‘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. 

Obesity: How neoliberalism made us fat

Posted by Ted Schrecker, Fuse Associate Member and Clare Bambra, Fuse Associate Director

A 2010 editorial in the Journal of the American Medical Association warned: “If left unchecked, overweight and obesity have the potential to rival smoking as a public health problem, potentially reversing the net benefit that declining smoking rates have had on the US population over the last 50 years”. Obesity increases the risk of developing cardiovascular disease (CVD), certain types of cancer, Type 2 diabetes, and orthopaedic problems. At the end of the 1970s it was estimated that 15% of US adults were obese. By 2012, this had more than doubled, to 35%. Among adolescents the increase is even more striking – from 5% at the end of the 1970s to 20% in 2012. In the UK, it is estimated that obesity nearly tripled between 1980 and 2002, from 6% amongst men and 8% amongst women to 23 percent and 25 percent women respectively. Amongst children in England, obesity has increased from 11% among boys and 12% among girls in 1995 to around 20% today.

In our book Neoliberal Epidemics: How Politics Makes Us Sick we argue that obesity in high–income countries is partly the result of political and economic choices made since the 1980s. Since the early 1980s, neoliberalism or “market fundamentalism” has dominated politics and economics across much of the globe, perhaps nowhere more conspicuously than in the post-Thatcher UK. Obesity is a neoliberal epidemic – one of four, along with austerity, stress, and inequality. They are neoliberal because they are associated with or exacerbated by the rise of neoliberal politics. They are epidemics because they are on such an international scale and have been transmitted so quickly across time and space that if they were a biological contagion they would be seen as of epidemic proportions.

North American contrasts between rich and poor urban areas, less than a mile from one another
Photo: T. Schrecker

Other high-income countries have also experienced increases in obesity. Obesity has no single cause; the many influences include changes in the food environment (including advertising, marketing, accessibility and affordability); the growth of sedentary work occupations and leisure time activity, such as television viewing; changing settlement patterns, notably the rise of a privatised approach to planning organised around driving rather than walking or the provision of public transportation; and changes in the built environment that reduce the safety and attractiveness of physical activity, especially for those who do not live in leafy places. However, countries that have gone farthest down the neoliberal road, the UK and the US in particular, have experienced greater increases in obesity – suggesting that neoliberalism has magnified and accelerated trends that are present to some extent throughout the high-income world.

Obesity is a neoliberal epidemic for several reasons. These include: (1) economic and social policies that have meant fewer people can afford a healthy and balanced diet; (2) increasing time poverty, as when the demands of work (often on unpredictable schedules), transportation, and (especially for women) child care within ‘flexible’ labour markets are combined, there is not much time or energy left for eating a healthy diet and the attraction of a quick stop at the shopping park’s fast food outlet are strong; (3) the role of aggressive corporate marketing of unhealthy, energy-dense foods, notably as multi-national supermarkets, manufacturers of ultra-processed food and fast food chains expand into developing economies with the lowering of barriers to foreign investment. This helps to explain why overweight and obesity are now also rising rapidly in many middle- and some low-income countries, with prevalence in Mexican adults comparable to levels in the United States.

Corporate food systems and time poverty interact at the shopping park.
Photo: T. Schrecker

A fourth connection was addressed at a groundbreaking workshop at the University of Oxford in 2009: political structures such as welfare state regimes. More specifically, higher levels of economic insecurity – associated with neoliberal policies like the rollback of welfare state protections and opening up labour markets to the “creative destruction” that Joseph Schumpeter extolled as a defining virtue of capitalism – are causally linked with a higher prevalence of obesity through both biological (stress-related) and psychosocial (comfort eating) mechanisms, in addition to the more direct effects on time and food budgets.

Public health researchers, who agree on little else, recognize that reducing overweight and obesity is a formidable challenge. A first step is to avoid the lifestyle trap. A recent literature review on policy interventions to tackle what has been called the obesogenic environment produced by the Scottish Collaboration for Public Health Research and Policy provides some useful directions. Its authors do not shrink from arguing the need for large-scale interventions that may be expensive or challenging to vested interests, noting (for example) that the transport mode split in urban areas is 84% by car versus 9 percent walking in the United States, while it’s 36% by car versus 39% walking in Sweden. “Suffice it to say, it has been a concerted combination of infrastructure provision, integrated transport planning and disincentives for private cars which has helped to bring about the higher active travel rates.” We have no easy solutions, but emphasise that neoliberalism and the associated political choices have exacerbated the obesity crisis. Obesity is an example of how politics makes us sick.

Links: Schrecker, T. and Bambra, C. (2015) Neoliberal Epidemics: How Politics Makes Us Sick, Palgrave Macmillan, available at: http://www.palgrave.com/page/detail/how-politics-makes-us-sick-ted-schrecker/?K=9781137463098

Professors Schrecker and Bambra will be discussing their new book 'How Politics Makes Us Sick' at an event at Durham University on 15 October 2015. For more details click here.

