Tag Archives: health equity

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

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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. 

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

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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.

‘Tax is not a four-letter word’: Why this matters for health inequalities, and why health professionals and researchers must take it to heart

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The title of this post is not at all original.  Rather, it is the title of a book co-edited with his son by the thoughtful former head of Canada’s public service, Alex Himelfarb (after his retirement).  In a newspaper column published at the time, Dr. Himelfarb described the book as an effort to correct the ‘dangerously distorted’ discourse surrounding tax policy, as a result of ‘the neo-liberal economic policy that began to dominate American and British politics in the early 1980s, and emerged more slowly and subtly in Canada at around the same time’.  Almost a decade on, the discourse remains distorted throughout much of the world, with increasingly serious consequences for inequality and quite probably for social stability. 

Exhibit A is the dire state of Canada’s and the United Kingdom’s tax-financed health systems.  (Although the National Health Service and Canada’s multiple provincial and territorial health systems are financed from general tax revenues and are mostly free at the point of use, they are otherwise quite different.)  That similarity is arguably why both countries are facing a crisis in access to care, worsened by the effects of Covid-19, that has demonstrably had fatal consequences.   Whilst users quite rightly and understandably want health systems to provide necessary care in a safe and timely fashion, resistance to the taxes necessary to finance not only the direct provision of care but also such strategically critical activities as training doctors and nurses has generated political paralysis. 

The explanation was succinctly stated around the same time the Himelfarbs’ book appeared by Robert Evans, the magnificently acerbic dean of Canadian health economists: ‘[A] well-functioning modern health system requires the transfer, through taxation, of a very significant amount of money from the healthy and wealthy to the care of the unhealthy and unwealthy’.  When we hear arguments that the NHS or Canada’s systems of health finance are ‘unsustainable’, this is code for saying that the richest members of those societies do not want to pay for the care of those presumptively undeserving others.  This problem is especially acute in the UK, where the rich have the option of buying private insurance or paying directly for care – something not available within Canadian borders outside the renegade province of Québec.  By 2017, HM Government was conceding the inadequacy of the NHS for treating the great and the good (see below).

Such problems are compounded by what is perhaps best described as a lack of policy literacy among the health care and public health community, who often remain unfamiliar with such basic concepts as progressive and regressive tax and spending patterns (and in public finance these terms have a technical, not a normative meaning).  Chapter 6 of David Byrne’s recent book Inequality in a Context of Climate Crisis after COVID provides a superb overview, and it – or something like it – ought to be a required part of all university public health and health policy curricula.

On, then, to Exhibit B: the catastrophic inadequacy of actual and proposed responses to the energy price crisis created by Putin’s weaponisation of Russian energy exports.  Like the equitable financing of a health system, responding to the crisis will require a substantial redistribution of resources from Mr. and Mrs. Range Rover and the corporate treasuries that have been swollen by windfall gains to the majority of UK households that will, based on estimates by the University of York’s authoritative Social Policy Research Unit, be pushed into fuel poverty by the start of the New Year.  At this writing, the silence of the public health community has been deafening.  Unfortunately, those who will be least hurt by energy price inflation, or who will actually benefit from it, can probably exercise an effective political veto over the degree of redistribution that will be necessary to avoid a humanitarian catastrophe.  In this case, the problem is compounded by a tongue-tied political class unwilling to state the obvious:  liberal democratic Europe is at war with Russia, and wartime situations demand wartime sacrifices.  But that is a posting for another day.

Hating to have been right

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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.

Globalisation and health: Looking backward, looking forward

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This piece was originally written for Policies for Equitable Access to Health, an Italian-based site that now offers a valuable ‘weekly snapshot of public health challenges’.  It is reposted here with their kind permission.

