The Covid-19 pandemic as tipping point (Part 2)

Acknowledgement:   This commentary was originally written for Policies for Equitable Action on Health.  It reposted here with some additional material with the kind permission of Daniele Dionisio, who runs PEAH.  Further republication consistent with the Creative Commons licence that applies to my entire blog is encouraged.

Introduction: The pandemic and the perils of averages

Figure 1.  Downtown Montréal, March 2023.  Photo: T. Schrecker

I wrote part of this post during my first post-pandemic visit to Montréal, a Canadian city that I love and once called home.  It has not been easy.  While many affluent parts of the city have largely regained their pre-lockdown vibrancy, other districts are now populated mainly by vacant shop fronts (Figure 1).  At the same time, sometimes almost next door, numerous glittering condo towers soaring as high as 61 storeys are under construction (Figure 2).  They are beyond the financial reach of most of the city’s residents, trapped like other Canadian city dwellers in a deepening crisis of housing affordability, which is part of a more general and widespread cost-of-living crunch. 

Policy analysts are lauding governments – and some governments are congratulating themselves – for having sidestepped the cataclysmic lockdown-induced recession that it was reasonable to anticipate (as I did) in the first months of the pandemic.  In both the United States and Canada, temporary responses to the pandemic reduced officially defined poverty rates to a degree that would have been highly improbable under less extreme circumstances.  The US Federal Reserve’s annual survey of households in 2021 found the highest levels of several indicators of financial well-being since the survey began in 2013. On the other hand, in the United Kingdom child poverty (and therefore family poverty) has continued to increase and deepen through the years of pre-pandemic austerity and since then.  

Figure 2.  Downtown Montréal, March 2023.  Photo: T. Schrecker

As this observation suggests, whatever the view from 30,000 feet, ‘on the ground’ the consequences of the pandemic can look very different.  Very early on, data from Montréal made it clear that the impacts of the pandemic were stratified by class and race (Figure 3).  Cities like Montréal may ‘recover,’ in a statistical sense, but many of the businesses that thrived there and the households that lived there are not likely to do so.  There is an important methodological point here.  As in any other inquiry related to the social determinants of population health, averages can be fatally misleading.  Eduardo Galeano wrote: “Where do people earn the Per Capita Income? More than one poor starving soul would like to know.”  Aggregates and averages cannot tell the story of life in a city where buyers of million-dollar condos move in, as tenants dispossessed by a wave of ‘renovictions’ move out.  Here is yet another illustration of why the tipping point concept is important.  Before the pandemic, researchers were writing about gentrification and “condoization” in Montréal.  The pandemic and policy responses to it have accelerated the processes, and as elsewhere magnified the impacts on inequality.  These are likely to be intractable and intergenerational.

The return to business as usual

The pandemic transiently made radical expansion of the realm of the possible in economic and social policy seem plausible.  While rhetoric about “building back better” proliferated, two detailed and thoughtful proposals in this vein actually appeared in 2019.  The annual Trade and Development Report of the United Nations Conference on Trade and Development (UNCTAD) called for a global Green New Deal organized around raising labour’s share of incomes worldwide, raising additional revenue to support fiscal stimuli, and expanding public investment in clean transport and energy systems and sustainable food production.  Also in that year, British historian Simon Szreter and colleagues published a prize-winning UK-focused proposal for “incentivizing an ethical economics” organized around raising taxes to invest in sustainable growth and offering universal care provision in old age – a “new social contract” and “new intergenerational contract”. 

Taking seriously building back better means, in the words of iconoclastic economist Mariana Mazzucato, “we need to radically reform and rearm the state.”  It is not as if the necessary policy instruments are unavailable, be they the public development banks to which UNCTAD devoted an entire chapter of its 2019 report; the range of measures described by Szreter and colleagues; or – to use an example from close to home – the housing co-operatives that provided affordable housing to many Canadians before senior levels of government abandoned the housing sector to market forces.  Especially in an age of long-term geopolitical instability, calling for more rather than less spending on defence, using those instruments to ensure that “the costs and benefits of a green transition are distributed equitably across society so that social injustices are tackled alongside environmental crises” (to quote Mazzucato again) will require substantial new revenue streams mobilized through progressive taxation. 

