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

Posted on 10th April 2023 by Theodore

Acknowledgement: This commentary was originally written for Policies for Equitable Action on Health. It reposted here with some additional material with the kind permission of Daniele Dionisio, who runs PEAH. Further republication consistent with the Creative Commons licence that applies to my entire blog is encouraged.

Introduction: The pandemic and the perils of averages

*Figure 1. Downtown Montréal, March 2023. Photo: T. Schrecker*

I wrote part of this post during my first post-pandemic visit to Montréal, a Canadian city that I love and once called home. It has not been easy. While many affluent parts of the city have largely regained their pre-lockdown vibrancy, other districts are now populated mainly by vacant shop fronts (Figure 1). At the same time, sometimes almost next door, numerous glittering condo towers soaring as high as 61 storeys are under construction (Figure 2). They are beyond the financial reach of most of the city’s residents, trapped like other Canadian city dwellers in a deepening crisis of housing affordability, which is part of a more general and widespread cost-of-living crunch.

Policy analysts are lauding governments – and some governments are congratulating themselves – for having sidestepped the cataclysmic lockdown-induced recession that it was reasonable to anticipate (as I did) in the first months of the pandemic. In both the United States and Canada, temporary responses to the pandemic reduced officially defined poverty rates to a degree that would have been highly improbable under less extreme circumstances. The US Federal Reserve’s annual survey of households in 2021 found the highest levels of several indicators of financial well-being since the survey began in 2013. On the other hand, in the United Kingdom child poverty (and therefore family poverty) has continued to increase and deepen through the years of pre-pandemic austerity and since then.

*Figure 2. Downtown Montréal, March 2023. Photo: T. Schrecker*

As this observation suggests, whatever the view from 30,000 feet, ‘on the ground’ the consequences of the pandemic can look very different. Very early on, data from Montréal made it clear that the impacts of the pandemic were stratified by class and race (Figure 3). Cities like Montréal may ‘recover,’ in a statistical sense, but many of the businesses that thrived there and the households that lived there are not likely to do so. There is an important methodological point here. As in any other inquiry related to the social determinants of population health, averages can be fatally misleading. Eduardo Galeano wrote: “Where do people earn the Per Capita Income? More than one poor starving soul would like to know.” Aggregates and averages cannot tell the story of life in a city where buyers of million-dollar condos move in, as tenants dispossessed by a wave of ‘renovictions’ move out. Here is yet another illustration of why the tipping point concept is important. Before the pandemic, researchers were writing about gentrification and “condoization” in Montréal. The pandemic and policy responses to it have accelerated the processes, and as elsewhere magnified the impacts on inequality. These are likely to be intractable and intergenerational.

The return to business as usual

The pandemic transiently made radical expansion of the realm of the possible in economic and social policy seem plausible. While rhetoric about “building back better” proliferated, two detailed and thoughtful proposals in this vein actually appeared in 2019. The annual Trade and Development Report of the United Nations Conference on Trade and Development (UNCTAD) called for a global Green New Deal organized around raising labour’s share of incomes worldwide, raising additional revenue to support fiscal stimuli, and expanding public investment in clean transport and energy systems and sustainable food production. Also in that year, British historian Simon Szreter and colleagues published a prize-winning UK-focused proposal for “incentivizing an ethical economics” organized around raising taxes to invest in sustainable growth and offering universal care provision in old age – a “new social contract” and “new intergenerational contract”.

Taking seriously building back better means, in the words of iconoclastic economist Mariana Mazzucato, “we need to radically reform and rearm the state.” It is not as if the necessary policy instruments are unavailable, be they the public development banks to which UNCTAD devoted an entire chapter of its 2019 report; the range of measures described by Szreter and colleagues; or – to use an example from close to home – the housing co-operatives that provided affordable housing to many Canadians before senior levels of government abandoned the housing sector to market forces. Especially in an age of long-term geopolitical instability, calling for more rather than less spending on defence, using those instruments to ensure that “the costs and benefits of a green transition are distributed equitably across society so that social injustices are tackled alongside environmental crises” (to quote Mazzucato again) will require substantial new revenue streams mobilized through progressive taxation.

