Tag Archives: social determinants of health

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

Posted on by
5

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

Posted on by
Reply

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

Posted on by
Reply

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

Posted on by
Reply

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.