The Political Economy of Public Health: Challenges for Ethics
Abstract and Keywords
As an analytical approach, the political economy of health “requires attention to the political and economic structures, processes and power relationships that produce” distributions of health and illness, in the words of epidemiologist Nancy Krieger. This chapter demonstrates the value of this approach with reference to domestic and global cases and is organized around three key messages. First, public finance is a public health issue. Second, the transnational corporate role in the spread of disease must be taken into account in public health ethics. Third, ethics and politics cannot be separated in public health. The chapter concludes with three challenges for building a public health ethics that “speaks truth about power” in an increasingly inhospitable policy environment.
(p. 842) Introduction: The Political Economy of Health
As an analytical approach, the political economy of health is best described by the iconoclastic epidemiologist Nancy Krieger: “[A]nalysis of causes of disease distribution requires attention to the political and economic structures, processes and power relationships that produce societal patterns of health, disease, and wellbeing via shaping the conditions in which people live and work” (Krieger, 2011, 168, emphasis in original; see also Birn, Pillay, and Holtz, 2017, 92–95 and chapter 7). As an illustration of the value that this perspective can add to public health ethics, consider Lisa Lee’s (2017) identification of the Flint, Michigan, lead poisoning crisis (Bosman, 2016; Carmody, 2016; Osnos, 2016; Bosman, 2017) as a case study in the need for an integrative, multidisciplinary health ethics that incorporates public health and environment as well as the more familiar concerns of bio(medical) ethics.
Lee (2017, 6) argues, correctly, that “[a]n attempt to solve one problem by removing bacteria from the polluted Flint River to make it potable resulted in another—the poisoning of the economically underserved community of Flint.” She does not, however, pursue such questions as why the community is economically underserved—a mode of inquiry that would include the history of deindustrialization in a once prosperous manufacturing center; racial segregation (Flint’s population is now predominantly African American); and, more proximally, a program of shrinking public sector services and budgets that had been actively promoted by a variety of neoliberal think tanks (p. 843) (MacLean, 2017, 213–215; MacLean’s book, and much of the recent scholarship she cites, are essential reading for anyone wishing to take seriously the political economy of public health, especially in the US context).
The Flint case shows that the production of patterns of health and illness to which Krieger refers is more than a metaphor. For an example in the global frame of reference, a history dating back to circa 1980 connects structural adjustment conditionalities demanded by the International Monetary Fund and the World Bank in return for loans to support a restructuring of countries’ external debts with rising inequality and destructive effects on health systems and social determinants of health (Kentikelenis, 2017). Several observers have connected the debilitating effects on national health systems of these conditionalities with the rapid spread of the Ebola outbreak in several African countries in 2014 (Rowden, 2014; Kentikelenis et al., 2015; Sanders, Sengupta, and Scott, 2015). Commentators differ about the motivations of those promoting such conditionalities; compare, for example, the view of the historian Ricardo Soares de Oliveira (2007, 44), writing specifically about sub-Saharan Africa, that “the goal was to debilitate the institutions and strategies that had thus far enabled the survival and prosperity of local elites and provided the structure for existing, if no longer viable, patronage systems” with the generic conclusion of a multidisciplinary panel of social scientists examining the prospects for “sustainable democracy” that “[a]n alliance of the international financial institutions, the private banks, and the Thatcher-Reagan-Kohl governments was willing to use its political and ideological power to back its ideological predilections” (Przeworski et al., 1995, 5), Whatever the operative motivations, the health consequences of structural adjustment show that understanding the relevant historical processes, institutional structures, and macro-scale policies is a prerequisite for intellectually responsible discussions of public health ethics.
Against this background, the chapter is organized around three core messages. First, and most fundamentally, public finance is a public health issue. Second, the transnational corporate role in the spread of disease, and the associated “power asymmetries” (Ottersen et al., 2014), must be taken into account in public health ethics. Third, these two observations (and others) indicate the inseparability of ethics and politics in public health. After an explication of these points, the chapter concludes with three challenges for building a public health ethics that “speaks truth about power” in an increasingly inhospitable policy environment.
