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

Posted on 10th April 2023 by Theodore

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)

Posted on 10th April 2023 by Theodore

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.

Hating to have been right

Posted on 23rd August 2022 by Theodore

In the slightly less frantic period of university activity that precedes my pending retirement and actually offers time to think, I am prompted to look back at some of the predictions I made about the pandemic and the UK’s social and economic future well over a year ago – notably, that post-pandemic economic contraction would mean 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’. Although the contraction does not (yet) approximate the ‘post-Soviet style economic and health collapse’ that I anticipated in January 2021, it was reported on 22 August that the UK economy contracted by 11 percent in 2020 – the largest year-on-year decline in GDP since 1709. Please note that this reflects only the first year of the pandemic, and neither the short-lived post-lockdown recovery nor the cataclysmic geopolitical events of 2022. (Proponents of ‘degrowth’ might nevertheless reflect on how well 2020 turned out, and for whom.)

Ongoing uncertainties and supply chain disruptions associated with the pandemic have now been compounded by the inflationary effects of Russia’s invasion of Ukraine; its weaponisation of natural gas trade and, at least temporarily, further disruption of agricultural exports; and a domestic political vacuum that sees the probable next prime minister characterised (accurately) as on ‘holiday from reality’ by a senior Cabinet colleague. Average real (inflation adjusted) earnings in the second quarter of 2022 fell at a record rate, whilst one forecast was that under existing institutional arrangements, the ‘capped’ amount a British household will pay for energy could rise to more than £6,000 by April 2023, from less than a third of that in August 2022. This will be a minor inconvenience for Mr. and Mrs. Range Rover, but on one estimate – based on a lower assumed energy price than what is in the latest forecasts at this writing – 45 million people will experience ‘fuel poverty’ on a standard definition.

These impacts are, of course, attributable not only to the pandemic but also to geopolitics, and it is plausible to argue that the impacts I’ve described would be much less severe had the Russian invasion not taken place. But the world is as it is, not as we might wish it to be. Further, I was wrong – I am thoroughly delighted to say – about some things, especially the prospects for what turned out to be a relatively successful UK vaccine rollout. Nevertheless, according to The Economist’s (paywalled) tracking of excess deaths from all causes – the most meaningful measure of successful pandemic response – Britain’s figure of 253 excess deaths per 100,000 people between the start of the pandemic and 23 August is comparable to Chile, Guatemala and Lebanon; almost twice as high as Sweden; and roughly three times as high as Norway, Denmark and Canada. So the glass is definitely only half full, and the British figure may well deteriorate further against the background of an already fragile and under-resourced health system; a social safety net stretched to the breaking point; and a political leadership seemingly bent on emulating the captain of the Titanic in its response to the economic emergency. Those castle walls will look awfully attractive to those for whom they are available.

Plutocrats rule, OK? A Canadian lesson about the realpolitik of ‘building back better’

Posted on 25th April 2021 by Theodore

Although I have lived in the United Kingdom for eight years, I continue to follow Canadian politics. As we move towards what we hope will be a post-pandemic world, there are also less personal reasons to consider the Canadian response. Canada has the most progressive – or at any rate, least reactionary – national government among the G7 countries. Although its Liberal Party lacks a Parliamentary majority, the slightly more left-leaning New Democrats have indicated that they will not trigger an election in the midst of a pandemic, thus giving the Liberals a temporary functional equivalent of a majority. More importantly and improbably, in her previous life as an accomplished business journalist finance minister Chrystia Freeland (the counterpart to the UK’s Chancellor of the Exchequer) published an award-winning book called Plutocrats: The Rise of the New Global Super-Rich that described in considerable detail the emergence of the new millennium’s hyper-inequality. If we leave aside most of the country’s stumble-bum public health response to the pandemic [i] – and Canada is hardly alone in that regard – Canada’s first pandemic-era budget, released on 19 April with the uplifting title A Recovery Plan for Jobs, Growth, and Resilience, might therefore provide a useful indicator of just how far the Overton window of political feasibility has shifted in the direction of reducing that hyper-inequality.

