Last year, my colleague Clare Bambra and I described the consequences of recent economic and social policy in the United States and the United Kingdom as ‘neoliberal epidemics’. In doing so, we actually combined three categories: a health outcome of rising concern (obesity); key social determinants of health outcomes (economic inequality and insecurity); and a policy driver of those social determinants (austerity). Arguably, this combination was justified because (a) an abundant evidence base connects inequality, insecurity and austerity with adverse health outcomes, of which obesity is only one; (b) the phenomena in question exist on such a scale and have spread so quickly across time and space that if they involved pathogens they would be seen as of epidemic proportions; and (c) the epidemics in question are direct consequences of neoliberal economic and social policies. Academics tend to preoccupy themselves with nitpicking about definitions, but the core elements of neoliberalism and its manifestations are described in a substantial research literature, as I have recently argued.
After six years of selective austerity in the United Kingdom, with economic inequality rising and the NHS in dire financial straits because of flatlined funding and cuts to social care, there would seem to be little reason to doubt that public finance is a public health issue. But particularly regarding the social determinants of health, we quickly encounter a conundrum when we try to answer the question of ‘how much evidence is enough’ to support or drive policy change. Writing in the Journal of Public Health, Katherine Smith and a colleague report that among the researchers they surveyed the favoured policy intervention was ‘more progressive systems of taxation, benefits, pensions and tax credits that provide greater support for people at the lower end of the social gradient’. Indeed, more of the researchers they surveyed considered such policies ‘strongly supported by available evidence’ than was the case for fluoridating water or raising tobacco taxes.
On the other hand, I have heard the Chief Executive of an affluent County Council claim that the evidence base for population-level interventions was quite limited. In 2009 the House of Commons Health Committee claimed to have ‘received no compelling evidence to suggest that anybody knows at present what changes’ in wider determinants of health ‘would be most effective at lowering health inequalities’ although it heard, and quoted, evidence from researchers including Richard Wilkinson and Sir Michael Marmot that some of us would consider quite compelling. Unfortunately, many physicians and epidemiologists share the parliamentarians’ skepticism. They regard the evidence base for acting on social determinants of health as weak because of the limited number of experimental or quasi-experimental studies, and consider policies to address them as ‘romantic but impracticable notions’, as a group of researchers wrote in 2005.
At issue here are the politics of evidence. Choosing a standard of proof – how much evidence, and what kind of evidence, is enough to justify a policy (or justify changing a policy) is fundamentally an ethical and political decision, driven by the relative weight attached to values that often come into conflict, and in turn by inequalities in power and resources. Debates about the strength of evidence for policies to reduce health inequalities seldom recognise this point, or the necessary conceptual distinction between the kinds of questions that can be answered by science and the kinds that can’t, despite decades of writing on this point by policy analysts (especially in the area of environmental regulation) and philosophers of science.
It must be emphasised that far more evidence exists for the adverse health impacts of neoliberal economic and social policies than for their economic merits, on their own terms. Nobel laureate and former World Bank chief economist Joseph Stiglitz points out that such policies, as promoted by the World Bank and the International Monetary Fund, ‘led to a lost quarter-century in Africa, a lost decade in Latin America, and a transition from communism to the market economy in the former Soviet Union and Eastern Europe that was, to say the least, a disappointment’. Closer to home, in the run-up to the 2015 election, Paul Krugman was one among many mainstream economists arguing that austerity as a macroeconomic policy for growth was a ‘delusion’. Further, its UK variant has proved spectacularly unsuccessful at deficit reduction, its stated rationale.
So what to do by way of resistance? Most fundamentally, in direct contrast to the caution about causation that is the hallmark of most epidemiology, we who are concerned about health inequalities should foreground a precautionary approach towards health consequences of economic and social policies. This approach or principle as articulated in environmental policy has numerous variants; the official European Commission definition
… covers those specific circumstances where scientific evidence is insufficient, inconclusive or uncertain and there are indications through preliminary objective scientific evaluation that there are reasonable grounds for concern that the potentially dangerous effects on the environment, human, animal or plant health may be inconsistent with the chosen level of protection.
Reasonableness, of course, is in the eye of the beholder, and the precautionary approach (which is my preferred terminology) in any of its variants does not provide a decision rule for individual cases. However, it underscores the value-driven nature of choices about how much evidence is enough to justify action.
The analogy with environmental policy controversies is useful. In a salvo in the ongoing debate with industry-funded toxicologists about regulating endocrine disrupting agents in the EU, a group of leading scientists pointed out that the precautionary principle as entrenched in EU law is ‘a legal concept for addressing scientific uncertainty, and not a scientific concept’. The key point here, they note, is the need to distinguish ‘between what constitutes science and what belongs to the realm of political, societal and democratic choices’ about acceptable levels of risk under conditions of uncertainty. We urgently need to apply similar insights to assessments of the strength of evidence for reducing health inequalities.
As David Stuckler and Sanjay Basu have written, in economic and social policy it is essential to adopt the axiom:
First, do no harm: if austerity were tested like a medication in a clinical trial, it would have been stopped long ago, given its deadly side effects. Each nation should establish a nonpartisan, independent Office of Health Responsibility … to evaluate the health effects of fiscal and monetary policies
To be meaningful, those evaluations must recognise the complexity, multiplicity, and sometimes brutality of the pathways that lead from social and economic inequalities to inequalities in health. Exhortations to eat a healthy diet when growing numbers of people just can’t afford to do that are among the more offensive examples of ‘lifestyle drift’, but the problem is more complicated.
