Against Covid-19 fetishism, and other musings

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

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

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

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

Let me suggest just one example of probable impacts:

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

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

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

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

This post was updated on 15 April.

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

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

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

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

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

This post was updated on 6 April 2020.

Power and pandemics: A thought experiment

Imagine you’re a far-right government bent on a particular political project, whose lead minister for domestic affairs is on record as saying governments are not responsible for poverty, and you have to respond to a fast-moving contagious disease, after a decade of austerity has left the national health system overstretched even under normal circumstances and eviscerated local authorities’ ability to respond to public health crises. 

You are also committed to leaving the customs union whose members buy almost half your exports and supply about 30 percent of the nation’s food, in nine months, with or without a replacement set of arrangements[1] and despite the social and economic disruption that may ensue, including disruption of food supply chains whose precariousness the epidemic is already demonstrating. 

What might your sharpest-minded strategists do? 

Well, one approach would start by playing down the seriousness of the epidemic.  The Prime Minister might urge people to minimise social contact, whilst sometimes ignoring his own advice.  As the scale and speed of the epidemic became clearer, you might go ‘evidence-based,’ relying on a particularly apocalyptic set of model predictions that ignore the possible benefits of basic public health measures such as contact tracing, clinical observation, and testingperhaps to avoid drawing attention to austerity’s effects on the country’s ability to carry those out. 

Now invoking wartime imagery, you would close schools and most businesses and public facilities countrywide.  Within a few days, enabled by a hapless simpering Parliamentary opposition that did not oppose, you would enact a 348-page piece of legislation that centralises almost all power in the hands of the political executive for at least two years, and among many other extraordinary measures gives police the authority to use roadblocks and drones to prevent non-essential travel, indeed to define it, with criminal prosecution as a backstop. You would also, quite understandably, commit to massive borrowing and spending in order partially to compensate for lost jobs and business revenues, and to keep the economy from collapsing completely.

Oh, wait – the UK has such a government, and it just did all that.  Lancet editor Richard Horton has written that ‘basic principles of public health and infectious disease control were ignored, for reasons that remain opaque’; the following day, former Conservative Secretary of State Jeremy Hunt made a similar point, noting – about countries that tested early and intensively – that ‘[t]he restaurants are open in South Korea. You can go shopping in Taiwan. Offices are open in Singapore’. Abundant evidence now shows that permissible movements are now determined only by police acting on their interpretation of the orders of the political executive. When the other shoe drops, in the form of post-pandemic, post-Brexit austerity that will solemnly be defended on grounds of fiscal prudence, resistance may be difficult if not dangerous.  Methinks that far from blundering, the Conservative response to the pandemic has been extremely calculating and politically sophisticated.  I desperately hope I’m wrong.

[1]   Thanks to the US, the World Trade Organization now is nothing more than a talking shop, but that’s another story.

This post was updated on 31 March

Snapshots and casualties from the pandemic

On the morning of 18 March, Andrew Ross Sorkin’s indispensable Dealbook blog asked ‘what a “wartime” economy looks like’, pointing to the roughly US$2.5 billion in stimulus spending that the United States, the UK, France, Germany and Spain had offered as of yesterday; warning that it might not be enough; and calling the ‘spending plans unlike anything seen during peacetime’.

Actually he’s not quite correct on that last point.  The Bank of England pointed out in 2009 that in response to the financial crisis, the US and UK governments quickly mobilised an estimated US$14 trillion in cash and credit guarantees to rescue financial institutions, ‘equivalent to about 50% of annual GDP in those economies, although that does not equate to losses as in some cases these obligations were offset by holdings of assets’.  It is becoming clearer by the day that a commitment of that magnitude, if not larger, will be needed to avoid a depression.  And the blog points out that during the Second World War, the UK and the US ran budget deficits equivalent to more than a fifth of their respective GDPs.  By 20 March, The Economist was citing a figure of US$7.4 trillion (about 23 percent of GDP) as the combined commitment from the US, the UK, Germany, France and Italy; warning that conventional fiscal policy is likely to have limited impact; and observing that ‘new financial tools need to be deployed, and fast’. An optimistic view is that Green New Deals may achieve a breadth of political support unimaginable two weeks ago.

On the other hand, Toronto’s Globe and Mail offered an important commentary pointing out that many people already living paycheque to paycheque and now facing the probability of job losses cannot afford to stockpile a fortnight’s worth of food and will probably have trouble keeping a roof over their heads – an obvious point that seems to have escaped most of the mainstream media.  Both the New York Times, whose epidemic coverage is now out from behind its paywall, and the Guardian offered ominous frontline accounts calling into question the National Health Service’s ability to cope with increased caseloads after a decade of austerity-induced fragility. Similar accounts are now emerging from (among other places) the United States and Italy. And outspoken Lancet editor Richard Horton excoriated the British response as ‘a collective failure among politicians and perhaps even government experts to recognise the signals’ emanating from China and India.  He concluded that ‘when we have suppressed this epidemic, when life returns to some semblance of normality, difficult questions will have to be asked and answered’. 

We must now confront the possibility that, if economic policy is mismanaged and some health services collapse, that return might take, not a few years, but a generation.

This post was updated on 20 March

COVID-19, state desertion and neoliberal epidemics

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.