Public Finance and Public Health Ethics
In the context of recent programs of fiscal austerity, in the United Kingdom in the first instance, the editor of The Lancet noted: “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” (Horton, 2017, 110). The choice does not, in fact, reflect any underlying (p. 844) economic necessity (Krugman, 2015), but rather a judgment about the relative value attached to protecting the lives and wealth of differently situated members of a society (Basu, Carney, and Kenworthy, 2017). Post-2010, a Conservative-led government expanded the Thatcher-era project of neoliberalization (Ward and England, 2007) by way of selective expenditure cutbacks that were, at this writing, on track to reduce the public sector’s share of the economy to pre–World War II levels—that is, to levels that predate the establishment of the National Health Service and the institutions of the postwar welfare state (Johnson, 2014). A senior social policy scholar observed that this amounted to a “root and branch restructuring” of the United Kingdom’s economy and society, of which “[t]he longer-term goal is to shrink the state, free the market and set British political economy on a new course” (Taylor-Gooby, 2012, 61). The cuts fell most heavily not only on the most vulnerable people but also on the poorest local economies (as summarized by Schrecker, 2017), which were already among the poorest regions in northern Europe (Eurostat, 2014). Notably, cutbacks in benefit levels and an aggressive and often capricious regime of benefit “sanctioning” (actual or threatened cutoffs) have been linked to rapid increases in reliance on charity food banks (Garthwaite, 2016), and—in both epidemiological studies and Parliamentary committee testimony—a rise in the prevalence of mental health problems and suicides (Mcdougall et al., 2015; Barr et al., 2016).
To reiterate: whatever the overall quantum of resources available to a government or other authoritative decision-maker, and keeping in mind that scarcity is seldom absolute in the sense that scarcities of rare earth elements or biologically compatible organ donors are absolute (Schrecker, 2013b), choices about public finance reflect assumptions or conclusions that some people’s lives matter more than others’ (Basu, Carney, and Kenworthy, 2017), and about why they do. This point was brought home in June 2017, when at least seventy-nine people died in a horrific fire in a London social housing tower block (Grenfell Tower). At the time of this writing, investigations were ongoing, but the use of flammable, and slightly less expensive, exterior cladding as a cost-cutting measure by contractors undertaking a refurbishment for the responsible local council (in the ultra-wealthy borough of Kensington and Chelsea) appears to have been an important factor, in turn enabled by deregulation and a lack of resources for inspection and oversight (Kirkpatrick, Hakim, and Glanz, 2017). It remains to be seen whether public revulsion in the aftermath will lead to changes in priorities. Furthermore, how that revulsion could be articulated is unclear.
Public finance is a public health issue in low- and middle-income countries (LMICs) as well. In a seeming turnaround from the legacy of structural adjustment conditionalities, universal health coverage (UHC) is now prominent on the global development policy agenda, and indeed is the topic of a target under the United Nations’ 2015 Sustainable Development Goals. Although increases in development assistance will be indispensable in some countries, in many the most important prerequisite for progress toward UHC will be the ability to mobilize domestic resources more effectively through taxation (Centre on Global Health Security, 2014). This mobilization may not be politically attainable, as can be seen from the example of India—a conspicuous underachiever on (p. 845) health indicators relative to economically comparable countries (Drèze and Sen, 2013), yet one where a newly elected government in 2015 opted to reduce an already minimal public sector health care budget (Mudur, 2015). A similar pattern can be seen on the African continent, where, more than a decade after a 2001 commitment by African Union member countries to raise health sector spending to 15 percent of the general government budget, many countries had made only modest progress (African Union, 2013). A recent World Health Organization analysis confirms this as a general pattern, finding a recent “overall deterioration in the role of domestic public funds for health spending, especially in low-income countries” (Barroy et al., 2017, vi). Thus, the interface of public finance and public health ethics involves choices on the revenue side as well as the expenditure side. This brief description cannot do justice to the complexities of the domestic politics of health care financing, but it underscores the central importance of a health ethics focus on public finance—at least unless one regards a state of affairs in which access to health care and the prerequisites for a healthy life is proportional to a household’s income or wealth as unproblematic.