The table shows that people who live in the centre of Stockton-on-Tees, where I live and work, and in the more affluent wards just a few miles away inhabit very different ‘epidemiological worlds’, to the extent that they might as well live in different countries. (The difference in male life expectancy shown in the table is comparable to the national average difference between the UK and Pakistan.) Many things go on at once in those worlds; they go on in ways that vary with the social position of the individual, the household and the community, and result in the accumulation of effects of (dis)advantage over the life course. Most epidemiological study designs, and many health promotion strategies and public health interventions fail to acknowledge that complexity and the associated ‘multiple sufficient causes of disease’.
A further strategy for foregrounding distributional choices and their consequences involves what I have called interrogating scarcity. A recent conference on healthcare priorities reminded me of how the rhetoric of ‘resource-scarce settings’ has become hegemonic in health policy analysis. Ethicists and economists routinely conduct studies in which they ask people to define and defend priorities for service provision within the presumption of a fixed health care budget, but hardly ever invite study participants to question or explore the political choices that define the fixed budget. The relevance to the current situation of the NHS is obvious, while resources seem to be almost endlessly abundant for financially imprudent, high-profile elite projects like HS2 and nuclear power expansion. And on the revenue side, corporate tax avoidance continues to be a major drain on the public treasury. These are manifestations of what French sociologist Loïc Wacquant calls the Centaur-state: enabling and supportive for those at the top of the income distribution, increasingly punitive and impoverishing for those at the bottom
The resource scarcities that constrain public health budgets, generate the racketeering language of ‘sustainability’ in the context of the NHS, and lead to slow-motion social disasters like the closing of libraries are the result of political choices, pure and simple. To restate the point: public finance is a public health issue. When the rhetoric of scarce resources is trotted out, the public health response must be: what policies created and perpetuate the scarcity? For whom are resources scarce? And for what purposes? It is worth recalling Calabresi and Bobbitt’s observation, in their remarkable book on Tragic Choices:
We must determine where – if at all – in the history of a society’s approach to the particular scarce resource a decision substantially within the control of that society was made as a result of which the resource was permitted to remain scarce. …. Scarcity cannot simply be assumed as a given (emphasis added).
Beyond these imperatives, lack of attention to the politics of evidence affects the way we live and work on a daily basis. Many health researchers genuinely believe that research ‘can engage policy makers in understanding the true costs of social disadvantage and motivate action’. In other words, it’s just a matter of producing more and better evidence, and policy will respond. Lack of response leads to the inference that we as researchers have somehow failed, and like the horse Boxer in Animal Farm, ‘I will work harder’ should be our guiding axiom.
You’ll recall that Boxer did indeed work harder, until one day he collapsed on the job, at which point the pigs who ran Animal Farm sold him to the knackers. Any resemblance to today’s academic environment is accidental.
Similarly, we may be enjoined to ‘generate evidence that is closely aligned with what policy makers and program planners can use’. But categories like ‘policy makers’ are decontextualised and problematic. We always need to ask who these actors are, and what their allegiances are likely to be. In a recent special issue of Social Theory & Health, Carles Muntaner and colleagues argued that ‘the vast majority of the population is on the opposite side of the class struggle than “policymakers”.’ Given today’s electoral alignments this is rather optimistic, but the idea of fundamentally antagonistic interests that force researchers and practitioners to take sides is indispensable. Being useful to policymakers (at least, to those currently in power) is often not consistent with a serious commitment to fighting neoliberal epidemics. And the preoccupation with generating stronger evidence can be destructive not only because very capable people spend their time beavering away on yet another body count rather than speaking truth about power, but also because it legitimises the claims of the powerful that the evidence base for acting on social determinants of health is not strong enough, when for many of us on any morally defensible standard of proof it is already quite strong enough.
Making this point and speaking truth about power are seldom popular. We are already seeing distortions of research priorities, as research careers become more precarious and more contingent on grant funding from the organisations of the powerful. (The Trades Union Congress and the National Association of Welfare Rights Advisers do not fund a lot of university research.) Katherine Smith’s important book on how research findings about health inequalities move, or don’t move, into public policy, quotes many respondents whose research priorities and presentations of findings were shaped, sometimes subtly and sometimes fundamentally, by the reinforcements provided by the organization. She found that ‘accounts of self-censorship,’ even on the part of senior researchers, ‘were far more frequent within the data than [she] had anticipated,’ including the pre-2010 period when health inequalities were at least a rhetorical priority of the New Labour government.
One of Smith’s respondents said that he or she had ‘almost come to the point where I think the challenge for public health is societal change’ but that in working with government ‘we can put that a bit on the shelf and talk about more practical things’. I understand the motivations, but this makes my skin crawl. I would counterpose an observation by the remarkable legal scholar Catharine Mackinnon. Speaking in 1982 during a groundswell of resistance to gender discrimination in the workplace, she said of her approach: ‘You may think that I’m not being very practical. I have learned that practical means something that can be done while keeping everything else the same.’ We can learn from that wisdom and apply it. If efforts to resist the advance of neoliberal epidemics are to have any chance of success, keeping everything else the same will not be good enough.
This posting is based on the annual Cost of Living symposium lecture given at the British Sociological Association Medical Sociology Study Group Conference, Birmingham, 8 September 2016.