How austerity undermined public health across Britain

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As COVID-19 continues to inflict terrible damage, it is the privatisation of social care, and the undermining of the NHS, that is the root of the crisis now facing healthcare

At the beginning of April, Queen Elizabeth II told a television audience: “Together we are tackling this disease, and I want to reassure you that if we remain united and resolute, then we will overcome it.” Her appearance was filmed by a single cameraman encased in body-covering protective clothing. No shortage of PPE here.

Compare this with a care home for older people in Liverpool run by Future Care Capital, a care provider increasingly reliant on venture capital.

The week before the Queen spoke, twothirds of its staff was in self-isolation and a majority of its vulnerable residents were displaying COVID-19 symptoms. The home’s manager Andrea Lyons put out a desperate plea for help. By mid-April, 16 residents had died. An already criminally stretched health and care sector was unable to respond until too late, with the Local Authority eventually finding resources to plug gaps.

As a result, local authorities are forced to offer contracts to private care providers that do not cover their costs. The consequences of this are a deterioration in standards of care, the growth of bigger residential homes in pursuit of economies of scale, fewer staff and less training.

In fact, a 2018 government report was not at pains to highlight the potentially deadly nature of the situation it had helped to create. Central government spending allocated to local authorities for social care declined by eight percent between 2010 and 2015.

What this means is that local authorities offer contracts to private care providers that do not cover their costs. The consequences of this are a deterioration in standards of care, the growth of bigger residential homes in pursuit of economies of scale, fewer staff and less training.

In other words, it is not just the volume of cuts in funding that is an issue. It is the very model of funding that is at fault, and which has led to the demise of even the largest of care providers, such as Southern Cross and recently Four Seasons.

A core “cost” for private care providers is the investors’ dividend. The payoffs for venture capitalists and others suck out millions from the care system — money that should be going to caring. The profit motive is the cause of premature death.

In a just and rational world, care for older people, disabled people and those with debilitating illness would be part of a broader agenda for public health. In the UK, and to a greater or lesser degree elsewhere, how is public health understood and delivered currently?

The Health & Social Care Act of 2012 created a separate entity, Public Health England (PHE), to “protect and improve the nation’s health and to address inequalities”. Since then health inequalities have sky-rocketed and the nation’s health has markedly deteriorated.

PHE funding comes from local authority budgets. These have been at the sharp end of austerity, and consequently funding for PHE has declined. Spending on the public health grant in 2019-20 was £850m lower in real terms than initial allocations in 2015-16.

Public health has been reduced to “health promotion” around a diminishing number of key areas. At a theoretical level, as indeed with the study of poverty, the concept of public health has been blurred and obfuscated, making it difficult to define or understand in either academic or popular discourse. Most often, public health is seen as something to do with addiction, or perhaps sexual health. As the table right shows, those areas to are also being fatally weakened.

In sexual health, cuts may mean the return to deadly prominence of the HIV virus, already killing millions globally each year. Health check cuts will affect early diagnosis rates of all sorts of disease, especially cancers.

Cuts to drug and alcohol services can mean more addiction-related mental health issues. This simple table paints a picture of a fatally sickening world.

At the level of analysis and impartiality, PHE was criticised by The Lancet medical journal in 2015 for endorsing e-cigarettes as an alternative to tobacco. Little is known about the long-term effects of e-cigarettes, and in this context The Lancet was worried about the reasons behind the rush to endorsing the e-cigarette industry without rigorous analysis of health risks.

Similarly, PHE’s “integrity” was questioned when it “confirmed” that municipal incinerators were not a public health risk, before the research it had commissioned had reached any conclusions on the matter. The worry is that PHE is more concerned with pro-business propaganda than with protecting — let alone improving — public health through research and policy.

The fatal weaknesses of PHE have been vividly illustrated by its pathetic and disastrously uncoordinated approach to virus containment.

PHE has failed miserably to provide anywhere near enough protective clothing, while the use of testing kits, averaging around 5,000 per week at time of writing, is way below usage in other EU countries. The false assertions with regard to “herd immunity”, and PHE’s decision in line with this approach to keep schools and workplaces open longer than was safe, will undoubtedly have increased the spread of COVID-19.

Poor public health provision is a worldwide phenomenon, another consequence of privatisation, financialisation and the shift to privatised health and social care provision. The US provides another example of public health consequences of this economic and ideological shift.