Canadian finance minister Chrystia Freeeland

The answer is: not much. The budget includes numerous, and laudable, incremental increases in federally provided social supports and reiterates, without specifics, an important long-standing commitment to pursue a national subsidised child-care programme of a kind that has long been in place in Québec province. Like many other aspects of social policy, this is a political minefield in the decentralised Canadian federation because of reflexively and zealously guarded provincial jurisdiction over health care, employment law (most of Canada’s provinces have refused to implement even minimal requirements for statutory sick pay) and social programming. Except when invoking emergency powers, which it has avoided, the federal government can do little more than write cheques with few strings attached to ensure accountability for their use. Where the federal government has far more policy space to reduce inequality is in the area of tax policy, where the budget is a virtual vacuum.

The major tax policy change in the budget that is specifically targeted at reducing inequality is a symbolic surtax on luxury cars and boats. This tax is estimated to bring in C$604 million in revenue (£350 million) over the next five years. By contrast, the budget takes no steps to raise the marginal income tax rate (the tax on every unit of additional income) paid by top-income taxpayers. It is also silent on the taxation of wealth, although research from the Canadian Centre for Policy Alternatives shows that Canada’s billionaires increased their wealth by C$78 billion (about £45 billion) in the year since the start of the pandemic. To put that into perspective, the amount is slightly more than the government of Ontario, Canada’s largest province, plans to spend on health care (C$69.8 billion) in 2021-22. Likewise, the budget does nothing to address the long-standing preferential treatment of capital gains on asset sales, which are taxed at half the rate paid on wage and salary income – a tax preference that overwhelmingly benefits corporations and the richest individual taxpayers. According to Canada’s admirable tax expenditure accounts, the finance ministry estimates revenue losses from this provision at C$19.7 billion (£11.4 billion) in 2021 alone. The complete exemption from tax of capital gains on the sale of principal residences, which in much of Canada have skyrocketed in value over the past year, is estimated to cost the treasury C$7.7 billion (£4.5 billion) in 2020-21 – or twice that amount were the generic tax preference on capital gains to be contemporaneously eliminated. All these figures are probably underestimates, given recent increases in share and property prices.

There are now so many property-rich Canadians that trying to tax unearned gains on their principal residences would probably provoke a coup d’état, but that is a post for another day.

If measures like those I’ve mentioned were implemented, tax avoidance strategies would no doubt reduce the revenue gains somewhat, as economists are quick to point out. But that isn’t the issue; the budgets of governments that choose not to strangle domestic growth and immiserate their populations will be in massive deficit for many years to come. However, Canada’s current government has not made any of the obvious commitments to reducing inequality in the building back process. Reducing inequality and its corrosive effects on health, which have been foregrounded by the Covid-19 pandemic, will never be achieved by incremental strategies of trying to level-up. This is not to minimise the value of those strategies in mitigating the worst consequences of the pandemic … and low- or zero-cost childcare, if it ever happens, could be critical to reducing gender inequalities on multiple dimensions. But mitigation is not structural change.

A columnist in Canada’s heavily business-oriented Globe and Mail newspaper (paywalled) cited poll results showing that 79 percent of Canadians support a wealth tax. That, too, isn’t the issue. Some of the best comparative political science research, from multiple, mostly high-income democracies, finds ‘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. Indeed … the influence attributed to poor citizens is not just less than that attributed to affluent citizens, but consistently negative’ (emphasis in original).

It’s really only the plutocrats whose preferences will count, without far more radical changes in political institutions and resources than seem likely in peacetime. Plutocrats rule, OK? Health inequalities researchers must resign ourselves to that, or be far more innovative than we have been so far in coming up with ways to do something about it.

[i] Sometimes, the vacuity of that response can hardly be believed. Here is a quotation from Canada’s Deputy Chief Public Health Officer, a highly paid federal bureaucrat, as reported on 22 April in a news story on possible restrictions on travel from India, which curiously has since disappeared from most news organisations’ web sites: “‘Our minister of health, other cabinet ministers and the prime minister are very seized with it. They are having active conversations about the data and so on’, he told a news conference today. ‘I think there will be a decision or something coming forward shortly’.” In the ‘decision or something’, Canada then banned direct incoming flights from India for 30 days, but not arrivals transiting from India via a third country. The logic is curious, to say the least.