Much of my academic work over the past 20-plus years has focussed on the processes of globalisation and what they mean for population health.  One of the early (2007) major products of that work, co-written with long-time colleague Ronald Labonté, came out of analysis done for the WHO Commission on Social Determinants of health.  It took the form of a three-part series in the journal Globalization and Health, discussing in turn historical context and methodological background; the role of the global marketplace; and prospects for promoting health equity in global governance.  (The later work on globalisation that informed the WHO Commission appeared in book form in 2009.)   In view of the cataclysmic world events of the last 30 months (at this writing) and my pending retirement from salaried academic life, I thought it useful to look back on some of our analysis to see what it got right, what it neglected, and how future research should learn from such reflections.

The work focussed, quite rightly in my view, on how the emergence of a global marketplace and the associated worldwide spread of neoliberal economic ideas and institutions transformed opportunities to lead a healthy life and the options for public policy to reduce health inequalities.  Indeed, we perhaps did not focus intensively enough on neoliberalisation and its transformative impact, about which I have written elsewhere.  The figure below shows (in blue) the seven interacting ‘clusters of pathways’ that we identified in Globalization and Health, and (in red) how I think this analysis needs to be modified and added to in light of recent events.  The rest of this post concentrates on three areas, obviously in insufficient detail.  

The first of these relates to the consequences of global environmental change, now observable in daily headlines about such climate-related phenomena as shrinking polar ice cover, heat waves, megadroughts and wildfires.  As conspicuous as these impacts are, the reflect only one dimension of what is now widely described as the Anthropocene Epoch – a new era of geologic time marked by the scale and extent of human-induced changes in the natural environment, exemplified by (for example) the prospect of the transformation of the Amazon rainforest into savannah as a result of continuing deforestation.  A key concept in the Anthropocene literature is the Great Acceleration, a multidimensional speeding up of economic activity and the associated biophysical transformations beginning, on many reckonings, around 1950 with the post-World War II period of economic growth.  Until recently, that growth was concentrated in the (mostly high-income) OECD group of countries.  Formidable questions of global justice are raised by the implausibility of sustainable growth within planetary boundaries if the rest of the world were to continue pursuing anything like the standard of living taken for granted within the OECD.  Anthropologist Jason Hickel has been one of the most vocal and articulate proponents of ‘degrowth’ in this context; whether intentional degrowth is feasible under any kind of democratic political arrangements is a question yet to be resolved.

The second area of neglect relates to the continued, indeed enhanced danger of transnationally dispersed pandemics.  With 20-20 hindsight, there was little reason for this.  Journalist Laurie Garrett had been warning of the prospect since 1994, and in 2019 – just a few months before the start of the Covid-19 pandemic – published a prescient article warning that: ‘The world knows an apocalyptic pandemic is coming … But nobody is interested in doing anything about it’.  This problem does not appear at first directly connected with the global marketplace, but in fact it is.  Public health infrastructure is one of the key prerequisites of societal survival that the so-called free market cannot and will not provide; it is one of the few truly public goods for health.  The neoliberal turn in public policy is thus implicated in the neglect of public health infrastructure to the extent that Matthew Sparke and Owain Williams recently (and correctly in my view) identified Covid-19 as a ‘neoliberal disease’.  Incredibly, if predictably given the current UK government’s tenuous hold on reality, it  has not learnt from the pandemic: in April 2022 the government announced staff reductions of 40 percent at the Health Security Agency, responsible for pandemic planning and response, at the finance ministry’s insistence.  In the same month, again predictably, a scientifically illiterate US Congress refused to continue Agency for International Development funding for vaccine delivery in low-income countries. 