Both UNCTAD and Szreter and colleagues emphasized the importance of this point, as did later analyses.  In 2020, as the scale of the pandemic’s impacts was already becoming clear, UNCTAD argued that “[in] light of the further increase in inequality resulting from this crisis the case for a wealth tax seems irrefutable.”  Even the Financial Times’ editors conceded that wealth taxes would “have to be in the [policy] mix” (paywalled).  Since then, policy silence on this point has usually been deafening.  US president Biden’s March, 2022 legislative proposal to levy a minimum tax on the ultra-rich and to tax unrealized capital gains on financial assets was a striking outlier, although the perverse structure of Senate representation doomed it from the outset.  Improbably, the UK’s Conservative government in November, 2022 introduced incremental tax changes that slightly reduced the preferences granted to the ultra-rich and lowered the level at which the highest marginal income tax rate applies, but will do nothing to reverse the magnification of inequality and hardship during the pandemic.  More conspicuously than in the aftermath of the 2007-2009 financial crisis, innovation has been abandoned and policy – in particular, commitment to reducing inequality – reset to business as usual in a wave of what the Roosevelt Institute in the US has called zombie neoliberalism

The reset is perhaps not surprising given the outsized and growing influence of money in politics, as described by Brooke Harrington, Jane Mayer, and Peter Geoghegan among many others.  Catherine Belton has focused on how Russian flight capital influenced British politics as it penetrated London property and financial markets, and in an important comparative study US political scientist Larry Bartels found “remarkably strong and consistent evidence of substantial disparities in responsiveness to the preferences of affluent and poor people. Insofar as policy-makers respond to public preferences, they seem to respond primarily or even entirely to the preferences of affluent people.”  This dynamic is likely to be more powerful than ever in a more unequal post-pandemic world where resistance emanates not only from transnational corporate tax avoiders and the one percent with their hypermobile assets, but also a substantial stratum of newly enriched property owners with an expanded stake in financialized housing markets. 

It is therefore dispiriting but arguably predictable that (for example) Britain’s opposition Labour Party has recently tried to lower expectations of future change, its leader “constantly calculating which of the people desperately awaiting his government he can afford to ignore because they have no powerful advocates” in the words of eloquent Guardian columnist Nesrine Malik.  The answer, probably, is most of them.  One must hope that such efforts fail, yet at the same time contemplate with unease the politics of desperation that the future is likely to bring. 

The Covid-19 pandemic as tipping point (Part 1)

Acknowledgement: This commentary was originally written for Policies for Equitable Action on Health.  It is reposted here with the kind permission of Daniele Dionisio, who runs PEAH.  Further republication consistent with the Creative Commons licence that applies to my entire blog is encouraged.

I began a (pessimistic) 2022 book chapter on the prospects for ‘building back better’ after the Covid-19 pandemic by quoting the first sentences of J.G. Ballard’s magnificent dystopian novel High-Rise:

Later, as he sat on his balcony eating the dog, Dr Robert Laing reflected on the unusual events that had taken place within this huge apartment building during the previous three months.  Now that everything had returned to normal, he was surprised that there had been no obvious beginning, no point beyond which their lives had moved into a clearly more sinister dimension.

The giveaway word here is “normal,” and the new normal to which Laing’s world has returned is one in which a deadly class war between the affluent and even more affluent residents of a 40-story tower block has completely destroyed the interior of the building and most of its vital systems, and survivors are reduced to killing and eating the pets of their less fortunate neighbours.  In a scene near the end of the novel, surviving children play with human bones in the tower block’s rooftop sculpture garden.

This rather dramatic introduction was designed not to suggest that post-pandemic societies will literally regress to that extent, although that could happen in some contexts, but rather that conditions of life that come to be regarded as normal in the post-pandemic world will probably look very, very different from those of late 2019, and for most of us more insecure and threatening.  I am more convinced of this now than I was when I wrote the chapter. 

