Malnutrition and poor health combined with the toxic impact of welfare cuts, run down health services and years of austerity has left many people at the mercy of pandemics.
The struggle between an abstracted version of nature and science is not what determines the health of global populations and it never has been. The nature we have is the one which has developed in its relationship with global capitalism. The threats nature now poses result from the multi-faceted failure of that relationship —the metabolic rift—which the current pandemic illustrates by its global attack on our health.
The pandemic is in a very real sense an embodiment of the climate crisis of the Anthropocene. Health is context-driven. We enjoy good or ill health according to the social circumstance in which we find ourselves. Do we have access to clean water? Do we have access to nutritious food? Do we have adequate shelter?
Is the world sufficiently stable such that we do not spend long periods of our lives in states of debilitating anxiety? Do these combine to ensure our immune systems are strong enough to withstand illness? Do they ensure our world does not continually generate new and ever deadlier pathogens?
Capitalism fails on all of these counts. More importantly, it is failing not because the system is malfunctioning but precisely because it is working as it must. Capitalism works through commodification driven by the profit motive and it is the profit motive and commodification which are the direct cause of this pandemic and the climate crisis in general.
We can explore the interlocking economic, political and social crisis we are living through via four key elements, bought into sharp relief by the Covid-19 pandemic and contextualised by the all-encompassing climate crisis: Ecological—viruses, agriculture and deforestation; Epidemiological—weakened hosts, austerity and vulnerable populations; Ideological—privatisation, “free market” health and social care and the collapse of “public health”; Political—individualised not collective solutions, indecision and lack of clarity from political leadership.
Older people in particular, one of the so-called “vulnerable groups”, are the central victim group dying from Covid-19. By drawing on what is known as the social determinants of health approach, an approach recognised as key to understanding the health of populations by most international bodies including the World Health Organisation (WHO).
Terms like vulnerable, susceptible and resilient circulate widely in popular discussion. Strictly “vulnerability” refers to something more than “susceptibility”. For example, older people are clearly susceptible to catching the virus—as the rest of us are— but would actually have low vulnerability to the more serious consequences of it were it not for the underlying illnesses many have. In other words, it is the socially determined poor health and immunodeficiencies that is the root cause of the higher death rates amongst older people, that make them vulnerable, not their susceptibility to the virus.
We can understand vulnerability as a threefold combination of elements—the extent of the external exposure (in this specific case to Covid-19); a population’s inherent susceptibility (the socially determined biomedical profiles of individuals and specific social groups) and how effective are social infrastructures—including health and social care provision—and a population’s capacity to adapt and make risk-limiting physical, technical, behavioural and organisational changes. This threefold conceptual framework loosely guides the arguments below.
The case fatality rate (CFR) is the number of people who die from a disease among individuals diagnosed. The CFR is calculated by dividing the total number of deaths from a disease by the number of confirmed cases. There is no single figure of CFR for any particular disease. The CFR varies by location and population group, and changes over time. Calculated by the Chinese Centre for Disease Control and Prevention at the end of March 2020, the global CFR for Covid-19 were: Globally: 3.7 percent, China: 3.9 percent, Rest of the world: 3.5 percent. Worryingly, the CFR for Italy is nearly double this, at 6 percent, for reasons I explore below.
The Chinese Centre for Disease Control and Prevention gives a breakdown of all known cases, deaths and CFRs by specific demographics (age, sex, pre-existing condition etc.) which shows clearly that older people are most at risk. Crucially, however, the research shows that those with underlying health conditions are at a higher risk. More than 10 percent of those diagnosed with Covid-19 who already had a cardiovascular disease, died as a result of the virus. Diabetes, chronic respiratory diseases, hypertension, and cancer—in fact, all of the modern-day global disease epidemics—were all risk factors as well.
The CFR for those without a pre-existing health condition was 0.9 percent. In other words, the higher rates of older people in China who are dying is because of the underlying diseases they have. So how do the Social Determinants of Health approach fit here? Discussing global health experiences the WHO says, “The unequal distribution of health-damaging experiences is not in any sense a “natural” phenomenon but is the result of a toxic combination of poor social policies, unfair economic arrangements and bad politics.”
