‘ran a dictatorship of finance capital in the British Isles’; this was the start of a rapid rise in inequality … but what would he make of Danny Dorling’s recent argument that the situation worsened on New Labour’s watch?  And how would he respond to an inequality in male life expectancy at birth in the small local authority of Stockton-on-Tees, where I live, that by 2015 was comparable to the difference in national averages between England and Tanzania?  This is another one of those important grounded comparisons.

The World Health Organization’s Commission on Social Determinants of Health reminded us a decade ago that health inequalities are underpinned by ‘the inequitable distribution of power, money and resources’.  Reducing those inequalities first of all demands speaking truth about power.  Galeano excelled at this, sometimes at considerable cost to his own safety; scathing description of the impunity enjoyed by the powerful was a consistent theme in his writing about Latin America, both during periods of dictatorship and after transitions to democracy.  He might have been pleased by today’s partly successful challenges to the massively corrupt Odebrecht combine , while simultaneously appalled by the failure to act on the continuing scandal of tax havens and by the alliance of big data and big money in the dissemination of disinformation and ‘fake news’ through social media.  This is a new form of coup d’état that social scientists are still learning to take seriously.

In these times of cynicism and resignation, the example of Eduardo Galeano’s courage and moral imagination is more valuable than ever.

Key references

Galeano, E. (1973; Spanish publication 1971).  Open Veins of Latin America: Five Centuries of the Pillage of a Continent [tr. C. Belfrage].  New York: Monthly Review Press.

Galeano, E. (1992). We Say No: Chronicles 1963-1991 [tr. Mark Fried and others]. New York: W.W. Norton [this is the source for the Caracas description].

Galeano, E. (2000; Spanish publication 1998). Upside Down: A Primer for the Looking-Glass World [tr. Mark Fried]. New York: Picador.