Both UNCTAD and Szreter and colleagues emphasized the importance of this point, as did later analyses. In 2020, as the scale of the pandemic’s impacts was already becoming clear, UNCTAD argued that “[in] light of the further increase in inequality resulting from this crisis the case for a wealth tax seems irrefutable.” Even the Financial Times’ editors conceded that wealth taxes would “have to be in the [policy] mix” (paywalled). Since then, policy silence on this point has usually been deafening. US president Biden’s March, 2022 legislative proposal to levy a minimum tax on the ultra-rich and to tax unrealized capital gains on financial assets was a striking outlier, although the perverse structure of Senate representation doomed it from the outset. Improbably, the UK’s Conservative government in November, 2022 introduced incremental tax changes that slightly reduced the preferences granted to the ultra-rich and lowered the level at which the highest marginal income tax rate applies, but will do nothing to reverse the magnification of inequality and hardship during the pandemic. More conspicuously than in the aftermath of the 2007-2009 financial crisis, innovation has been abandoned and policy – in particular, commitment to reducing inequality – reset to business as usual in a wave of what the Roosevelt Institute in the US has called zombie neoliberalism.

The reset is perhaps not surprising given the outsized and growing influence of money in politics, as described by Brooke Harrington, Jane Mayer, and Peter Geoghegan among many others. Catherine Belton has focused on how Russian flight capital influenced British politics as it penetrated London property and financial markets, and in an important comparative study US political scientist Larry Bartels found “remarkably strong and consistent evidence of substantial disparities in responsiveness to the preferences of affluent and poor people. Insofar as policy-makers respond to public preferences, they seem to respond primarily or even entirely to the preferences of affluent people.” This dynamic is likely to be more powerful than ever in a more unequal post-pandemic world where resistance emanates not only from transnational corporate tax avoiders and the one percent with their hypermobile assets, but also a substantial stratum of newly enriched property owners with an expanded stake in financialized housing markets.

It is therefore dispiriting but arguably predictable that (for example) Britain’s opposition Labour Party has recently tried to lower expectations of future change, its leader “constantly calculating which of the people desperately awaiting his government he can afford to ignore because they have no powerful advocates” in the words of eloquent Guardian columnist Nesrine Malik. The answer, probably, is most of them. One must hope that such efforts fail, yet at the same time contemplate with unease the politics of desperation that the future is likely to bring.

The Covid-19 pandemic as tipping point (Part 1)

Posted on 10th April 2023 by Theodore

Acknowledgement: This commentary was originally written for Policies for Equitable Action on Health. It is reposted here with the kind permission of Daniele Dionisio, who runs PEAH. Further republication consistent with the Creative Commons licence that applies to my entire blog is encouraged.

I began a (pessimistic) 2022 book chapter on the prospects for ‘building back better’ after the Covid-19 pandemic by quoting the first sentences of J.G. Ballard’s magnificent dystopian novel High-Rise:

Later, as he sat on his balcony eating the dog, Dr Robert Laing reflected on the unusual events that had taken place within this huge apartment building during the previous three months. Now that everything had returned to normal, he was surprised that there had been no obvious beginning, no point beyond which their lives had moved into a clearly more sinister dimension.

The giveaway word here is “normal,” and the new normal to which Laing’s world has returned is one in which a deadly class war between the affluent and even more affluent residents of a 40-story tower block has completely destroyed the interior of the building and most of its vital systems, and survivors are reduced to killing and eating the pets of their less fortunate neighbours. In a scene near the end of the novel, surviving children play with human bones in the tower block’s rooftop sculpture garden.

This rather dramatic introduction was designed not to suggest that post-pandemic societies will literally regress to that extent, although that could happen in some contexts, but rather that conditions of life that come to be regarded as normal in the post-pandemic world will probably look very, very different from those of late 2019, and for most of us more insecure and threatening. I am more convinced of this now than I was when I wrote the chapter.

