Austerity, the homicidal present, and the probable Russian future

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

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

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

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?

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.

Why no talk of an inequality emergency?

We hear much talk now of a climate emergency.  As I was revising a talk I give frequently on ‘global health in an unequal world’, I realised that there is no talk of an inequality emergency, either globally or close to home, although the same macroeconomic trends and political choices driving increased inequality within national borders and on a variety of smaller scales are often involved wherever on the map one happens to look.  (On these inequalities at metropolitan scale, I cannot recommend too highly photographer Johnny Miller’s compelling aerial images.)

Why is there no talk of such an emergency?  Many manifestations of climate change occur on a scale that makes them fodder for our spectacle-hungry visual media: think Californian and Australian wildfires; collapsing glaciers; and catastrophic damage from hurricanes and floods.  The casualties of inequality tend to be smaller in scale and less visible: the lives ended sooner and more painfully than they should have been because of the accumulated damage done by relying on food banks and fearing the ‘brown envelope’ that initiates the vicious privatised process of fitness-for-work assessments here in the UK, or the estimated 300,000 women per year who die in pregnancy or childbirth from causes that are routinely avoided in the high-income world.   Academically, it may be effective to compare the annual toll from death in pregnancy and childbirth to the crash of two or three airliners every day of the year, as a colleague and I have done, but such comparisons have little salience in the broader, media-corrupted world of political priorities.

Relatively vast resources have been devoted to climate science – the Intergovernmental Panel on Climate Change is the world’s largest-ever scientific collaboration – and climate researchers  long ago realised that just generating more evidence was never going to be enough to generate the change needed.   So many became advocates, for example tracing 63 percent of cumulative worldwide emissions of carbon dioxide and methane between 1751 and 2010 to just 90 massive state- and investor-owned corporations (and their customers, of course).  More recently, another group of authors (supported by more than 11,000 signatories) argued that ‘Scientists have a moral obligation to clearly warn humanity of any catastrophic threat’.  Researchers on health inequalities, in particular, have generally been more circumspect.  In the UK, advocacy that looks far enough ‘upstream’ at the economic and political substrates of health inequalities – more on that point later – is unlikely to be acceptable to agencies of the capitalist state and the trustees of billionaires’ fortunes whose funding priorities shape the direction of academic research and the career paths of academics.  And the health inequalities of greatest concern, by definition, do not affect ‘all of us’.  Whether the consequences of climate change will genuinely do so is too complex a question to be investigated here, but the question is well worth asking.  Certainly, its effects will be felt first and worst by those least implicated in its origins.

Another issue is the decades-long rhetorical and ideological Thatcherite drumbeat that ‘there is no alternative’ to rising inequality and the policies that drive it.  This problem is particularly acute with regard to the austerity that has been thoroughly discredited in terms of the macroeconomic objectives of sustaining growth that it was supposed to achieve, whether in the era of World Bank and IMF-mandated structural adjustment or, more recently, in post-2010 responses to the financial crisis.  As Nobel prize-winning economist Paul Krugman commented in the run-up to the 2015 UK election: ‘All of the economic research that allegedly supported the austerity push has been discredited. On the other side of the ledger, the benefits of improved confidence failed to make their promised appearance. Since the global turn to austerity in 2010, every country that introduced significant austerity has seen its economy suffer, with the depth of the suffering closely related to the harshness of the austerity’.  Post-2015, of course, austerity in the UK became harsher still, demonstrably redistributing income and resources upward within British society, through both tax and benefit ‘reforms’ and savagely destructive cuts to local authority budgets.

Now, austerity has become normalised; it is part of the quotidian policy landscape to the extent that we are almost no longer capable of rage when the strutting, glossy Home Secretary straightfacedly claims that poverty is not the government’s problem, when the evidence is overwhelming that post-2010 public policy has systematically and premeditatedly made the problem worse.  Despite the best efforts of the fossil fuel industry, we can imagine a decarbonised economy, even though we may not be able to specify its details.  Too many of us now have difficulty imagining economic systems that do not operate as what Serge Halimi, the editor of Le Monde Diplomatique, has called an ‘inequality machine’.  A powerful antidote to this well-funded intellectual cauterisation is the United Nations Conference on Trade and Development’s 2017 blueprint for a global new deal.  How many global health researchers have read it, I wonder?  How many medical or MPH students have been asked to do so?

Back to the view looking upstream.  Failure to understand and declare an inequality emergency reflects the success of neoliberalism or ‘market fundamentalism’ as a global class project of restoring inequality and the privileges of the rich to the levels that prevailed before what has been called the ‘great compression’ that reduced inequality after World War II in much of the high-income world, and inspired egalitarian visions far outside it.  The evidence on this point can’t even be summarised here – I am glad to provide key sources – but in the context of the work that academics do, two decades of marketisation in British universities must be understood as part of the project.  Centrally funded institutions that served a public educational and scholarly purpose were dismantled, replaced by corporate-style enterprises organised around generating income from deep-pocketed funders and indebted students, with careers often ended by failure to put out salable products.   