Third and finally, researchers like myself took too seriously and literally the idea of a ‘Borderless World’ put forward by Japanese economist Kenichi Ohmae.  The book in question, originally published in 1990, remains an iconic paean to a world in which governments have become largely irrelevant; ‘if a corporation does not like its government, it can move its headquarters to other, more hospitable places’; and the future resembles nothing so much as a global duty-free shop.  Many elements of this vision, notably its focus on the footloose corporation and its tacit acceptance of rising inequality, remain accurate if dispiriting descriptions of the world economy.  At the same time, nationalism and geopolitics continue to render the world anything but borderless, and political institutions anything but irrelevant, in many respects.  In 2016, UK voters narrowly supported leaving the European Union and its single market, an act of economic self-harm that will have consequences for decades, most of them magnifying existing inequalities and their destructive effects on health.  And several European countries, Germany most particularly, appear to have believed that the world really was borderless for purposes of energy policy.  This catastrophic inattention to geopolitics led directly to today’s vulnerabilities associated with reliance on Russian natural gas supplies and may yet pave the way to deep recession, widespread social unrest, and domestic political pressure to accept Ukraine’s dismemberment.  Much of this could have been avoided through careful attention to a long list of books drawing attention to Russia’s internal political transformation, going back at least to the late Anna Politkovskaya’s 2004 Putin’s Russia. (She was murdered shortly after its publication.)

Much more can and should be said on all these matters, and others.  For example, global health researchers have not yet come to grips with the implications of a widespread retreat from democracy and drift into autocracy in which, according to the respected Varieties of Democracy Institute, ‘the last 30 years of democratic advances following the end of the Cold War have been eradicated’.   As historical sociologist Margaret Somers points out in the US context, this trend is not unrelated to the hegemony of neoliberalism, although the connections are likely to vary among country cases.   Faced with such complexity, many researchers will be tempted to retreat into the familiar territory of health systems design and what might be called global medicine.  This tendency should be resisted, not least because – as Martin McKee notes in an important recent article – ‘politics is at the heart of public health’.  This is even more true in the global frame of reference than at the national level about which he was writing.  

Austerity, the homicidal present, and the probable Russian future

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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

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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.

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

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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.

Marmot +10 and the grim prognosis for health equity

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Most readers will now be aware of the release on 25 February of the ten-year followup to the 2010 ‘Marmot review’ of health inequalities in England.  To say that the report makes depressing reading is putting it mildly.  Despite the epidemiologist’s caution expressed in Sir Michael Marmot’s foreword – ‘We were reluctant to attribute the slowdown in health improvement to years of austerity because of difficulty in establishing cause and effect – we cannot repeat years without austerity just to test a hypothesis’ – the report as a whole offers a devastating portfolio of evidence of the human damage done by a decade of austerity.  Its accumulation of graphs and charts makes a compelling case for the point I try to bring home to postgraduate students at every opportunity: public finance is a public health issue.  An especially bitter irony, of course, is the emerging recognition across much of the political spectrum, and of the economics profession, that the decade was not only unnecessary but even counterproductive in macroeconomic terms.

Unfortunately, that kind of evidence is not relevant to the broader post-2010 project of redistributing income, wealth, and opportunity upward within British society.  (The brilliant and iconoclastic economist Branko Milanovic has pointed out that the rich have much more to gain from such upward redistribution than from stimulating growth across an entire national economy; their ready access to tax avoidance opportunities unavailable to the rest of us further distorts the incentive structure.)  Neither does evidence of macroeconomic (in)effectivess bear on what might be called the micro-level attack on the poor, marginalised and precarious.  The day after the release of Marmot +10, The Independent reported that the Department of Work and Pensions had shredded ‘up to 49’ internal reviews of suicides that occurred after people’s benefits had been cut off.  This followed an earlier report of 69 suicides among benefit claimants in the past five years, which is almost certainly a low figure. 

Just a few items from the report deserve flagging.  Fewer than 200,000 workers in the UK were on zero hours contracts in 2010; by late 2018 the figure was close to 900,000.  For the poorest tenth of English households, eating healthily would require three-quarters of all their disposable income after housing costs.  And the targeted financial destruction of local government has led (for example) to an England-wide reduction of 42 percent in local spending on transport and a 52 percent cut in housing.  As the report points out, ‘councils have used reserves, sold assets and reduced spending on the non-statutory services they are not legally required to deliver’.