In a recent conference paper, I argued that the pandemic should be understood as a tipping point, initiating processes that magnify and accelerate existing trends, in particular those involving rising inequality and its direct and indirect effects on health. The concept of a tipping point is used in several, slightly different ways depending on context, but it is now most familiar from research on climate change. Leading climate researcher Timothy Lenton explains: tipping points “occur when there is strongly self-amplifying (mathematically positive) feedback within a system such that a small perturbation can trigger a large response from the system, sending it into a qualitatively different future state.” Stated more colloquially, “sometimes little things can make a big difference,” or at least a disproportionate difference, “to the state and/or fate of a system.”

Figure 1. Schematic representation of cascading effects in the vegetation–rainfall system

(a) Vegetation–atmosphere system in equilibrium. (b) Initial forest loss triggered by decreasing oceanic moisture inflow. This reduces local evapotranspiration and the resulting downwind moisture transport. (c) As a result, the rainfall regime is altered in another location, leading to further forest loss and reduced moisture transport. Reproduced without change from Zemp, D. C., Schleussner, C. F., Barbosa, H. M. J., Hirota, M., Montade, V., Sampaio, G. et al. (2017). Self-amplified Amazon forest loss due to vegetation-atmosphere feedbacks. *Nature Communications, 8,* 14681 under a Creative Commons Attribution 4.0 International Licence.

An especially striking example is provided by deforestation in large tropical rain forests (Figure 1). As much as half of the precipitation that falls on such forests originates from evapotranspiration within the forest itself. The concern is that deforestation resulting from human activity (forest clearance) will combine with reduced oceanic moisture inflows to lead to a tipping point in which reduced rainfall accelerates forest dieback, and the rain forest transitions to savannah or steppe. This will itself accelerate climate change, as the forest no longer provides a carbon sink. Researchers write that findings about multiple processes of this kind “imply that shifts in Earth ecosystems occur over ‘human’ timescales of years and decades, meaning the collapse of large vulnerable ecosystems, such as the Amazon rainforest and Caribbean coral reefs, may take only a few decades once triggered.” This is a long time in the context of such phenomena as election cycles, but an eyeblink in geological time. Whatever the time scale, once a tipping point has been reached, the pace of changes that were already under way accelerates rapidly, and entirely new changes may begin.

My pre-retirement colleague Clare Bambra and colleagues have provided an especially compelling account of how distribution of health outcomes during the pandemic reflected and magnified economic inequalities (open access, and essential reading). Looking ahead, here are a few of the patterns (far from an exhaustive list) that suggest the value of considering the pandemic as tipping point:

Concentration of wealth at the very top of national and global economic distributions: The number of US dollar millionaires worldwide increased from 46.8 million in mid-2019, the last pre-pandemic year, to 62.5 million in 2021. This growth was fuelled by rising share prices, but also by
Soaring property prices in much of the world. US homeowners saw their wealth increase by more than US$6 trillion between the start of the pandemic and the third quarter of 2022; average house prices across Canada’s 15 major metropolitan areas rose by as much as 45 percent between 2019 and 2021, depending on distance from the city centre. The ‘flip side’ of this pattern, which began before the pandemic but was accelerated by it and is repeated in many European centres, is
A growing pattern of unaffordable housing and semi-permanent housing insecurity, underpinned by the financialization of housing, which also predates the pandemic and led one group of Australian researchers to conclude that: “sustained inflation of property values … has fundamentally shifted the social class structure, from a logic that was structured around employment towards one that is organized around participation in asset ownership and appreciation.”
Housing prices are an important part of a larger cost-of-living crisis, originating in supply chain disruptions associated with the pandemic and worsened by Russia’s invasion of Ukraine and its weaponization of energy exports. Interest rate increases – a conventional central bank inflation-fighting tactic – cannot address these impacts because they have no effect on supply, and in fact are likely to magnify inequality, as they raise the cost of consumer debt and are passed through to consumers by producer firms.
In a global frame of reference, countries differed in the fiscal capacity they were able to deploy in initial responses to the pandemic, which will probably lead to increased inter-country inequality. Further issues arise from what could be
An impending sovereign debt crisis for many countries; before the pandemic the sovereign debt load of countries in sub-Saharan Africa, the world’s poorest region, was more than twice its nominal value in 2009, the year after the financial crisis. In early 2023 the American Public Health Association called on the International Monetary Fund, World Bank and G20 “to eliminate debt for the poorest countries and expand fiscal space for public financing of health services and public health programs.”
Finally, of course, there are the effects of climate change on various social determinants of health, including food security.