In a recent conference paper, I argued that the pandemic should be understood as a tipping point, initiating processes that magnify and accelerate existing trends, in particular those involving rising inequality and its direct and indirect effects on health. The concept of a tipping point is used in several, slightly different ways depending on context, but it is now most familiar from research on climate change.  Leading climate researcher Timothy Lenton explains: tipping points “occur when there is strongly self-amplifying (mathematically positive) feedback within a system such that a small perturbation can trigger a large response from the system, sending it into a qualitatively different future state.”  Stated more colloquially, “sometimes little things can make a big difference,” or at least a disproportionate difference, “to the state and/or fate of a system.”  

Figure 1.  Schematic representation of cascading effects in the vegetation–rainfall system

(a) Vegetation–atmosphere system in equilibrium. (b) Initial forest loss triggered by decreasing oceanic moisture inflow. This reduces local evapotranspiration and the resulting downwind moisture transport. (c) As a result, the rainfall regime is altered in another location, leading to further forest loss and reduced moisture transport.  Reproduced without change from Zemp, D. C., Schleussner, C. F., Barbosa, H. M. J., Hirota, M., Montade, V., Sampaio, G. et al. (2017). Self-amplified Amazon forest loss due to vegetation-atmosphere feedbacks. Nature Communications, 8, 14681 under a Creative Commons Attribution 4.0 International Licence.

An especially striking example is provided by deforestation in large tropical rain forests (Figure 1).  As much as half of the precipitation that falls on such forests originates from evapotranspiration within the forest itself.   The concern is that deforestation resulting from human activity (forest clearance) will combine with reduced oceanic moisture inflows to lead to a tipping point in which reduced rainfall accelerates forest dieback, and the rain forest transitions to savannah or steppe.  This will itself accelerate climate change, as the forest no longer provides a carbon sink.  Researchers write that findings about multiple processes of this kind “imply that shifts in Earth ecosystems occur over ‘human’ timescales of years and decades, meaning the collapse of large vulnerable ecosystems, such as the Amazon rainforest and Caribbean coral reefs, may take only a few decades once triggered.”  This is a long time in the context of such phenomena as election cycles, but an eyeblink in geological time.  Whatever the time scale, once a tipping point has been reached, the pace of changes that were already under way accelerates rapidly, and entirely new changes may begin.

My pre-retirement colleague Clare Bambra and colleagues have provided an especially compelling account of how distribution of health outcomes during the pandemic reflected and magnified economic inequalities (open access, and essential reading). Looking ahead, here are a few of the patterns (far from an exhaustive list) that suggest the value of considering the pandemic as tipping point:

  • Concentration of wealth at the very top of national and global economic distributions: The number of US dollar millionaires worldwide increased from 46.8 million in mid-2019, the last pre-pandemic year, to 62.5 million in 2021.  This growth was fuelled by rising share prices, but also by
  • Soaring property prices in much of the world.  US homeowners saw their wealth increase by more than US$6 trillion between the start of the pandemic and the third quarter of 2022; average house prices across Canada’s 15 major metropolitan areas rose by as much as 45 percent between 2019 and 2021, depending on distance from the city centre.  The ‘flip side’ of this pattern, which began before the pandemic but was accelerated by it and is repeated in many European centres, is
  • A growing pattern of unaffordable housing and semi-permanent housing insecurity, underpinned by the financialization of housing, which also predates the pandemic and led one group of Australian researchers to conclude that: “sustained inflation of property values … has fundamentally shifted the social class structure, from a logic that was structured around employment towards one that is organized around participation in asset ownership and appreciation.”
  • Housing prices are an important part of a larger cost-of-living crisis, originating in supply chain disruptions associated with the pandemic and worsened by Russia’s invasion of Ukraine and its weaponization of energy exports.  Interest rate increases – a conventional central bank inflation-fighting tactic – cannot address these impacts because they have no effect on supply, and in fact are likely to magnify inequality, as they raise the cost of consumer debt and are passed through to consumers by producer firms.
  • In a global frame of reference, countries differed in the fiscal capacity they were able to deploy in initial responses to the pandemic, which will probably lead to increased inter-country inequality.  Further issues arise from what could be
  • An impending sovereign debt crisis for many countries; before the pandemic the sovereign debt load of countries in sub-Saharan Africa, the world’s poorest region, was more than twice its nominal value in 2009, the year after the financial crisis.  In early 2023 the American Public Health Association called on the International Monetary Fund, World Bank and G20 “to eliminate debt for the poorest countries and expand fiscal space for public financing of health services and public health programs.”
  • Finally, of course, there are the effects of climate change on various social determinants of health, including food security.