Globally, populations experience health differently, and not for genetic or individualised heath-behaviours reasons as global capital would have us believe, but for social and political ones as the far from radical WHO plainly points out. This social determinant of health approach is useful for socialists. It highlights the fact that our everyday and long-term health is determined by the types of societies we live in.
At a broad ecological level, in the 21st century, nature’s microbial pathogens (disease-causing bacteria and viruses) have been strengthened by the socially determined modern agricultural and food production practices, while host populations have been weakened. There are many elements of social determinants of health which help explain health experiences generally and specifically why the virus is having the affect it is. Diet is an obvious one.
Tuberculosis (TB) is a pathogenic bacteria which has been identified in prehistoric remains. It remains a global threat today, impacting especially upon the poor and those made vulnerable by poor living conditions and diet. TB rates in the UK fell after—and during—World War II as, for many, diet, healthcare and housing improved. However, by 2015 it was back. Public Health England has named TB as one its health priorities in greatest need of improvement, along with smoking, obesity, alcohol and dementia, as the incidence of TB rises.
Research shows modern diets lacking sufficient nutritional value impact negatively on immune systems, debilitating them from resisting pathogens, such as TB. Obesity and eating disorders, chronic diseases such as cardiovascular disease, hypertension, cancer and diabetes mellitus are other common modern-day illnesses linked to twenty-first century diets. These disorders are unequally distributed in the population, affecting working-class, and especially poorer working-class people disproportionately. How does all of this relate to older people and Covid-19?
During the past decades, malnutrition resulting from too little food or food lacking in nutritional value has become a common experience for older people. Age-related changes in systems of appetite regulation, resulting in so-called anorexia of aging, when accompanied or set in train by additional risk factors like health or social problems including loneliness and social isolation and/or inadequate residential care facilities is likely to cause malnutrition.
Consequently, malnutrition is widespread in the older population, especially in those who are institutionalized. Malnutrition by itself can, of course, result in death. However, epidemiological research conclusively shows that it greatly increases susceptibility to and severity of infections, and is a major cause of illness and disease-related death.
In the UK, across the population as a whole malnutrition is the direct cause of about 300,000 deaths per year and indirectly responsible for up to half of all deaths in young children. Social isolation and loneliness experienced by older people are contributing factors to malnutrition and associated illness and there are clear trends that this is getting worse in the UK and globally.
Even in the more collective environments of residential homes, following the privatisation of care provision malnutrition is increasingly common. Research by Sheffield Hallam University found that care homes are spending on average just £2.44 feeding each resident per day. Gary FitzGerald, chief executive of Action on Elder Abuse, said: “It’s very clear that the issue of low-quality food in care homes is a widespread problem and we believe it should be seen as a warning sign for more serious abuse and neglect.” We can add to that vulnerability to deadly disease.
The British Association for Parenteral and Enteral Nutrition estimates one in five residents of care homes are at medium to high risk of malnutrition. Vitamin and mineral deficiencies resulting from poor diet lead to a greater risk of bone fractures, increased susceptibility to infections, skin problems, wounds failing to heal, depression and even loss of appetite. While it is true that older people need fewer calories than the young, they still require the same nutrients as the rest of us to keep healthy.
Austerity has accelerated these lethal trends greatly. European Union research shows a clear rise in old-age mortality observed over the last few years across Europe.
In 2015, Italy witnessed the highest mortality rate since WWII, primarily due to a marked rise in the 75—95 years bracket. This is the context of the 6 percent CFR in Italy. A snapshot of the impact of austerity across Italian society tells us that in 2012, the majority of Italian households, 83 per cent, were basing their food shopping around special offers and less expensive foods, while 2.7 million Italians have chosen to start growing vegetables for their own consumption. 65.8 per cent of Italians have reduced their travel routines to save money on petrol and 42 per cent have stopped travelling altogether.
This has only severely worsened over the eight years since research was carried out, a social and political context in which old people have become weaker and more vulnerable while the fascists of the Northern League cling to the gates of government by exploiting people’s fears.
The US is looking down the barrel of a virus-led meltdown. In the middle of March, all schools in the state of New York were closed until the end of April. This is partly in response to the threat of Covid-19 . New York administrations have at least recognised, as has the rest of Europe apart from, as this is written, the UK, that schools have very little beneficial effect in developing “herd immunity” to Covid-19 but do provide excellent transmission environments to spread the disease more freely.
