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.

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

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. 

From tragedy to farce

The Telegraph, whose coverage of the coronavirus pandemic has been consistently excellent, reports today (21 April) that UK firms are shipping millions of pieces of personal protective equipment (PPE) to Europe, while frontline NHS personnel do without; UK firms cannot get a reply to their offers of supplies; individual hospitals are ‘sidestepping the government’s procurement process’ (thank heavens); and central government longingly awaits imports from Turkey.

If accurate, the report confirms that the UK’s response to the pandemic has descended past tragedy into homicidal farce.  Sadly, having now observed British universities for seven years, I can understand what’s probably going on within the similar bureaucracy of NHS procurement: quality is a byproduct, although it may be achieved (and in universities, as on the NHS frontlines, it often is); the real concern is ticking boxes, Following Procedures and not annoying superiors.  Those managing the process have little stake in the outcome.

With a brief hiatus after the initial shock of panic buying and lockdown, within days the shelves at Tesco and Sainsburys were filling up again: these and other companies, unlike the NHS, have experience with doing logistics on the fly.  As hard as it is for a committed social democrat to say this, it is hard to avoid the conclusion that turning PPE procurement over to private sector logistics contractors, with RAF aircraft at their disposal if necessary, would have produced a superior outcome and saved lives.*  The government will have to try this route if it is to have any hope of protecting professionals and the public as a step towards a lockdown exit strategy, before the economy collapses beyond hope of repair. 

And on that note Prof. Carl Heneghan of Oxford, one of British medicine’s most conspicuous overachievers, was quoted yesterday as having told BBC Radio 4 that ‘the damaging effect now of lockdown is going to outweigh the damaging effect of coronavirus’.  Indeed, the social science tells us precisely that.  The question now is who will listen.

* Update: The Times reported on 22 April, unfortunately behind a paywall, that the NHS has in fact simplified its PPE supply chain to involve both the armed forces ‘and Clipper Logistics, a private contractor’, but that the military are ‘appalled’ by continuing inability to procure PPE and deliver it where it is needed. Clearly managers cannot get even the simplified logistics right … the fatal farce continues.

No exit? The United Kingdom’s probable Russian Future

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.

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.

Starting a conversation: Evidence-informed polemic and the need for a new social movement

I am re-reading, not for the first time, some of the work of legal scholar Catharine MacKinnon.  (I used to refer to her as a feminist legal scholar; I don’t do this any more, since the adjective can be read as a qualifier, or a denigration.  Scholarship is scholarship, full stop.)  Her work has been an inspiration to me for a long time, since she combines impeccable, meticulously documented philosophical argumentation and legal reasoning with incandescent critique of injustice, gender inequality and misogyny.   

But MacKinnon is much more than a hyper-accomplished academic.  Among a host of other achievements, she was co-counsel in the first US Supreme Court case that recognised workplace sexual harassment as a form of discrimination; contributed to the development of Canadian equality law under the country’s Charter of Rights and Freedoms; was co-counsel in the suit that won a landmark US damage award against Serbian warlord Radovan Karadzic, establishing rape as an act of genocide in the context of ‘ethnic cleansing’; and subsequently served as the first gender adviser to the International Criminal Court.  MacKinnon’s advocacy played an important role in generating what is now widespread recognition of rape as a weapon and crime of war.  She has written extensively about these experiences, and much else, in a style I think of as evidence-informed polemic. [1]

The literature on health inequity includes at least a few examples of this style.  For example, in 2013 David Stuckler and Sanjay Basu argued (in The Body Economic) that: ‘The price of austerity is calculated in human lives.  And these lost lives won’t return when the stock market bounces back’.  Immodestly, in 2015 Clare Bambra and I put forward (in How Politics Makes Us Sick) the idea of neoliberal epidemics, specifying neoliberalism as a fundamental cause of health inequalities.  And in 2017, Lancet editor Richard Horton memorably described austerity as ‘a political choice that deepens the already open and bloody wounds of the poor and precarious’.   Outside the academic bubble of citation counts, these interventions (we) have had approximately zero impact in the real world. This post is an effort to start a conversation about how to change that.

One obvious observation is that MacKinnon’s impact results from a combination of advocacy and creative litigation using existing bodies of statute and doctrine.  One of the researchers interviewed by Katherine Smith characterised health inequalities as ‘the most fundamental abuse of human rights in the developed world. [I]f you imagine locking up a substantial proportion of your population for the last five or ten years of their life without any justification at all, well actually this is worse than that, it’s like executing them arbitrarily’.  Stated thus, the point seems obvious, but it’s hard to see avenues for turning it into a basis for litigation.  Maybe concerned academics have simply not connected with the right litigators, but issues of causation might present formidable barriers to success, given courts’ (and many epidemiologists’) tendency to set standards of proof that are often inappropriately high

At least in the UK, the deliberate corruption of universities by organising priorities and career paths around generating research income means fewer and fewer academics – mainly those near the end of their working lives, without dependents or with independent wealth – can engage in evidence-informed polemic rather than forelock-tugging before funders without fear of reprisal.  Professionals working in public health in government are likely to be even more limited in their ability to speak out, however sophisticated their private understandings of the origins and politics of health inequality (and in many cases, again in the UK at least, these are very sophisticated indeed).  The tendency of too many health promoters to acquiesce in the popular conception of poor health as somehow the fault of the individual affected does not help. 

Perhaps the most important issue is suggested by Sir Michael Marmot’s call, after the release of the 2008 WHO Commission report, for ‘a social movement, based on evidence, to reduce inequalities in health’.  That movement has yet to materialise.  Writing about women’s resistance to workplace sexual harassment in the United States, Carrie Baker defines social movements as ‘a mixture of informal networks and formal organizations outside of conventional politics that make clear demands for fundamental social, political, or economic change and utilize unconventional or protest tactics’.  Crucially, many coalitions that formed to fight sexual harassment connected women who were not otherwise similarly situated in socioeconomic terms.   Another, much more recent manifestation of such a coalition is the powerful anti-violence performance ‘A rapist in your path’, which originated in last autumn’s Chilean protests against inequality and has now gone viral in much of the world.  

Here’s the rub.  As I wrote a decade ago in the Canadian context, effective social movements need not only evidence and coalitions, but also rage, hopelessness, desperation, hope, shared passion, shared vulnerabilities, or some combination of these.  That’s where their energy comes from.  If one adopts a suitably precautionary standard of proof, as suggested by the human rights frame, there is no shortage of evidence – certainly not of the damage done by the past decade’s systematic upward redistribution of resources and opportunity.  What possible coalitions could move the health equity agenda forward, and how can the necessary emotional energy be mobilised?  Let the conversation begin.


[1] A selection of MacKinnon’s earlier work appears in Feminism, Unmodified (1988); somewhat later work in Are Women Human? (2007); and her landmark explication of feminism as political theory in Toward a Feminist Theory of the State (1991).  A very recent open access introduction to her perspective is available here.

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.  

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.