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About the authors

In June 2013, Ted Schrecker moved from Canada to take up a position as Professor of Global Health Policy, Centre for Public Policy and Health, Durham University (UK). Since 2002, most of his research has focused on the implications of globalization for health; he also has long-standing interest in issues at the interface of science, ethics, law and public policy. A political scientist by background, Ted worked as a legislative researcher and consultant for many years before coming to the academic world, and co-edits the Journal of Public Health. Among his publications, he is editor of the Ashgate Research Companion to the Globalization of Health (2012) and co-editor of a four-volume collection of key sources in Global Health for the Sage Library of Health and Social Welfare (2011). Ted is also an Associate Member of Fuse. Ted can be followed on Twitter @ProfGlobHealth.

As well as being an Associate Director of Fuse, Clare Bambra PhD is Professor of Public Health Geography and Director of the Centre for Health and Inequalities Research, Durham University (UK). Her research focuses on the health effects of labour markets, health and welfare systems, as well as the role of public policies to reduce health inequalities. She has published extensively in the field of health inequalities including a book on Work, Worklessness and the Political Economy of Health (Oxford University Press, 2011). She contributed to the Marmot Reviews of Health Inequalities in England (2010) and Europe (2013); the US National Research Council Report on US Health in International Perspective (2013); a UK Parliamentary Labour Party Inquiry into international health systems (2013), as well as the Public Health England commissioned report on the health equity in the North of England: Due North (2014). She is a member of the British Labour Party and can be followed on Twitter @ProfBambra.

Social policy and public finance: Are possibilities for health equity shrinking?

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

With the publication of Thomas Piketty’s massive book Capital in the Twenty-First Century, the acceleration of economic inequality has belatedly begun to receive the attention it deserves. His is, in fact, just one of several indispensable recent treatments of the topic. Another, which has received less publicity, is Hard Times: The Divisive Toll of the Economic Slump, by Guardian editorial writer Tom Clark and sociologist Anthony Heath – a meticulously researched treatment of how the recession has affected the United States and the United Kingdom. Readers too impatient to read Capital’s elegantly written 655 pages can find a highly condensed summary of much of Piketty’s work in the 23 May 2014 issue of Science. The summary is especially valuable for a conclusion that comes through more emphatically than it does in the book: ‘Inequality does not follow a deterministic process. …. There are powerful forces pushing alternately in the direction of rising or shrinking inequality. Which one dominates depends on the institutions and policies that societies choose to adopt’.

This is not new to those of us concerned with the social determinants of health; consider the WHO Commission on the topic and its focus on ‘the inequitable distribution of power, money, and resources’. Against this background, what are we to think of a new report on The Condition of Britain from the Institute for Public Policy Research? Since it was released in the same week as initial findings from the Project on Social Exclusion indicating that the proportion of British households living with multiple forms of material deprivation has doubled in the past three decades, one might have expected recommendations for a frontal assault on the elements of economic inequality that are most destructive of health to be the centrepiece of the IPPR report.

Not so. Instead, we get prescriptions for a ‘richer version of equality [that] is more complex than one focused purely on the distribution of material resources’ (p. 16) and the priceless statement that: ‘Like many other countries, Britain has experienced an unwinding of the postwar compression of market inequalities, and its tax and benefit system has had to work increasingly hard to reduce disparities in wealth and income. Fiscal constraints will limit the scope for post-tax redistribution in the years ahead, while tendencies towards greater wealth inequality may intensify (Piketty, 2014)’. This goes on for almost three hundred pages.



Crisis, what crisis?

In a jurisdiction that taxes huge incomes and accumulations of wealth as lightly as the United Kingdom, talk of fiscal constraints and the limited scope for post-tax redistribution is, to put it politely, nonsense. I prefer a stronger term, but Fuse probably doesn’t. The imperative of eliminating the deficit cannot be ignored, but as George Monbiot recently pointed out, on the revenue side the options include financial transactions taxes, wealth taxes and ‘a progressively banded council tax’. The most straightforward option is a return to much higher marginal tax rates on the personal incomes of the ultra-wealthy, which were the norm in many countries until quite recently. Thomas Piketty and his long-time collaborator Emmanuel Saez have themselves suggested this. (All these observations are also relevant to the proliferation of nonsense about the crisis of financial sustainability supposedly facing the NHS, now being regurgitated even by people who should know better.) On the expenditure side, massive welfare programmes for the propertied and the arms traders like HS2 and Trident replacement could be rethought.  

None of this would matter much – the IPPR report could be dismissed as an uninformed and unfortunate reprise of the discredited Third Way – except that the report apparently will shape much of the Labour Party’s agenda for 2015, and if elected thereafter. In other words, it represents the current limit of permissible official discourse, what one might call the frontier of political possibility for reducing inequality, and the message is clear: too bad, it can’t be done.

