Tag Archives: health inequalities

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

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

Canadian finance minister Chrystia Freeeland

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

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

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

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

A columnist in Canada’s heavily business-oriented Globe and Mail newspaper (paywalled) cited poll results showing that 79 percent of Canadians support a wealth tax.  That, too, isn’t the issue.  Some of the best comparative political science research, from multiple, mostly high-income democracies, finds ‘remarkably strong and consistent evidence of substantial disparities in responsiveness to the preferences of affluent and poor people. Insofar as policy-makers respond to public preferences, they seem to respond primarily or even entirely to the preferences of affluent people.  Indeed … the influence attributed to poor citizens is not just less than that attributed to affluent citizens, but consistently negative’ (emphasis in original).   

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

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

New Year, New Lockdown: ‘The Great Deception’

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Predictably, the New Year started in the United Kingdom with new lockdowns.  Given the negligent and cavalier stance of the Conservative central government towards basic public health principles since the start of the pandemic, and the consequent peril to the National Health Service, this was inevitable, although one may argue with some of the specifics.  It is important to remember, though, that both the parlous state of the NHS and the neglect and defunding of public health infrastructure are consequences of a homicidal decade of Conservative austerity, correctly described in 2017 by the editor of The Lancet, Richard Horton, as ‘a political choice that deepens the already open and bloody wounds of the poor and precarious’.     

One of the knock-on effects is that we are now living in a police state – so far, a non-violent one, but violence is not a necessary element of the definition.  Hyperbole, you say?  Well, what else would you call a polity in which the decision about what constitutes a ‘reasonable excuse’ for leaving home is decided, in the first instance, by police, who will be defended by Cabinet ministers?   I wish politicians and self-styled progressive colleagues alike would stop dissembling on this point.  They might well defend the situation as necessary, but they should stop lying about its nature.  Presumably some of these fines and arrests will be successfully contested by those with the time and money to do so, should government eventually permit courts to resume routine operation, which is far from certain.  

Speaking of lies, porkies* of Trumpian proportions have been emanating from central government.  We are told that, if we obey the rules and all goes well with vaccination, restrictions might be eased in ‘tulip season’ (May, in these parts) or ‘spring’ (technically, before 21 June).  If any reader believes that, then I can offer a really good deal on some oceanfront property in the Canadian province of Saskatchewan.  (Spoiler alert: there isn’t any.)  Given the government’s record of destroying any public health initiative it touches, the UK will be doing well to be out of the worst of lockdown by September.  In fact, more severe restrictions are threatened.  As John Harris observed in an important Guardian commentary: ‘The lack of alarm about these moves is remarkable’.

Disturbing manifestations of burnout can be anticipated by the end of a summer without holidays (I quote from the government guidance: ‘holidays in the UK and abroad are not allowed’).  Some of us would in theory have the attractive option of sitting on the local seafront and reading once the weather warms up … except that under current guidance this would not count as exercise, one of the ‘reasonable excuses’ to leave home, so would be a crime.  Such constraints weigh most heavily, of course, on those without gardens of their own or with caring responsibilities.  The incidence of deaths of despair is likely to soar, as is the number of employers using depression and anxiety as a pretext for forced redundancies.

All this means that the chances of a post-Soviet style economic and health collapse in the UK, lasting for a generation or longer, are considerably greater than they were when I first raised the possibility last summer.  It could be, of course, that vaccination will proceed more quickly and effectively than expected (pigs might fly, too) or that some other remarkable advance in prevention will be found.  Unfortunately, it is much more likely that the United Kingdom is over as a desirable place to live and work, for a very long time, except for those living in gated communities or behind castle walls. 

The ways in which the pandemic is magnifying inequality – on which I will expand in a subsequent posting, based on material from the postgraduate course in Advanced Social Determinants of Health that I lead – continue to be given limited attention.  Most of the ‘experts’ calling for even stricter lockdowns probably have gardens of their own, job security, and substantial savings, unlike many other Britons; they have generally been silent on inequality issues.  Still less often have they taken up Horton’s pre-pandemic injunction that: ‘The task of health professionals is to resist and to oppose the egregious economics of our times’.  One wishes that members of the government’s Scientific Advisory Group on Emergencies had to disclose their households’ incomes and net worth, along with their professorial titles and British Empire honours, as part of their declaration of interests.

Here is a thought experiment, keeping in mind two propositions.  First, people working in front-line occupations (think essential retail like supermarkets, delivery, driving those buses that continue to operate, Amazon warehouses, meat packing, care homes) cannot work from home, and especially if on zero-hours contracts or without union protection cannot afford to self-isolate after a positive test or if symptomatic.  (The jobs of many others, working in the sector broadly described as hospitality, have vanished under lockdown, possibly never to return.)  Second, as of 25 September almost nine out of ten deaths from Covid-19 involved people 65 or older (more recent figures are maddeningly hard to find on official web sites).  Most of these represented an actuarial boon for the UK treasury, no longer paying state pension, and many for defined-contribution pension plans.   