The World Economic Forum’s 2023 Global Risks Report devoted an entire chapter to the concept of “‘polycrisis’ – a cluster of related global risks with compounding effects, such that the overall impact exceeds the sum of each part.” This is a useful way of capturing the interactions discussed here, yet at the same time we must acknowledge that many trends in question will present as crises for many, and opportunities for others. (Housing price escalation is a case in point.)

Perhaps my view of the future is excessively bleak. After all, high-income countries were able to buffer many of the pandemic’s economic effects, and the US improbably experienced a substantial, if temporary, drop in poverty. The situation outside the high-income world was, and is, considerably more grim, like the “vaccine apartheid” that has now largely faded from public consciousness, reflecting the multiple dimensions of global inequality and the relative invisibility of the global majority. Numerous blueprints, some quite detailed, exist for ‘building back better’. The second part of this posting will direct readers to a few of these; assess some of the formidable political obstacles to their realization against the background of rising inequality; and offer a few conjectures about health in the post-pandemic new normal.

Hating to have been right

Posted on 23rd August 2022 by Theodore

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

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

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

New Year, New Lockdown: ‘The Great Deception’

Posted on 10th January 2021 by Theodore

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

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

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

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

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

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

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

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

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

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

Indeed.

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

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

Posted on 19th November 2020 by Theodore

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

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

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

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

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

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

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

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

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

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

Realism versus Monbiot: Thoughts on possible worlds of post-pandemic reconstruction

Posted on 8th May 2020 by Theodore

George Monbiot is only one of many commentators who have argued the need for a post-pandemic programme of economic reconstruction that will address environmental concerns as well as the imperative of restoring and securing the livelihoods of literally hundreds of millions of people. The importance of this latter imperative cannot be overstated. In the US alone, unemployment by the end of April quadrupled to 14.7 percent, with 20.5 million jobs lost. In the UK, the Bank of England has warned of a doubling of unemployment to nine percent and a shrinkage of the economy’s overall output to a 300-year low. The UK unemployment figures are less horrific than they otherwise would be because of a massive debt-financed programme of wage and salary compensation that the Chancellor of the Exchequer has correctly characterised as unsustainable.

Against this background, Monbiot (and I am not picking on him here; he is rather the most articulate and best informed proponent of this perspective, and therefore the most difficult target) argues that ‘[g]overnments should provide financial support to company workers while refashioning the economy to provide new jobs’ outside the automobile, fossil fuel and airline industries. It is now a commonplace that after the financial crisis of 2008, governments bailed out many of the financial institutions that had caused the crisis – that is, their shareholders, managers and workers – rather than those who bore the worst consequences. Monbiot argues that: ‘This is our second great chance to do things differently’. But with government debt and expenditure levels relative to GDP already approaching twentieth-century wartime levels, just to finance short-term remediation, the unavoidable question is: do things differently with what? And where will the investment necessary for such new jobs, and the financing needed to support workers’ transition to them, come from?

It is nice to envision, as a team of luminaries including Nobel laureate economist Joseph Stiglitz and climate economics authority Sir Nicholas Stern has recently argued based on an expert survey, that post-pandemic reconstruction can contribute to reducing climate impacts through investment in ‘clean physical infrastructure, building efficiency retrofits, investment in education and training, natural capital investment, and clean R&D’, whatever that is. The authors do not explain where the money will come from, in a world where the estimated US$2.5 trillion annual investment needed to meet the Sustainable Development Goals before the pandemic was nowhere in sight.

It is possible, in theory, to envision mobilising the needed resources by way of income and wealth tax rates that were prevalent after the Second World War, responding to wartime government debt and expenditure levels. Many of these are now probably infeasible because of the concentration of ultra-wealth in financial instruments and tax haven real estate, and because of possibilities for capital flight that can best be limited through transnational cooperation in a world where a corporate-financed US Congressional candidate has claimed that ‘[f]reedom and democracy are best secured when banking secrecy and tax havens exist’.