In the international economic and political environment, the legacy of health systems weakened by structural adjustment has already been mentioned. A further problem, only recently recognized as consequential for health and health policy, involves the fiscally debilitating effects of capital flight (Schrecker, 2014a) and tax avoidance, which along with the desire for higher and more secure returns on investment is one of the primary motivations for capital flight (Harrington, 2016; Cobham and Jansky, 2017; Cobham, 2017). Some of the magnitudes remain contested (Forstater, 2017), but it is now clear that these processes have drained and are draining many LMIC economies of resources that—at least under favorable domestic political conditions—could have been invested in health care systems, public health programming, and efforts to address social determinants of health (for a nontechnical overview in the African context, see Ndikumana and Boyce, 2011).
An important caveat is in order at this point, given the increasing attention being paid to an approach usually described as “health in all” policies (WHO, 2015). The principle that public policy in areas that do not directly or obviously relate to health should be made with knowledge of the likely consequences for health (both positive and negative) is unexceptionable. This does not, however, imply that policies with negative consequences for health, or health inequalities, should never be adopted. As Daniel Weinstock (2015) points out, public policy is unavoidably about trade-offs among competing priorities, and it is impossible to optimize for multiple values simultaneously except as a matter of serendipity. Accepting the value of health in all policies as an approach to policy analysis does not mandate prioritizing health in all policy fields. Norms limiting the permissible negative consequences for health can be derived not only from principles of distributive justice (which admittedly represent contested terrain), but also from the norms embodied in international human rights instruments, notably those related to core obligations, progressive realization and non-retrogression (Schrecker, 2014b), but elaborating on these points would take us far beyond the scope and allowable length of this chapter.
(p. 846) The Corporate Role: “Vectors of Spread” for “Industrial Epidemics”?
Noncommunicable diseases (NCDs) represent most of the burden of illness in the high-income world, and their importance is rapidly increasing elsewhere. These are often inaccurately thought of as diseases of affluence, “lifestyle,” or both (Ezzati et al., 2005; Glasgow and Schrecker, 2015). Alternatively, a political economy perspective foregrounds two specific phenomena. Socioeconomically patterned differences exist within societies in people’s opportunities to live healthy lives. Manifestations include the unaffordability of healthy diets and the way in which housing markets in some settings segregate people on low incomes into “food deserts” (Beaulac, Kristjansson, and Cummins, 2009; Walker, Keane, and Burke, 2010; Burns, 2014). Against this background, large, mainly transnational corporations (TNCs) and their formidable investment, marketing, and lobbying resources shape both the choices available to individuals and households and the trajectory of public policies that affect health. Focusing on this dimension of public health policy, Rob Moodie and colleagues (2013, 671) have argued that the rising burden of NCDs is best explained as a congeries of “industrial epidemics” in which “the vectors of spread are not biological agents, but transnational corporations” in the tobacco, food, and drinks industries.
Comparisons with the tobacco industry are both provocative and instructive. Tobacco TNCs based in the United States and the United Kingdom are now notorious for a history of efforts to obscure or distract from scientific evidence of harm, by means ranging from selective citation to straightforward fraud (Glantz et al., 1996). They have also lobbied aggressively against public health measures, notably in expanding markets in LMICs (e.g., Egbe, Bialous, and Glantz, 2017; Boseley, 2017; Kalra et al., 2017a). Notably, recent years have also seen an intensification of the industry’s efforts to shape and use the provisions of trade and investment agreements to override requirements for plain packaging and warning labels (Fooks and Gilmore, 2014), on grounds related to lost revenues or expropriation of intellectual property (Russell, Wainwright, and Mamudu, 2015; Steele et al., 2015; Eckhardt, Holden, and Callard, 2016; Roache, Gostin, and Bianco, 2016). Such efforts have so far been largely unsuccessful, but defending against them, especially at the level of trade dispute resolution, requires substantial public sector resources. In such contexts, power asymmetries between TNCs and their acolytes and governments seeking to protect public health are especially marked—as they are with regard to the tobacco industry’s continued, well-resourced efforts to frustrate national implementation of the Framework Convention on Tobacco Control (Kalra et al., 2017b).