New Year, New Lockdown: ‘The Great Deception’

Posted on 10th January 2021 by Theodore

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.

Whistling past the graveyard of dreams: Hard truths about the likely post-pandemic world

Posted on 19th November 2020 by Theodore

This post originally appeared on 2 November in the excellent global health blog Policies for Equitable Access to Health; it is reproduced here by permission, with minor edits. All views expressed here are exclusively those of the author. Others quoted here do not necessarily agree with them.

Whistling past the graveyard is a long-ago expression that describes the behaviour of people who are afraid of ghosts, but like to pretend that they are not. So, they whistle as a show of nonchalance while walking past graveyards late at night. The expression well describes the current behaviour of academics and apparatchiks alike, in much of the world, as they respond to the coronavirus pandemic. The malevolent spirits that they try to ignore are long-term economic and health implosion and possible state collapse. No one really wants to admit how bad things could get, and how long the damage could persist. On the part of political classes and oligarchs, such behaviour is perhaps understandable; they want to risk neither riots nor collapsing financial markets. On the part of academics who should stand up for serious scholarship, it is inexcusable.

In June 2020 – how long ago that now seems! – I argued in a webinar that the best available model for understanding the probable long-term consequences of the pandemic is the experience of post-Soviet Russia, where over a period of a few years the economy shrank by about 50 percent; social provision mechanisms and large portions of the health care system crumbled; and life expectancy plunged by several years. Subsequent economic recovery was accompanied by drastic increases in inequality and massive capital flight, so that half of all Russians’ financial wealth is now held offshore, and the emergence of a new stratum of politically connected billionaire oligarchs. They now own, among much else, substantial chunks of London. The leading authority on the post-Soviet mortality crisis and colleagues have pointed out that a quarter-century later, Russian life expectancy still did not reflect the country’s economic recovery. In other words, it was several years lower than would be expected given its GDP per capita – years lower than in (for example) slightly poorer Brazil, Chile and China. Back to this model later.

The UK has been an especially disturbing case thanks to the fecklessness, despotic inclinations and corruption of Prime Minister Johnson’s Conservative government. These have been ably described by George Monbiot, whose commentaries are essential reading. The most disturbing aspect of events over the past few weeks, in Europe in the first instance but not only there, is the demonstration they have provided of just how widespread the evisceration of basic public health capabilities has become. It helps to understand this process by way of a political science construct known as the Overton window – an idea emanating from a right-wing think tank that was concerned, in the first instance, with ways to soften public opposition to privatising education. The window frames the universe of public policies that are considered at least plausible, rather than beyond the pale. ‘Shifting the window’ means that, over time, policies that once were well outside the mainstream, on either end of the left-right political spectrum, come to be considered plausible and, eventually, just common sense.

President Trump’s destruction of a range of political norms is one illustration of shifting the window. Over the longer term, decades of well-funded neoliberal efforts to shift the Overton window rightward, the trajectory of which is clear for those willing to do the necessary reading, have led to a situation in which maintaining basic public health infrastructure needed for pandemic preparedness came to seem like an extravagance, an unnecessary expenditure on a too-large state, despite authoritative warnings about the economic and public health importance of that infrastructure. In much of the world, Covid-19 must therefore be understood as a neoliberal epidemic – a phrase my colleague Clare Bambra and I coined in 2015. As another colleague, public health physician Allyson Pollock, has put it, austerity in the UK has led to a situation in which ‘[n]ational and local expertise has been lost and many of [her] colleagues in communicable disease control were made redundant.’

The unwisdom of such abandonment of precaution was articulated in 2015, on a small scale, by 267 economists led by Lawrence Summers – Lawrence Summers, of all people – writing about the benefits of universal health coverage: ‘The debilitating effect of Ebola could have been mitigated by building up public health systems in Guinea, Liberia, and Sierra Leone at one-third of the cost of the Ebola response so far.’ If there really were such a thing as the international community, it might usefully reflect on how much it would have been worth investing in measures that could have mitigated a pandemic now anticipated to result in the loss of more than US $12 trillion in economic output in 2020 and 2021 alone, according to the International Monetary Fund.