However, in the US there is also a sense in which the closure could be a response to the other major epidemic the USA is experiencing, that of flu. According to the US Centre for Disease Control and Prevention so far this “flu season” beginning in October 2019 the flu virus has led to between 36 and 51 million illnesses, 17 to 24 million medical visits, 370-670,000 hospitalisations and between 22,000 and 55,000 deaths. It’s easy to see why Trump is intent on targeting Covid-19 as a “Chinese Virus”.
When you have no strategy, few centralised mechanisms to implement social and health plans and no ideas, far better to blame rising premature death tolls on foreigners than acknowledge the epidemic raging in your own backyard. Again, rising poverty and social deprivation with their incumbent malnutrition and weakened immunities is at the centre of the deadly impact of (so far) the flu, and increasingly Covid-19.
Research has found around 56 million Americans live in poverty and/or with combinations of social, economic and other deprivations. This is acknowledged as an underestimation. One in five Americans live in poverty. Coupled with this, research shows a higher proportion of older Americans are below the poverty threshold set by the OECD than all other advanced economies in the world except for Australia and Switzerland. The US has a large, older population living in poverty, potentially malnourished, often with underlying health conditions resulting from the combination of social determinants of health they’ve grown up with and the resultant immune weaknesses combined with limited access to health care. This is an apocalyptic scenario for the US and a terrible and tragic prospect for America’s older citizens.
In the UK some predict that the virus will last until spring 2021 with nearly eight million people hospitalised. The proportion of elderly people living in severe poverty in the UK is five times what it was in 1986, the largest increase among western European countries. Two million (16 percent) of pensioners in the UK live in poverty and, worryingly, numbers have grown alarmingly in recent years. Some groups of older people are at particular risk of being in poverty—35 per cent of private tenants and 29 per cent of social rented sector tenants.
Some 31 per cent of Asian or Asian British pensioners and 32 per cent of Black or Black British, are in poverty compared to 15 per cent of white pensioners. Financial disadvantage is not just about income—for example, people may have higher costs if they have disability or care needs, or have to spend more on heating if they live in a cold, poorly insulated home. Recent Citizens Advice (CA) research showed that distributions of food vouchers rose by 11.2 percent in the last two years.
More specifically, the proportion of those in receipt of food vouchers over 50 and over 60 years of age both rose (from 26 percent to 31 percent for over 50s and from 6 percent to 9 percent for the over 60s) despite well-known barriers to older people accessing CA services. In some CA offices debt enquiries dealt with by advisers rose by 47 percent between 2017-18 and 2018-19, and the proportion attributed to the over 50s and over 60s both rose.
Benefits enquiries also rose, by 14 percent, during this period. However, the number of enquiries about Pension Credit and Attendance Allowance (the primary disability benefit for older people) rose by 31 percent and 42 percent respectively. The “roll out” of Universal Credit then, is having a deadly impact at financial, diet, health and vulnerability levels.
The picture is clear. Austerity driven poverty forms the backdrop to the high numbers of older people dying from Covid-19. Covid-19 may be delivering the coup de grace, but it is the generally poor and deteriorating general levels of health, determined over the longer term by a lethal cocktail of interlinking social determinants of health, sharpened over the last decade by austerity with its destruction of welfare support systems and rising levels of poverty, malnutrition and tragically weakened immune systems that have prepared working class older people for premature death.
The response from the UK government could hardly have been worse, at every level. Instead of decisive leadership we’ve been given Johnson’s daily briefing, a muddle-headed insult. No plans, no additional resources to support “vulnerable” groups, confusion and fear in our schools, hospitals and in older people’s homes, the “self-isolate” advice only likely to compound the nutritional, physical and mental health problems that group already suffers from.
Closed wards and mothballed health centres remain closed. Even in the short-term capitalism can provide no answers save from the vague promise of a biomedical response some time in the future. This is not primarily a biomedical problem, it’s a social and political one. We’ll not solve this or the pandemics to come until we solve the social and political problem presented by capitalism itself.
Lee Humber is the author of Vital Signs: The Deadly Costs of Health Inequality, published by Pluto Press.