None of this matters to Mr. and Mrs. Range Rover, of course.  An Arizonan interviewed by US journalist Ken Silverstein captured the underlying political economy a decade ago: ‘People who have swimming pools don’t need state parks. If you buy your books at Borders you don’t need libraries. If your kids are in private school, you don’t need K-12. The people here, or at least those who vote, don’t see the need for government.’  And The Times recently reported that residents in some of London’s ultra-wealthy boroughs pay less than £1 in council tax for every £1,000 of property value, whilst those in ten poor local authorities in the Midlands and the North such as Hartlepool, Middlesbrough, Gateshead and Stockton-on-Tees pay between ten and fourteen times as much (unfortunately behind a paywall; contact me if you would like the figures.)

 It is hard to know how to respond to such situations, beyond despair and resignation.  These responses are heightened by the fact that many of the new report’s ‘case studies,’ seemingly intended as success stories, are at best sticking plasters, doing little to address the critical upstream drivers of inequality – the ‘toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics’ correctly targeted by the 2008 Commission on Social Determinants of Health.  I have to remind myself more and more often that the last word in Albert Camus’ famous essay on suicide is hope.  One hope is that public health researchers and practitioners might disengage themselves from producing yet more systematic reviews of the evidence, organised around impossibly and inappropriately high epidemiological standards of proof, and turn attention, energy and pedagogy to more practical questions such as what to do when government adopts homicidal social policies and then destroys the evidence.  

What now for trade and health politics post-Brexit?

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With the election over and the United Kingdom’s exit from the European Union on some terms or other now a certainty, it is useful to reflect on the trade negotiations that will follow.  I offer these  initial observations.

First, there has been much talk of the option of reverting to World Trade Organization (WTO) rules in trade relations if ‘deals’ to replace the agreements to which the UK was party by virtue of its EU membership cannot be negotiated by the end of 2020.  However, thanks to the United States’ refusal to agree to appointing new members of the WTO Appellate Body, effectively there will be no WTO rules going forward, until and unless a future US government changes this position in 2021 or thereafter.  Once out of the EU, the UK is effectively unprotected in a trade policy jungle, not having been able to negotiate independently of the EU, so pressure quickly to negotiate new agreements will be intense.  Domestic proponents of a deregulated, ultra-liberal future, including (for example) further privatisation in the NHS and opening the country’s arms even wider to dodgy flight capital, will make use of this opportunity. The government’s announced intent to legislate an exit from the EU at the end of 2020, whether or not an agreement has been reached, is a first step in this process.

Second, in this process the UK will be at a substantial disadvantage as it negotiates with entities like the United States (an economy more than six times larger, based on GDP at purchasing power parity) and the comparably large European Union.  It will have to offer more, in terms of market access and other considerations, to get less.  And when anyone in an official capacity says that a particular service or health protection measure, such as the NHS or food safety standards, ‘will not be on the table’, we have to ask what else will be on the table instead.  That is the reality of asymmetrical trade negotiations, as countries throughout the Global South have found out.

Third, the House of Commons will be largely irrelevant.  A former Canadian cabinet minister pointed out decades ago that: ‘Under our parliamentary system, a Prime Minister or a Premier with a majority has immense power …. [In] 1688 we traded the divine right of kings for the divine right of a Premier or a Prime Minister with a majority at his or her back for a period of five years’.  The new Conservative government has a large enough majority that even with a unanimous opposition, close to 40 defections would be necessary in order to defeat whatever legislation the government proposed, and that is all but unthinkable.  Advocates for health equity concerned with the implications of post-Brexit trade policy will have to look elsewhere for points of influence.  There may not be many.

Thus, fourth, a final irony. The campaign to leave the EU was waged using the mantra of taking back control. During the process of leaving and after its completion, influences and actors outside the UK’s border will probably be more important in terms of shaping the direction of the economy, society and everyday life than they were during the country’s EU membership.