According to projections from the Institute for Health Metrics and Evaluation at this writing (30 October, 2020), on current trends the virus will have killed approximately 2.5 million people as of 1 February 2021, with a wide variation in outcomes possible depending on what precautions are taken, and where. This projection deals only with the short term, and cannot address the longer term health consequences of the pandemic, for at least two reasons.

First, it does not include deaths attributable to reduced access to treatment or prevention for other conditions among people not infected by the virus. In the UK alone, a former Conservative health secretary is warning of ‘tens of thousands of avoidable deaths within a year.’ Second, it does not and cannot anticipate health impacts of the economic depression and ratcheting-up of inequality that will follow the locking down of major segments of entire economies and societies. Unfortunately, and despite everything we know about the social determinants of health and health inequalities, in much of the academic world arguing for consideration of these health impacts is immediately equated with callous indifference to human life. This should not be the case.

This is why I am more convinced than ever of the distinctive relevance of the Russian experience. As the UK enters another nationwide lockdown, with an economic cataclysm that will be life-threatening for some certain to follow, all that will remain of some local and regional economies, and millions of individual futures, is wreckage. Much the same can be said for many other jurisdictions. It is possible, of course, that an effective vaccine will be developed and rolled out sooner rather than later, avoiding some of the more disastrous scenarios. But there is no vaccine for the inequalities that were already devastating lives before the pandemic. As just one illustration, in 2011 – at just the start of the UK’s decade of viciously disequalising Conservative austerity – the ‘Great British Class Survey’ found that one-third of British households, supported by low-wage or precarious employment, had an average of just under £1,000 in savings.

Even in the best possible post-pandemic world, inequalities that have been further magnified will be remediable only through huge programmes of public investment and direct redistribution, realistically financed by way of long-term borrowing at current low interest rates and progressive income, wealth and land value taxes. Such policies, for the moment, remain well outside the Overton window anywhere I know of, despite important advocacy by agencies like the United Nations Conference on Trade and Development. In a world of increasingly ungovernable private wealth and the opportunities for capital flight and tax avoidance offered by a borderless financial world, it is far from clear that most governments even have the political capacity to undertake them. Many dreams of the young and the old alike will be consigned to the graveyard referred to in my title. Truth-telling on this point is long overdue.

Epidemiology, history and heartbreak: Reflections from North Yorkshire

Posted on 19th July 2020 by Theodore

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

Posted on 23rd June 2020 by Theodore

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.’

Superb virus reads from around the Web – 10 May update

Posted on 10th May 2020 by Theodore

A Canadian Broadcasting Corporation news team – yes, a state broadcaster that still does real journalism! – takes a look inside the slaughterhouse that has produce one of Canada’s largest clusters of cases, and the working conditions that virtually guaranteed its spread.

A team of Scottish researchers and Martin McKee point out that the pandemic response itself will have negative health effects, which seems bleedin’ obvious, but for some reason most of the health research community prefers to ignore the point, and indeed much else about the post-pandemic future.

Naomi Klein points out that big technology firms in the US are using the pandemic as a platform for new systems that will ratchet up inequality, making the billionaires even richer and expanding the precariat. (The Intercept, where this piece appeared, is proving indispensable for truth-seekers in these times.)

Two articles in The Atlantic, which is making its coronavirus coverage free at the moment, are also valuable. One offers a succinct description of how South Korea dealt with the virus, and what should be learned from its experience. The other is a searing examination of the racism revealed in multiple ways by the US response to the pandemic. For anyone still under the impression that it’s a civilised country, this is a must-read.

Finally, The Times – unfortunately behind a paywall – offers a thoughtful take on the question ‘Supermodeller Neil Ferguson: should we trust his science’? One might question the description of what the Imperial College crew do as science in the first place, but that’s a topic for another day.

More in good time. Meanwhile, stay safe.

Health as if Everybody Counted (second edition)

by Ted Schrecker, Emeritus Professor of Global Health Policy, Newcastle University

Tag Archives: coronavirus

Hating to have been right

Plutocrats rule, OK? A Canadian lesson about the realpolitik of ‘building back better’

Epidemiology, history and heartbreak: Reflections from North Yorkshire

More important reads from across the web: Bank Holiday edition