‘First, do no harm’: How to think about austerity and public health

Posted by Ted Schrecker, Fuse Associate and Professor of Global Health Policy, Durham University

The current ‘neoliberal epidemic’ of (selective) austerity directs our attention to public health impacts of choices about public finance in several ways. Most fundamentally, anticipated post-2015 public expenditure cuts in the UK will reduce public expenditure as a proportion of Gross Domestic Product (GDP) to the levels of the 1930s, ‘taking the size of the state to its smallest in many generations’, in the words of a 2014 Institute for Fiscal Studies briefing. In fact, on recent projections by 2020 public spending in the UK as a proportion of GDP will be below the figure for the US, despite the latter country’s bloated defence budget. It is implausible that a National Health Service that is free at the point of use can be maintained with pre-World War II levels of public spending. Even a brief conversation with anyone familiar with US health care reminds us just how much that matters.

Meanwhile, the health consequences of social spending cuts that fall disproportionately on the poorest people and regions are beginning to be manifest in rising food insecurity and increased use of food banks – the latter trend probably related to the rising rates at which benefit recipients are sanctioned. Further health impacts, more difficult to isolate epidemiologically but probably at least as significant, are associated with the stresses of chronic insecurity, powerlessness, and lack of ‘control over destiny’.

There is a basic ethical and political point here about the politics of evidence. Sir Michael Marmot and colleagues wrote in 2010 that ‘It is hard to see how even ideologically driven commentators could think that having insufficient money to live on is irrelevant to health inequalities’. Good point.

In a previous blog with Clare Bambra, we demonstrated that politics can make us sick; Clare recently wrote a similar blog highlighting large health divides across Europe, showing that where you live (and the health policies implemented there) strongly affects how long you live. Against the background of austerity and the rising costs of healthy diets, it is indefensible to ask public health professionals and advocates to demonstrate, over and over again, that (for example) inadequate incomes lead to unhealthy diets and poor health. Rather, the burden of proof should be shifted: we must insist on clear and convincing evidence that national governments’ choices about the level and composition of public expenditure first, do no harm to health, except in extraordinary and clearly justified circumstances. This is an important part of the case for (independent, third party, adequately resourced) health impact assessments, especially of policies and programmes outside the health sector. Such a shift in the burden of proof is also congruent with the strong presumption in international law against retrogression (backsliding) with respect to human rights such as the right to health – a presumption that assumes special importance in an era of austerity.

Is corporate tax avoidance a public health issue?

Public finance, then, is a public health issue. This point applies to the revenue side, as well. The publication of the ‘Panama papers’ reminds us of the extent to which cross-border tax avoidance, whether legal or questionably legal, represents one of the ‘fiscal termites’ that can undermine states’ ability to provide everyone with the prerequisites for a healthy life. (Interestingly, the phrase ‘fiscal termites’ was coined by the former director of the International Monetary Fund’s Fiscal Affairs Department.) The question of how maintaining health services free at the point of use and investing effectively in prevention could be financed should be asked as a routine element of public health practice and advocacy – part of a broader strategy of interrogating scarcity. One answer could be using revenues from clamping down on UK corporate taxes avoided by major transnational corporations. In the real world, resources can almost always be found for the purposes of the powerful: think HS2, Trident renewal, and so on.

Choices about public finance are political choices with consequences for health and health inequalities; academics and practitioners must not be shy about pointing out those consequences.


A more extensive list of references is available from the author.  All views expressed are exclusively those of the author.

Photo: Servizi Mediali.  Reproduced under a Creative commons 2.0 licence.