Now, if you wanted to design a pandemic response that pretended good intentions whilst concealing a subtextual agenda of culling the working class (potential claimants of state benefits, after all, and therefore intrinsically suspect for Conservatives) and the elderly, the current UK response is what it would look like.  The UK is hardly unique in this regard, but along with Canada and its charnel house care homes and even more calamitous vaccine rollout it is an especially egregious case. 

The title of this post refers to what I consider the greatest song by Irish troubadour Van Morrison, ‘The Great Deception’.  Part of the refrain goes like this:

‘I can’t stand it / Can’t stand it nohow / Livin’ in this / World of lies’.

Indeed.

* For those outside the UK: short for porky pies, rhyming slang for lies.

Epidemiology, history and heartbreak: Reflections from North Yorkshire

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As any academic would, I took some work-related reading with me during a short holiday break in North Yorkshire.  Here are some reflections.

First up: Johan Mackenbach’s 2019 book Health Inequalities: Persistence and change in European welfare states.   This remarkable book displays not only the author’s formidable scholarship (there are 738 cited references) but also his laudable willingness to engage with multiple literatures, like those on theories of justice and the politics of responses to inequalities.

That said, there is much to disagree with here – for instance, Mackenbach’s privileging of epidemiology in assessing “what works” to reduce health inequalities, and the selection of relatively crude outcome measures as indicators of success or failure.  A more nuanced approach would better integrate findings from such disciplines as ethnography and programme evaluation, and – in particular – would unpack the fetishisation of “significance” as defined by a 95 percent level of confidence.

This is very different from what might be called colloquial, or more action-oriented, understandings of the term, and population health research and policy need urgently to rethink this definition.  To give a simple and provocative example, many of us individually would take, and are taking, protective measures against coronavirus infection on the basis of far lower than 95 percent probabilities that they would prevent infection.  Public health authorities should be guided by a similar insight.   The combination of privileging epidemiological findings and fetishisation of statistical significance can generate reluctance to infer probable causation that can be pernicious.  Those of us who cut our professional and activist teeth on environmental and occupational health issues learned this decades ago. “We don’t know what works” is a conclusion welcome to the rich and powerful.

Nevertheless, this book is a must-read and an essential resource for anyone seriously concerned with reducing health inequalities.

And then: an even more remarkable volume on Slavery’s Capitalism: A New History of America’s Economic Development, edited by Sven Beckert and Seth Rockman.  Historian Beckert’s previous book, Empire of Cotton, made a powerful case that the textile industry that developed in the early nineteenth century was the first truly globalised industrial production system, enabled by the combination of technological innovation in the UK and the possibilities for low-cost slave labour in the US South enabled by the transatlantic slave trade, with Liverpool as the epicentre first of the slave trade and then, after its abolition in the UK (1807), of the cotton trade.  The edited book is chilling in its documentation of such patterns as the routine use of torture – the lash and more devious instruments – as a way of increasing production, and the use by plantation managers of commercialised methods of scientific management decades before the routine was applied to manufacturing production by F.W. Taylor.

The volume is also a salutary reminder that history matters – a point neglected by Mackenbach, perhaps because of his European focus (there is no index entry for race).  Recent historical analysis indicates that the hard realities of African-American health deprivation in the US must be understood, and responded to, as a global health issue.  Analogously, outside the high-income world, global health research that neglects the destructive effects of decades of ‘structural adjustment’ conditionalities demanded by international financial institutions and driven by the priority of protecting creditor interests is intellectually irresponsible, even if still widespread.

Finally, heartbreak.  A 16 July Guardian article by LSHTM professor Val Curtis described a history of repeated delays in NHS diagnosis and treatment for her now probably terminal cancer.  Read it; any summary would do a disservice to its author, and her observation that she ‘still can’t get my head around the brutal fact that I’m dying’ at age 61.  She correctly notes that: ‘My story is only one of many thousands of people in England whose deaths can be linked to austerity.’  I have trouble containing my rage whilst reading this, and the scandal of almost four million people on NHS waiting lists for elective care has now hit The New York Times.  Like the fate of the Grenfell Tower casualties, Prof. Curtis’ situation demonstrates that policy choices made during the past decade of austerity, like the most recent knock-on effects on the coronavirus response, have been homicidal.  Let’s repeat that word, for emphasis: homicidal.

Whether the health research, policy and practice community are willing to use that word, and to call out those responsible, remains to be seen.

This post was updated on 20 July to add reference to the New York Times article.