Public policy toward the tobacco industry has sometimes been characterized by what has been termed “tobacco exceptionalism,” but according to one leading tobacco policy researcher, “there is little to suggest that the corporate strategies of alcohol or food corporations are inherently more conducive to positive health outcomes” (Collin, 2012, 277; (p. 847) see also Freudenberg, 2014, 37–69). The motor and fossil fuel industries should almost certainly be added to this list. The strategy of “manufacturing uncertainty” with respect to scientific evidence originated with the tobacco industry, but it has since been adopted by other industrial interests, with respect not only to environmental and workplace exposures (Michaels and Monforton, 2005; Michaels, 2006; Davis, 2007, 296–434), but also to diet, perhaps most conspicuously with regard to the effects of dietary sugar, as documented in an important journalistic exposé (Taubes and Couzens, 2012). Even when such strategies are not deployed, the sheer value of resources that large corporations can devote to refining and marketing their products provides them with substantial, often unhealthy, influence on consumption patterns (Moss, 2013). This is a global concern: as barriers to trade and investment are lowered, rapid expansion of supermarket, ultra-processed food, and fast food TNCs into LMIC markets is having serious negative consequences for dietary patterns (Popkin, Adair, and Ng, 2012; Popkin and Slining, 2013; Friel et al., 2013; Monteiro et al., 2013; Freudenberg, 2014, 153–178; Popkin, 2014, 2015; Popkin and Hawkes, 2016). These portend a perfect storm in terms of future morbidity patterns and health system costs related to such NCDs as cardiovascular disease and diabetes, in addition to the obvious direct human consequences.
Such patterns are problematic because, like the tobacco industry’s lobbying activities, they are a manifestation of the raw power of money to shape decisions that affect people’s lives and health. This is a larger problem in democratic theory, one of several at the interface of political theory and health ethics. In addition, industry strategies distort the content of public health policy discussions by miscasting them as discussions of the strength of scientific evidence—sometimes in highly disingenuous ways—rather than of the underlying values that should guide public health policy in a context where waiting for further evidence inescapably embodies a choice to value certain outcomes and interests over others, and public health policy must accept “the inevitability of being wrong” some of the time (Jellinek, 1981). Four decades of analysis on the importance of standards of proof (choices about how much evidence is enough) in environmental policy and law have had minimal impact elsewhere in the study of population health and public health ethics (Schrecker, 2013a).
Analysis: Ethics Meets Politics in Public Health—“Choice” for Whom? From What Menu? And Who Selects the Items on the Menu?
The political economy of health foregrounds multiple economically driven power asymmetries between transnational corporate actors and others. Some of us would go beyond a focus on transnational corporations to identify a transnational capitalist class (p. 848) (see Sklair, 2005; Robinson, 2010; Carroll, 2014; Carroll and Sapinski, 2016, among many other sources), although the point is contested. The political economy of health thereby provides an important counterpoint to framings of public health ethics issues that focus on the extent to which policy measures represent (im)permissible restrictions on individual autonomy as manifested through consumer choice (about such matters as diet, consumption of pleasurable substances, or mode of transport). Such framings are familiar from polemics against restrictions on corporate activities that invoke the idea of the “nanny state” (Magnusson, 2015), but are also evident in more subtle form in, for example, the “intervention ladder” devised by the UK’s Nuffield Council on Bioethics (Krebs et al., 2007)—a device that fails to reflect many of the nuances correctly identified in the Nuffield report’s background discussion. Only two, related problems with such conceptions of choice can be identified here.