Though that country has been consistently plagued over recent years by annual and often new strains of influenza viruses, money spent on public health has been consistently reduced. This has left millions of people vulnerable to infection and death. For example, the latest figures for this year’s influenza deaths, measured from October 2019, reveal that up to 62,000 people have so far died from this deadly home-grown epidemic.

Yet in 2018, the Trump administration cut $15 billion from public health provision and got rid of the entire pandemic response chain of command.

Following this, a report by the Centre for Strategic and International Studies concluded that lack of epidemic preparedness was so acute that the “United States must either pay now and gain protection and security or wait for the next epidemic and pay a much greater price in human and economic costs”. These words have very quickly come back to haunt Trump and, much more seriously, illustrate the lethal threat his policies pose to American workers.

At an international level the World Health Organisation (WHO) has been charged with setting global health agendas and responding to health crises such as COVID-19. It has established a Global Preparedness Monitoring Board (GPMB) to respond to epidemics. In September 2019 it published a report just as COVID-19 was breaking out.

It alluded to the irresolvable conflict between the search for profit and the maintenance of public health, arguing that Fatal weaknesses have been vividly illustrated by uncoordinated approach to virus containment "prioritising economic growth and profit over the equitable distribution of wealth [and thus health] and the provision of public goods and services sets the context in which the increasing incidence of global epidemics and pandemics take such an annual toll”.

But the WHO can provide no solutions because it is tied into the very same political economy it criticises. The body’s role in championing the so-called Public-Private Partnerships — notorious here via the New Labour governments’ Private Financial Initiatives that crippled the NHS — has established more of the private healthcare market as the solution to the failings of privatised health.

This blinkered and compromised position provides no solution to the profit-driven crisis of world health.

Class Struggle

If organisations such as the WHO have no solutions to the global health crisis, who does? The health experiences of UK industrial capitalism provide some answers.

There have been two phases of general health improvement during the life of capitalism in the UK. The second half of the 19th century saw an average general improvement in the health experiences of working class people in the UK; what Simon Szreter professor of History and Public Policy at Cambridge University, calls the period of the “modern mortality decline”.

Similarly, the generation born in the aftermath of the Second World War had improved health experiences that were better than previous generations. According to many academics, this led to the increase in life expectancies in the current era, a trend now halted and potentially in decline.

There have been numerous suggestions as to the causes of this. Until the mid-1970s it was believed that medical advance, in particular the practice of inoculation against disease, was the main driver of the 18th century mortality decline.

This was disproved, however, by the work of Thomas McKeown, who showed that medical advances occurred long after the trend of mortality decline had begun. Instead, McKeown argued that economic growth led to better diets for the working class.

Though it remains ideologically dominant, McKeown’s thesis has been challenged by others, notably population studies professor Simon Szreter at Cambridge University.

He and his colleagues argue that rather than an amorphous “economic growth” as the driver of health improvement, it was improved sanitation, resulting from the activism of those involved in the sanitation movement of the second half of the 19th century, that led to improved health outcomes.

This approach has obvious interests for socialists because it introduces the idea that material change in people’s living conditions, their day-to-day activity and struggle, is the key to understanding why public health improved. Its weakness, however, is that the analysis does not go deep enough.

We learn much about historical figures such as Joseph Chamberlain and, of course, Edwin Chadwick, pioneer of the UK’s first two public health acts in 1848 and 1875. But we learn little about the social and political contexts in which these parliamentary figures were operating.

A modern welfare approach has its roots in this period when legislation covering the social determinants of health — such as housing, diet, employment and political rights — radically changed the political ground on which these issues were fought.

Apart from the specific Public Health Acts there were numerous important policy developments in housing, culminating in the Housing of the Working Class Act of 1890 that authorised the building of council houses.

Although it did not provide a meaningful solution for most working class people, it did clear the way for more than 80 municipal authorities nationwide to build houses. This improved the lives of at least some and, importantly, set the tone of change and raised expectations.

In terms of diet, the passage of the Adulteration of Food and Drink Act of 1860, the Adulteration of Food and Drink and Drugs Act 1872 and the Sale of Food and Drugs Act of 1875, achieved little. Nevertheless, the fact that governments felt constrained to pass such legislation tells us that concerns about these issues were being voiced at the base of society and, increasingly as this period progressed, by their chosen representatives.

