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Economists are the gods of global health. Their dazzling cloak of quantitative authority and their monstrously broad range of inquiry silence the smaller voices of medi cine, trapped as we are in the modest discipline of biology. Economists stepped beyond the boundaries of the body long ago. They now bestride the predicaments of our planet with confident insouciance. It is economists we must thank for the modern epidemic of austerity that has engulfed our world. Austerity is the calling card of neoliberalism. Its effects follow an inverse harm law—the impact of increasing amounts of austerity varies inversely with the ability of communities to protect themselves. Austerity is an instrument of malice. Search under austerity and you will find few countries unaffected. Greece, of course, but also Mozambique, France, Scotland, Brazil, Portugal, Spain, Cameroon, Belgium, the Netherlands, South Africa, and England. Economists advocating, and governments implementing, austerity naturally reject the word. Instead, they call austerity, “living within our means”. But be clear. What is promoted as fiscal discipline is a political choice. A political choice that deepens the already open and bloody wounds of the poor and precarious. The Financial Times, a newspaper usually in thrall to the spectacle of economics, called these policies “inhumane” last weekend. *
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But austerity is also a social contract. People accept severe restraints in public spending, actively in democracies or passively in autocracies, because they accept the unpalatable prescription of abstinence. Yet the public too has a choice. And they are exercising that choice in countries across the globe. Take the UK. Back in 1991, twothirds of the British population wanted more taxation and spending. But by 2006, only a third of people backed redistribution of wealth. If not welcomed, austerity was accepted. Not now. In the latest British Social Attitudes Survey, published last week, public opinion had turned against the idea of brutal scarcity. 48% of people wanted taxation increased to enable greater investments in society. 42% supported redistribution of income. And health was their priority—83% of people wanted more spending on our collective wellbeing. After a decade of cutting back the reach of government, the public is now demanding a stronger and more generous state. The contract authorising austerity has been torn up. 110
* How should the medical community respond to this turn towards health and equity? By listening, a skill that remains rather rudimentary. Epidemiology is poorly suited to monitoring the ideas and opinions of those we are supposed to serve. The powerful methods of population science we have refined over a century are often insensitive to the lives of the most vulnerable. Epidemiology is congenitally deaf to suffering. It ignores the lived experiences of those populations it studies. Kayleigh Garthwaite and Clare Bambra have taken a different approach to austerity (reported recently in Social Science and Medicine). They described lay perspectives about austerity in Stockton-on-Tees, a post-industrial town with some of the highest health inequalities in England. If one approached people with an epidemiological frame of mind, one could certainly confirm the individualised risk factors that shape much of modern medical thinking— smoking, alcohol, poor diets, and so on. But another perspective emerged too—namely, that often the “odds are stacked against you”. Children brought up in families where having a job was rare. Where education was poor. Where homes were derelict. Where stress was high. Where stigma was pervasive. Where opportunities were absent. Where attitudes and judgments towards those living in poorer areas were harsh. Where, as Garthwaite and Bambra put it, deprivation was written into the body. * What do these feelings of fatalism and hopelessness, being unable to see a way out, thinking “what’s the point, nothing I do will make a difference” mean for the wellbeing of people? They create, in Matthew Sharpe’s recent analysis of “austerity and the embodiment of neoliberalism as ill-health”, a kind of biological subcitizenship, a permanent second-class status in a withered and weakened society. Exclusion, exploitation, and dispossession disenfranchise. Political, cultural, and social violence lacerate minds and bodies. Too many economists are willing to trade these sufferings for growth. The task of health professionals is to resist and to oppose the egregious economics of our times. Richard Horton [email protected] www.thelancet.com Vol 390 July 8, 2017
Offline: Not one day more
Brendan Smialowski/Stringer/Getty Images
NurPhoto/Getty Images
Economists are the gods of global health. Their dazzling cloak of quantitative authority and their monstrously broad range of inquiry silence the smaller voices of medi cine, trapped as we are in the modest discipline of biology. Economists stepped beyond the boundaries of the body long ago. They now bestride the predicaments of our planet with confident insouciance. It is economists we must thank for the modern epidemic of austerity that has engulfed our world. Austerity is the calling card of neoliberalism. Its effects follow an inverse harm law—the impact of increasing amounts of austerity varies inversely with the ability of communities to protect themselves. Austerity is an instrument of malice. Search under austerity and you will find few countries unaffected. Greece, of course, but also Mozambique, France, Scotland, Brazil, Portugal, Spain, Cameroon, Belgium, the Netherlands, South Africa, and England. Economists advocating, and governments implementing, austerity naturally reject the word. Instead, they call austerity, “living within our means”. But be clear. What is promoted as fiscal discipline is a political choice. A political choice that deepens the already open and bloody wounds of the poor and precarious. The Financial Times, a newspaper usually in thrall to the spectacle of economics, called these policies “inhumane” last weekend. *
View Pictures/UIG via Getty Images
Bloomberg/Getty Images
But austerity is also a social contract. People accept severe restraints in public spending, actively in democracies or passively in autocracies, because they accept the unpalatable prescription of abstinence. Yet the public too has a choice. And they are exercising that choice in countries across the globe. Take the UK. Back in 1991, twothirds of the British population wanted more taxation and spending. But by 2006, only a third of people backed redistribution of wealth. If not welcomed, austerity was accepted. Not now. In the latest British Social Attitudes Survey, published last week, public opinion had turned against the idea of brutal scarcity. 48% of people wanted taxation increased to enable greater investments in society. 42% supported redistribution of income. And health was their priority—83% of people wanted more spending on our collective wellbeing. After a decade of cutting back the reach of government, the public is now demanding a stronger and more generous state. The contract authorising austerity has been torn up. 110
* How should the medical community respond to this turn towards health and equity? By listening, a skill that remains rather rudimentary. Epidemiology is poorly suited to monitoring the ideas and opinions of those we are supposed to serve. The powerful methods of population science we have refined over a century are often insensitive to the lives of the most vulnerable. Epidemiology is congenitally deaf to suffering. It ignores the lived experiences of those populations it studies. Kayleigh Garthwaite and Clare Bambra have taken a different approach to austerity (reported recently in Social Science and Medicine). They described lay perspectives about austerity in Stockton-on-Tees, a post-industrial town with some of the highest health inequalities in England. If one approached people with an epidemiological frame of mind, one could certainly confirm the individualised risk factors that shape much of modern medical thinking— smoking, alcohol, poor diets, and so on. But another perspective emerged too—namely, that often the “odds are stacked against you”. Children brought up in families where having a job was rare. Where education was poor. Where homes were derelict. Where stress was high. Where stigma was pervasive. Where opportunities were absent. Where attitudes and judgments towards those living in poorer areas were harsh. Where, as Garthwaite and Bambra put it, deprivation was written into the body. * What do these feelings of fatalism and hopelessness, being unable to see a way out, thinking “what’s the point, nothing I do will make a difference” mean for the wellbeing of people? They create, in Matthew Sharpe’s recent analysis of “austerity and the embodiment of neoliberalism as ill-health”, a kind of biological subcitizenship, a permanent second-class status in a withered and weakened society. Exclusion, exploitation, and dispossession disenfranchise. Political, cultural, and social violence lacerate minds and bodies. Too many economists are willing to trade these sufferings for growth. The task of health professionals is to resist and to oppose the egregious economics of our times. Richard Horton [email protected] www.thelancet.com Vol 390 July 8, 2017