A week is a long time in politics, and the location of the frontier could change – not least in response to spirited advocacy for considering public finance and its equity implications as a public health issue. In the absence of such change, Johan Mackenbach’s gloomy 2010 conclusion that ‘reducing health inequalities is currently beyond our means’ will turn out to have been spot-on. We must be very clear, in private and in public, about the implications: the best that can be hoped for is a reduction in the pace at which health inequalities are growing, and even that is uncertain. Harsh words, but the times demand them. To quote Bob Dylan, ‘let us not talk falsely now, because the hour is getting late’.

All views expressed are exclusively those of the author.

Not necessarily useful, and unapologetic: Speaking out on health equity

Posted by Ted Schrecker

We should now be familiar with some hard facts about health equity. In the United Kingdom, despite rhetorical commitments by the previous government to reduce health disparities between rich and poor, by 2007 such disparities were on many measures greater than at any point since the 1930s. This was before the economic crisis and subsequent austerity measures, which have disproportionately affected the UK’s poorest regions, including of course the North-East.

North end of Stockton high street

Yet in discussions of how to reduce health disparities, a frequent refrain is that the evidence is not strong enough to serve as the basis for new policies that change the conditions in which people live and work. Tobacco control initiatives and encouraging people to eat a healthy diet are fine, but not so challenges to ‘the inequality machine [that] is reshaping the whole planet,’ in the words of the editor of Le Monde Diplomatique. Since (for example) the Canadian experience shows that a healthy diet is often unaffordable for benefit recipients or the working poor, and more than 46 million people in the United States are relying on the government vouchers known as food stamps, that would seem to be a major omission.

Debates about the strength of evidence are hardly new: think about tobacco, or climate change, or any number of environmental and workplace exposures the lethality of which is now widely acknowledged. The ethical and political nature of choices about standards of proof (how much evidence is enough) in these debates is often neglected. I began a recent article on this point with an analogy to the case of former professional athlete O.J. Simpson. Acquitted of the murder of his estranged wife and her friend in a criminal trial, he was nevertheless found liable for damages in a civil proceeding initiated by the survivors of his alleged victims. The difference simply reflects the much higher standard of proof that must be met, in common law countries, in criminal proceedings.

My points were that (a) the concept of a standard of proof is crucial for public health policy; (b) the choice of a standard of proof with respect to social determinants of health, as for environmental exposures, is a matter of public health ethics with respect to which scientists qua scientists have no special competence; and (c) unreflective insistence on a definition of scientific quality organised around avoiding false positives, or Type I errors, can be highly destructive of health, and in particular health equity, under conditions of uncertainty. Waiting for more evidence is itself a decision about risks and benefits. This point has been made in the literature for decades, yet it continues to be either ignored or willfully misunderstood.

A case in point: in The Body Economic, David Stuckler and Sanjay Basu assemble abundant evidence of the destructive consequences of austerity for population health, although much of it is not derived from experimental or quasi-experimental studies. Stuckler and Basu correctly observe that ‘in countries where austerity is ascendant, we’re undergoing a massive and untested experiment on human health, and left to count the dead.’ In ten or 20 years, that experiment may indeed provide answers to some of the questions epidemiologists would like to ask about social determinants of health, although there will always uncertainty because in the real world many things go on in people’s lives at the same time. Whether or not the experiment is justifiable is a matter of public health ethics, although it is seldom recognised as such.

Indifference to the role of competing values in making policy based on scientific evidence, and to the politics of such choices, is a generic problem. It is exemplified by the frequency with which speakers at a recent conference on urban health in Paris talked about the need for research to be useful to decision-makers. Similarly, an article on the relation between health research and public policy exhorts social epidemiologists to concentrate on narrowly defined questions amenable to experimental or quasi-experimental study designs that will generate ‘the kind of evidence wanted by policymakers.’

Anyone familiar with contemporary politics and public policy will realise that the quality of evidence demanded by policymakers – and that term is itself curiously decontextualised – depends entirely on what those in power have at stake. Often, no evidence or fabricated evidence is sufficient; think about the weapons of mass destruction that Iraq was declared to possess, or the nonexistent jobs into which George Osborne wants to herd impoverished under-25s. And in the population health context, what if policymakers have decided that some segments of the population are disposable, even though they cannot state this for public consumption?

I would argue that this is true of many national governments, as demonstrated by the policies they adopt. But even those who disagree should recognise the need for critical (and explicitly normative) perspectives on the relations between researchers and those in official positions outside the academic world. Local-level public health practitioners and organisations trying to reduce health disparities in a hostile environment deserve all the support we can give them. At the same time, progressive health researchers must choose our allies and audiences, and I for one have little interest in whether my findings are ‘wanted’ by David Cameron, Eric Pickles, or Iain Duncan Smith. The most appropriate guidance for health researchers of conscience as they interact with governments is sometimes the three R’s: Resist, Ridicule, and Replace.

All views expressed are exclusively those of the author.