As Griffiths and West (2015, 1093) point out, the intervention ladder, organized as it is around a unidimensional conception of “liberty,” embodies the presumption “that no policy can do more to promote liberty than non-intervention.” A moment’s reflection on this proposition in other contexts—think for example about domestic violence—suffices to show its vacuity. The implicit presumption that there are only two categories of relevant actors, the state and the individual, ignores the complex policy landscape and the role of actors such as large corporations—as well as disparities in social and economic situation—that affect what choices are available to particular individuals. The implicit, and undefended, presumption is that only state agencies are capable of choice-limiting actions or “coercion.” However, as noted in the lead author’s foreword to the Nuffield report: “It takes only a moment’s thought to recognize that many of the ‘choices’ that individuals make about their lifestyle are heavily constrained as a result of policies established by central and local government, by various industries as well as by various kinds of inequality in society” (Krebs et al., 2007, v). Ignoring these dimensions in discussions of choice and autonomy is intellectually irresponsible; if state decisions about public finance shape the options available to individuals in different life situations, so too do decisions made by large corporations about such matters as investment and product line characteristics (cf., Nadel, 1976). Further, state decisions articulate the scope that such actors have to operate independently of collectively agreed-upon restrictions. Indeed, discussion of contemporary public policy that ignores corporate influence is a bit “like Frankenstein with the monster left out” (Hacker, 1973, 173).
Further, as noted in the Nuffield foreword and the extensive literature on social determinants of health, consumer choices are always constrained by a substrate of inequality. They are limited by purchasing power, which is unequally distributed, and other stratifiers related to socioeconomic position (as in the case of food deserts). Beyond this, public health ethics must interact with political theory with regard to the distinction between individual choices and collective choices about the conditions in which we may want to live and work, which, at least in idealized democratic polities, we make together. Thus, given a particular set of circumstances and life chances, we might personally want to be able to smoke at our local pub or drive home after several beers, yet also favor eliminating that option out of concern for the health of those we care about (p. 849) who are fellow road users or are exposed to secondhand smoke during long shifts as servers. We may want to drive to work in a single-occupancy vehicle and bring fast food home for dinner on the return journey, yet at the same time we might prefer a set of social arrangements that raised taxes to support functioning public transport, or at least vehicle sharing, and local tax structures that would have offered preferential rates to now-defunct local grocery stores offering healthy food choices.
The environmental law scholar Mark Sagoff (1981a, 1981b, 1981c) has made a homologous point using, as an illustration, the responses of students presented with a plan to develop a ski resort in a wilderness area. By their own account, the students would probably never visit the wilderness area and were enthusiastic about the recreational opportunities offered by the ski resort. Nevertheless, when asked whether the development proposal should proceed, the students’ reaction “was unanimous, visceral and grim. All of the students believed that the Disney plan was loathsome and despicable; that the [US] Forest Service had violated a public trust by approving it; and that the values for which we stand as a nation compel us to preserve the little wilderness we have for its own sake and as an historical heritage” (Sagoff, 1981c, 284). The distinction in play is that between our preferences and values as consumers and as citizens; despite the best efforts of the acolytes of cost-benefit analysis and of public choice interpretations of political activity (MacLean, 2017), they are not reducible to one another.