The World Economic Forum’s 2023 Global Risks Report devoted an entire chapter to the concept of “‘polycrisis’ – a cluster of related global risks with compounding effects, such that the overall impact exceeds the sum of each part.”  This is a useful way of capturing the interactions discussed here, yet at the same time we must acknowledge that many trends in question will present as crises for many, and opportunities for others.  (Housing price escalation is a case in point.) 

            Perhaps my view of the future is excessively bleak.  After all, high-income countries were able to buffer many of the pandemic’s economic effects, and the US improbably experienced a substantial, if temporary, drop in poverty.  The situation outside the high-income world was, and is, considerably more grim, like the “vaccine apartheid” that has now largely faded from public consciousness, reflecting the multiple dimensions of global inequality and the relative invisibility of the global majority.  Numerous blueprints, some quite detailed, exist for ‘building back better’.  The second part of this posting will direct readers to a few of these; assess some of the formidable political obstacles to their realization against the background of rising inequality; and offer a few conjectures about health in the post-pandemic new normal.  

Globalization and health: Now more than ever, a need for scepticism and multidisciplinarity

We who have been working in global health for a long time will recall Richard Feachem’s 2001 argument that ‘Globalisation is good for your health, mostly’.  The claim was that the economic growth stimulated by globalization – specifically, increased volumes of trade as a share of a country’s gross domestic product (GDP) – reduced poverty and increased resources available for providing health care.  Although the role of poverty as a primary determinant of ill health is beyond dispute, later assessments called into question both the World Bank data on trade flows and growth on which Feachem relied and the necessary connection among economic growth, poverty reduction and better health.  The work of historian Simon Szreter is especially noteworthy on this latter point.

More than 20 years on, it is disturbing to find The Economist’s leader writers ignoring much of the evidence that has since accumulated about the questionable human benefits of globalization.  Instead, they call (in the weekly’s January 14 issue) for governments to reject such policies as national or regional industrial strategies in a world that has been transformed by the pandemic and the knock-on effects of Russia’s invasion of Ukraine.  The claim in the leader and accompanying briefing (which, to be fair, is considerably more nuanced) is that only renewed efforts to support the global reorganization of production that has occurred over the last four decades or so, in the name of economic efficiency, will continue past progress in reducing poverty and render less formidable the costs of decarbonizing the world economy.

Neither the desirability of reducing poverty nor the imperative of decarbonization is in question, but globalization in anything like its pre-pandemic form is as likely to make things worse as it is to make things better, with important implications for the health of people worldwide.  

Let’s take the decarbonization claim first.  In 2020, the United Kingdom’s National Audit Office (NAO) produced a remarkably detailed examination of the economic and societal changes that will be needed if the UK is to reach its stated goal of ‘net zero’ emissions by 2050.  Any thoughtful reader of this report, which can serve as a model for similar analyses elsewhere, will conclude that market theology of Ayn Randian proportions is required to sustain belief that so-called free markets will do the job.  Creative, thoughtful dirigisme across a range of sectors will be necessary, although not sufficient.  The same is true of any other complex economy one can think of.  The work of innovation scholar Mariana Mazzucato is especially persuasive on this point, and on the misguidedness of past decades’ market fundamentalism more generally.  

Then, there is the claimed connection between globalization and poverty reduction.  Based on the World Bank’s contentious definition of extreme poverty, the meanness of which was commented on by The Economist itself in 2016 (‘It is hard to imagine how anyone could subsist on so little’), hundreds of millions of people have been lifted out of poverty since the start of the era of contemporary globalization.  Even leaving aside the problematic nature of the definition, until early in the new millennium global extreme poverty reduction was entirely a China story.  In other words, everywhere outside China as someone escaped poverty on the World Bank’s definition, someone else fell into it.  According to the Food and Agriculture Organization and other United Nations agencies, before the pandemic healthy diets were unaffordable to three billion people on ‘the most conservative estimate’ and ‘[t]wo billion people, or 25.9 percent of the global population, experienced hunger or did not have regular access to nutritious and sufficient food in 2019’.  This is hardly stellar performance on the part of the dominant paradigm for organizing the global economy during a period when the value of the world’s economic product roughly tripled.