If the ultra-rich are probably beyond the reach of national public policy, then the menu of policy options shrinks considerably. When many dividends have already been cancelled, whose income does Monbiot propose to reduce, whose assets to tax or seize, and how? What happens to firms that cancel dividend payouts when investors flee their shares, making it impossible for them to raise new capital in response to lockdown-created shortfalls? How can green jobs be created by seizing foreign oligarchs’ London property holdings, their financial assets having long ago been safely shifted elsewhere? How many of the Russell Group universities’ 508 senior staff who were paid more than the prime minister in 2018-19 will agree to salary cuts or marginal tax rate increases for the greater good? Will their response be representative of their broader posh demographic? Will clinicians who own second homes be content with strongly progressive taxation of their increased value over the years? What are the legalities of much-needed retrospective wealth taxation?

In short: How are these dreams to be paid for?

These are not rhetorical questions, and they should be the starting point for conversations that substitute serious consideration of political economy for cheerleading. Even in high-income countries, the post-pandemic menu of policy options is likely to be circumscribed by the International Monetary Fund’s role as a gatekeeper to financial markets – a role that low- and middle-income countries (LMICs) have experienced with often bitter consequences over the past decades, with the impacts compounded by capital flight. Given the dire situation of LMICs, what justification can the high-income world offer to the world’s majority outside its borders for not taking advantage of fossil fuel prices that have sunk to the pre-1973 levels that enabled today’s rich to get that way, unless its development assistance agencies and investors are willing to increase their commitments by at least an order of magnitude? Such conversations may have begun, but I am not hearing them.

No exit? The United Kingdom’s probable Russian Future

Posted on 18th April 2020 by Theodore

As many governments are announcing strategies for ending lockdowns, we have the curious situation in which the leader of the Labour Party and the Adam Smith Institute agree that the UK government needs to set out such a strategy, but the government refuses to do so. It says only that five tests must first be met, but gives no evidence of being able to meet any one of them.

This is dangerously irresponsible, and is likely to have long-term negative consequences for public health and health inequalities – consequences that most public health researchers and practitioners seem determined to ignore. Look ahead, for example, to next January when new border controls (the UK imports 30 percent of its food from the European Union) create food shortages whilst economic collapse worsens fuel poverty that was already a substantial public health issue before the pandemic.

In the absence of a clear, credible and rigorously implemented exit strategy, the future may well resemble the situation in Russia after the collapse of the former Soviet Union. The economy contracted by close to 50 percent, existing social provision mechanisms and large portions of the health care system crumbled, and life expectancy – especially for men, who now are hit harder by the coronavirus – plunged by several years. Conventional wisdom attributes a substantial part of this transition to alcohol consumption, but from a social determinants of health perspective this is explanandum rather than explanans: that is, it demands explanation rather than providing one. Twenty-five years on, Russian life expectancy still did not reflect the country’s economic recovery. That recovery was accompanied by rising economic inequality, massive capital flight, and the emergence of a new stratum of politically connected billionaire oligarchs.

All this could be avoided, but there is no sign that either the UK government or the public health community are even taking these risks seriously.

Additional sources on the Russian experience:

Field MG and Twigg JL, eds. Russia’s Torn Safety Nets: Health and Social Welfare during the Transition. New York: St. Martin’s Press; 2000.

Field MG, Kotz DM, Bukhman G. Neoliberal Economic Policy, “State Desertion,” and the Russian Health Crisis. In: Kim JY, Millen JV, Irwin A, Gershman J, eds. Dying for Growth: Global Inequality and the Health of the Poor. Monroe, Maine: Common Courage Press; 2000: pp. 155-73.

Against Covid-19 fetishism, and other musings

Posted on 14th April 2020 by Theodore

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

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

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

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

Let me suggest just one example of probable impacts:

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

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

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

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

This post was updated on 15 April.

Why no talk of an inequality emergency?

Posted on 3rd December 2019 by Theodore

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,

Health as if Everybody Counted (second edition)

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

Tag Archives: inequality

Hating to have been right

More important reads from across the web: Bank Holiday edition

Against Covid-19 fetishism, and other musings

Why no talk of an inequality emergency?