Three Future Challenges
Political economy focuses on “upstream” influences on health—what Sir Michael Marmot, borrowing a phrase from Geoffrey Rose, calls “the causes of the causes” (Marmot, 2005). This formulation leaves open the question of how far upstream to look. In the Flint example that began the chapter, is it sufficient to examine the proximal political choices that led to the poisoning of this relatively vulnerable population—which have led to criminal charges against senior public officials (Glenza, 2017)—or is it necessary, as suggested in the introduction, to consider such structural issues as systemic racism, the nature and sources of pressures to shrink public budgets, and even the mechanisms by which revenues to support public services are raised? The author leans strongly in this latter direction, while recognizing that in many cases the “how far upstream” choice represents what Kristin Shrader-Frechette and Earl McCoy (1993, 84) refer to as methodological value judgments. Sometimes, however, the line between such judgments and scientific or explanatory incompleteness is blurred. Thus, in a critique of studies of neighborhood effects on life chances, the geographer Tom Slater (2013, 369) questioned the presumption that causal pathways run from residential location to such outcomes as escaping poverty rather than in the opposite direction: “If where any given individual lives affects their life chances as deeply as neighborhood effects proponents believe, it seems crucial to understand why that individual is living there in the first place.” This means inquiring into such variables as influences on the distribution of (p. 850) income, and such processes as the socio-spatial sorting function performed by housing markets. It was not the white middle class that inhabited New Orleans’ Lower Ninth Ward, the community most devastated by Hurricane Katrina in 2005, and least benefited by subsequent reconstruction efforts.
Such questions assume increasing importance against a background of rising inequality, in countries rich and poor alike (Bourguignon, 2015), often magnified rather than attenuated by policy choices. In the United Kingdom, the Conservative prime minister David Cameron (2009) (in)famously claimed that his government’s approach to austerity would embody the principle that “we’re all in this together”—a claim that was decisively refuted at the end of his first term by analysis of cumulative budget impacts (De Agostini, Hills, and Sutherland, 2015). Presciently, the editor of New Perspectives Quarterly observed in 1993 that “[a]lready people merely surviving in places like Bangladesh and across vast stretches of Africa are superfluous from the standpoint of the market. By and large, we don’t need what they have; they can’t buy what we sell”; from a public health perspective, the epidemiological worlds inhabited by these populations are in most important aspects completely different from “the archipelago of the connected classes that reside in every megacity from Bombay to São Paulo” (Gardels, 1993, 3). Even within high-income countries, barriers to replicating the “cross-class political alliance” that the historian Simon Szreter (1999) sees as having driven public health policy advances in nineteenth-century England in today’s contexts are often formidable.
This is partly because, as production and finance have been reorganized across multiple national borders over the past few decades, distributional conflicts can no longer be contained and need not be resolved within national borders—a necessary precondition for settlements between labor and capital in the high-income world, many of which are now unravelling, and one reason among several to doubt that the politics of the future will be like those of the postwar past. Much ethical and policy analysis related to public health operates on the implicit and decontextualized assumption that some form, albeit rudimentary, of social contract exists between rulers and subjects. We assume that governments can be expected to care at least a little bit about the welfare of people within their national borders. However, serious consideration of the changes in social structure associated with contemporary globalization raises the prospect that even in formal democratic jurisdictions, governments and political elites may simply not care about the welfare of a substantial portion of their compatriots, whose command of political resources is minimal. Again, the example of Hurricane Katrina is instructive (see Hartman and Squires, 2006; Somers, 2008, 63–117).
An additional layer of complexity is introduced by the spread of “illiberal democracy” (Zakaria, 1997)—the breakdown of political accountability and the rule of law, and the simultaneous spread of authoritarianism. A founding editor of the Journal of Democracy has described what he calls a “democratic recession” post-2006, a turning point identified by Freedom House, with particular focus on “a class of regimes that in the last decade or so have experienced significant erosion in electoral fairness, political pluralism, and civic space for opposition and dissent, typically as a result of abusive executives intent upon concentrating their personal power and entrenching ruling-party hegemony” (Diamond, 2015). One need not look further than the lead stories of any reputable news (p. 851) outlet. In a growing range of contexts, it is problematic, if not fatal, for subjects to advocate for protecting their own health and to attempt to mobilize the political coalitions that drove earlier advances in public health—as shown, for example, by the work of Global Witness (2017) on the killings of activists organizing against environmental destruction. Public health ethics must come to grips with this reality, as with others, by engaging with the relevant social science, and with the relevant protagonists “on the ground.”
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