Perhaps the most problematic aspect of The Economist’s encomium to globalization is its indifference to inequality.  In 2013 Serge Halimi, the editor of Le Monde Diplomatique, described globalization – correctly, in my view – as ‘[t]he inequality machine [that] is reshaping the planet’.  The effects have now become too conspicuous to ignore within national borders, and despite some short-term ameliorative effects associated with programmes to compensate for earnings losses, the pandemic amplified the reshaping process.   For example, a 2022 annual report on the world economic situation – one of several under-used resources generated annually by United Nations agencies – observed:  ‘According to preliminary estimates, the top 1 per cent of income earners in the United States registered net wealth gains of about $3.5 million per person between the first quarter of 2020 and the second quarter of 2021. The bottom 20 per cent recorded an increase of only about $5,300 per person’. 

Complicating the picture, even as pre-pandemic globalization eased extreme poverty in China, and more recently in other jurisdictions outside the high-income world, it devastated the economic futures of many working families in countries like the United States – contributing to what Anne Case and Angus Deaton eloquently describe as ‘deaths of despair’ among the left-behind.  In the US the ready availability of guns, the marketization of health care and the criminal marketing practices of commercial opioid producers also played a role, which is probably why the pattern identified by Case and Deaton was distinctive to that country before the pandemic.  Even before we consider the implications of continued growth on earth systems – what key researchers on the Anthropocene Epoch of geological time have called the Great Acceleration – the report card on globalization’s human benefits is decidedly mixed. 

Much more can and should be said about all these matters.  With important exceptions, researchers and practitioners writing in the global health literature do not provide adequate discussions, despite their importance for the future of the field.  Indeed, the same is true of population health more generally.  Rather, it is necessary to explore work that has been generated and published in various areas of social science and law that are not necessarily connected to health in obvious ways – at least, not in ways that are apparent to the biomedical gaze.  This is where multidisciplinarity comes in: ability to engage with a range of disciplines and assess the implications of their findings for global health is indispensable for critical assessment of claims like those about the benefits of globalization. 

The Economist itself is among the business-oriented sources – another being the Financial Times – that have sometimes generated valuable correctives to Panglossian views of globalization.  The Economist’s reckoning, for example, suggests that deaths outside Ukraine from Russia’s weaponization of gas exports will outnumber war fatalities within the invaded country’s borders – hardly a ringing endorsement of the ‘borderless world’ beloved of globalization’s enthusiasts as it involves energy.  Globalization of financial markets has not only multiplied opportunities for fiscally debilitating tax avoidance and capital flight, which among other consequences undermine social protection measures and progress towards universal health coverage, but also facilitated recurring debt crises in the developing world.  The most recent such crises – again as The Economist pointed out – compromised many responses to the Covid-19 pandemic, and are squeezing already straitened low- and middle-income health budgets.

Before I retired, some of my postgraduate students wondered why the learning objectives in my global health courses included the ability to read articles in the business press and explicate their implications for global health.  This is why.

Acknowledgements and disclosures

A shorter version of this commentary has been posted on the web site of the Collective for the Political Determinants of Health, based at the University of Oslo’s Centre for Development and the Environment. Parts of this analysis are based on the author’s chapter on globalization in L. Bharadwaj and C. Schuster-Wallace, eds., Handbook on Global Health and Sustainable Development (Edward Elgar, forthcoming).  The author owns shares in firms including Intel and TSMC that will benefit from US technology subsidy programmes critiqued in the Economist leader cited here, although the merits of that critique were not addressed.  Unfortunately, some of the links used here are protected by paywalls.  The author will endeavour to provide copies of the cited materials for the personal use of readers without access.