Isn’t this a form of conspiracy theory, you ask?  Empirically, the best rejoinders come from the work of journalists like Jane Mayer and historians like Stefan Collini and Nancy MacLean.  Conceptually, an especially apposite riposte comes from the brilliant legal historian Douglas Hay, who established himself in the field with the research that underpinned the following conclusion: ‘The private manipulation of the law by the wealthy and powerful’ in eighteenth-century England ‘was in truth a ruling-class conspiracy, in the most exact meaning of the word. …. The legal definition of conspiracy does not require explicit agreement; those party to it need not even all know one another, provided they are working together for the same ends.  In this case, the common assumptions of the conspirators lay so deep that they were never questioned, and rarely made explicit’ (1).  Enough said.

(1)  Hay, D.  Property, Authority, and the Criminal Law. In D. Hay et al., Albion’s Fatal Tree: Crime and Society in Eighteenth-Century England (pp. 17-64). New York: Pantheon, 1975,  

The Commission on Social Determinants of Health: Ten years after

Ten years ago, the World Health Organization’s Commission on Social Determinants of Health released its final report.  The authors, led by Sir Michael Marmot, began by stating that the ‘unequal distribution of health-damaging experiences is not in any sense a ‘natural’ phenomenon but is the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics’.  The unsparing critique proceeded from there.  In a generally laudatory review, The Economist wondered whether the Commission was ‘baying at the moon’ when it attacked such ‘global imbalances’.

However, the financial crisis that was spreading across the world even as the report was released made it clear that the Commission’s analysis was spot-on.  Against that background Margaret Chan, then Director General of WHO, warned the United Nations General Assembly in October, 2008 that ‘[t]he policies governing the international systems that link us all so closely together …. need to be put to the true test. What impact do they have on poverty, misery, and ill health – in other words, the progress of a civilized world? Do they contribute to greater fairness in the distribution of benefits? Or are they leaving this world more and more out of balance, especially in matters of health?’  As was often the case, Dr. Chan was far ahead of the organisation she led – and as we know, in the decade of counterproductive austerity that followed, her advice was seldom heeded.

Ten years on, where are we?  In an article I have just published in Critical Public Health (if you don’t have access through your institution please e-mail me), I argue that – as in many other areas of global health policy and politics – the glass can be considered either half empty or half full.  Is the fate of the Commission’s report the tale of a sinking stone …

… or of promise yet unrealised?

On the one hand, the international community has now signed on to at least the rhetoric of the Sustainable Development Goals – a legacy of the World Commission on Environment and Development, which reported not ten years ago, but 31.  On the other hand, on most measures and in most contexts economic inequality is rising, and an expanding body of social science research suggests that the reductions in inequality that occurred in the twentieth century, in the context of two world wars that required mass mobilisation and a devastating depression, are an anomaly that is unlikely to be repeated.

As I point out in the article, references to ‘social determinants of health’ in the scientific literature are increasing in number.  A PubMed search turned up 75 references in 2008, rising steadily to 1042 in 2017.  Research ventures like the LIFEPATH consortium are expanding the already substantial evidence base for acting on social determinants of health.  Whether the strength of that evidence matters is ultimately a political issue; getting health equity and the corollary need for redistributive economic and social policies onto mainstream political agendas remains a formidable challenge, but perhaps not an insurmountable one.

The article was finalised before the remarkable primary victory of Democrat Ayanna Pressley in Massachusetts’ 7th District.  Here’s what she had to say about health equity in her ‘equity agenda’ (MBTA is the Massachusetts Bay Transport Authority):

‘Today, when you board the MBTA’s number 1 bus in Cambridge, it’s less than three miles to Dudley Station in Roxbury, but by the time you’ve made the 30-minute trip, the median household income in the neighborhoods around you have dropped by nearly $50,000 a year.[2]/[3] As the bus rolls through Back Bay, the average person around you might expect to live until he or she is 92 years old, but when it arrives in Roxbury, the average life expectancy has fallen by as much as 30 years.[4]  …. These types of disparities exist across the 7th District, and they are not naturally occurring; they are the legacy of decades of policies that have hardened systemic racism, increased income inequality, and advantaged the affluent’.

If the ‘social movement, based on evidence’ that Sir Michael and colleagues envisioned after the Commission’s report is to take shape – it hasn’t, yet – this is the kind of language we need to hear, from political actors and public health professionals alike.