In employment, nine separate pieces of legislation were passed between 1844 and 1878, setting negotiated limits on working hours for all and ending the era of children of all ages being worked to an early grave. Six acts between 1867 and 1918, culminating in the Representation of the People Act of 1918, secured the vote for all men over 21 and some women over 30. This changed the way people both thought about and became involved in national politics.

Mainstream historians would have us believe that these reforms were piloted through by visionary and well-meaning members of the bourgeoisie, driven by concerns for their fellow human beings. This is nonsense. All individuals act within specific social and political contexts.

The years between 1850 and 1900 saw unprecedented and far-reaching politicisation and organisation of the working class in expanded trades unions, trades councils, political parties and collective organisations of every stripe.

This was the great period of the growth of socialist ideas, theory and organisation, out of which the two traditions of socialism — reformist and revolutionary — evolved. The bourgeoisie, still smarting from the decade of at times revolutionary struggle of the militant Chartist movement, and with the noise of European–wide revolutionary struggle still ringing in their ears, faced the latter half of the 1800s in a state of fear and loathing.

They used brutality and, when forced, reforms to contain and control the working class threats to their system. A quote from just one ruling class figure illustrates this. Robert Rawlinson, president of the Royal Sanitary Institute of Great Britain, had previously described the slums of Dublin as “seed-beds of disease and revolution”.

He subsequently argued that: “Sanitation is an all-round question, and the improvements connected with it cannot come from below — they must come from above. If the highest classes will not voluntarily forego some of the wealth they accumulate and give some attention to enabling these people to be healthier, happier and live better, then you may depend upon it there is a stratum of vice and misery now existent which, if made desperate by famine and neglect, would be quite sufficient to overturn all that is above. If this state of things should continue for any length of time you may have social disturbances like the French Revolution of the past century, which upset society from top to bottom.

Collective Organisation

“Give them reform or they will give you revolution” was (and remains) the oft-repeated cry of the bourgeoisie. The threat of the overthrow of their profit-driven system is the context in which reforms that benefit working people are granted. In the 19th century this process drove successive governments to appease us by in part setting a legislative framework in which we could improve our living conditions. What was true of the health improvement of the “modern mortality decline” of the 19th century, is true of the increase of average life expectancies of the 20th. Working class organisation, a shifting of the balance of class forces in our favour, shaped the living, and so health conditions of the post-WWII period. A few examples will suffice to illustrate this.

Over the six years of war, average wages rose by 76 percent. Though inflation also rose, this represented a real increase in living standards and embedded the expectation of high-wage conditions in the context of secure employment.

Union organisation and collective agreements in previously untouched industries spread widely, with union membership rising from six to nearly nine million over the period. There were more strike days between 1939 and 1944 than throughout the rest of the 1930s.

This bigger, more combative and well organised class contributed to the Labour Party winning a landslide in 1945. There followed nearly 30 years of council house building, improvements in diet and general levels of nutrition, as wells as a proper health service supported by functioning welfare systems and an extended period of secure employment conditions.

Poverty persisted and deep inequalities remained and continued to widen. Class struggle continued throughout. However, in terms of average health, many of its social determinants and the conditions in which we lived combined through the period to maintain and improve health outcomes and expectations. Our health was relatively strong because, as a class, we were relatively strong.

One can correlate the onset of the current day epidemics of non-communicable diseases (more properly called socially transmitted disease) such as diabetes, heart disease, obesity and cancer fairly closely to the retreat of our class following the defeats of the late 1970s and 1980s. As we weaken collectively, the conditions of our health worsens and consequently so do our health outcomes.

Housing shortages, nutritionally deficient diets, working harder and insecurity of all kinds have been the order of the day since the ear of Thatcher and Regan. Little wonder then that today we live in a world of epidemics, pandemics and hyperendemics created by the industrial agriculture and intensive factory farming practices.

Viruses grown and set free to attack global populations debilitated by undermined immune systems and riddled with socially transmitted disease, are a result of decades of austerity and increasing exploitation. The
solution remains the same as it has been throughout the history of capitalism — a strong, organised, politicised working-class.

Healthy futures and the very survival of the planet now depend on building that and using our collective strength to change the world for good.