You’ll recognise this image – aka the champagne glass distribution of income – but did you know it first appeared on the big screen in 1992 in the UNDP’s Human Development Report (p35)? It’s a shocking graphic, more so when you consider that it draws on data compiled a quarter of a century ago! Has the wealth gap reduced since then? Has it fuck: Oxfam published a Briefing Paper in January last year – An Economy for the 99% – which estimated that eight men owned the same wealth as the poorest half of the world*! If you want to understand global health – governance, systems, financing, whatever – then this is the place to start. Put down your copy of Frenk and Moon and ask yourself from which quintile do the ‘rules of the game’ originate? Economic power begets political power, which in turn generates policies designed to increase economic power, thus completing the circle. It’s not rocket science, it’s basic political economy. Oh, and it has a name too – capitalism. But is capitalism good for global health? That’s a difficult question, and one which I begin to answer below.
In my opinion, the best book on the global economy is Douglas Dowd’s Capitalism and its Economics. Sadly, Dowd passed away last year but he left us a really useful framework with which to structure a critique of capitalism’s effect on global health. Much of my analysis in this post draws on his book and I’ll add page numbers at various points to indicate where you can find the original economic insight.
It is important to appreciate that the reason why capitalism exists is not because it is the economic model that best meets the social and ecological needs of the majority of the global population; rather, it is designed to fulfil the needs of a small minority. Furthermore, a historical reading of economics suggests that the intellectual inspiration for capitalism emerged from a small number of individuals who took the opportunity to imbue economics with their own individual prejudices: Adam Smith’s repulsion of mercantilism in favour of the nascent industrial capitalist; industrialist David Ricardo’s prejudice towards the landed gentry; and Thomas Malthus’ misanthropic attitude towards the poor. All three economists were also extremely wealthy individuals and very much part of the economic and intellectual elite of their time. The dominant economic model that defines our world today is the result of their intellectual legacy.
Mention of Karl Marx can elicit panic (Marxist alert – run away!) or a general rolling of the eyes (Marxism – yawn). Fear not, je ne suis pas marxiste. But, and here’s the cool bit, he did have something interesting to say about economics that explains the champagne glass outcome illustrated above. Dowd helpfully distinguishes three “imperatives” of capitalism, each of which provides an entry point into the effects of capitalism on global health.
Why does capital have to expand? Marx provides a mechanistic explanation (p6):
“the development of capitalist production makes it constantly necessary to keep increasing the amount of the capital…in a given industrial undertaking, and competition makes the immanent laws of capitalist production to be felt by each individual capitalist, as external coercive laws”.
The capitalist is thus compelled: once the process of capitalist production begins, she becomes a “wheel” in a “social mechanism” (Marx in 1867 or thereabouts). Tragically, as Kate Raworth documents in her cookery course on Doughnut Economics, under the influence of capitalism the discipline of Economics has lost its utility. Rather than helping to identify and then satisfy our social and ecological needs, in its dominant neo-classical form Economics has a quite specific focus – to allocate scarce resources to unlimited wants.
But that begs the question, scarce for whom (champagne glass again)? Oil is plentiful in Iraq; relatively scarce in the US. But wait a second, resources are not scarce and human wants are not unlimited, are they? Well, they kind of are “in the sense that resources are made to be scarce through some combination of frivolous and wasteful patterns of consumption and production, and that wants are induced through advertising to become unlimited”(p.15). Don’t believe me? Then consider that consumers in the United Kingdom (UK) discard 1.4 million bananas worth £80 million every day.
The consequences of capitalist expansion for planetary health is best visualized through Johan Rockström’s ‘planetary boundaries’. Rockström et al’s analysis illustrates the extent to which biodiversity loss, climate change and human interference with the nitrogen cycle exceeds a ‘safe operating space for humanity’. The imperative of capitalism to expand underpins each of these excesses. In terms of biodiversity loss, to give one recent example, 8,000 hectares of Brazilian rainforest were cleared in 2016 for palm oil plantations and cattle pastures, a process that produced, ironically, two thirds of the country’s annual carbon emissions. If tropical rainforests comprise more than 750 tree and 1,500 higher plant species in a single hectare (2.5 acres), deforestation will quickly result in an increase in the rate of species extinction, which is precisely what is happening.
The World Health Organisation (WHO) links biodiversity loss to a variety of direct and indirect health effects notably via ecosystem degradation, nutritional impact, patterns of infectious diseases, and the opportunity loss for advances in medicinal innovation. But in addition, biodiversity loss has a cultural effect that can impact negatively on health (see below).
“Throughout its history, capitalist profitability has required, and capitalist rule has provided, ever-changing means and areas of exploitation…The central relationship making this possible is the ownership and control of productive property: a small group that owns and controls, and a great majority that does not, and whose resulting powerlessness requires them to work for wages to survive” (p.5).
Exploitation is regarded as normal and necessary by Smith and Ricardo, and later by neoclassical economists justified in terms of risk (where risk is understood as financial risk rather than risk to life from undertaking more dangerous labour). There is a distinction in Marx’s ‘early writings’ between work and labour, where the former is life-maintaining while the latter is conducted under the control of another (p. 42). You’ll probably have heard of the phrase “the alienation of labour”. Yes, that’s one of Marx’s. By it Marx means labour that is “external to the worker; that is not part of his nature; and that consequently…he… has a feeling of misery rather than well-being, does not develop freely his mental and physical energies but is physically exhausted and mentally debased” (Marx, 1963, pp.124-5). David Graeber has a slightly more prosaic description – ‘bullshit jobs‘. The concept of alienation does little to convey the feelings of demoralisation and fear of men, women and children consigned to work in the dark and satanic cotton mills of 19th Century Britain, or, indeed their 21st Century equivalent, the gold and mineral mines of Latin America or Africa, but it draws attention to the fact that labour, rather than work, is not undertaken voluntarily but of necessity.
The psychological distress and resulting mental health problems that result from feelings of powerlessness have been well-documented in more modern times (Fromm’s The Sane Society and Smail’s The Origins of Unhappiness, for example) and in the current century, specifically in relation to conditions of austerity and the so-called ‘GIG’ economy. The United Nations Development Program (UNDP) 2014 report – Sustaining Human Progress: Reducing vulnerabilities and building resistance – notes that such conditions generate a “widespread sense of precariousness in the world today-in livelihoods, in personal security, in the environment, and in global politics” (page 1 of the report).
Temporary work, unpredictable, often ‘zero-hours’ working contracts, and the removal of worker rights through a reclassification of labour as self-employment, characterise the lives of a new, 21st Century, class of individuals who exist in a state of permanent insecurity: the precariat. A study of the Italian workforce a couple of years ago found that workers on temporary contracts were more likely to seek medication for depression. Of the GIG economy, Chris Quill notes:
“We need to understand the effects, because we associate being in control with good health. And there are good indications that workers [in the gig economy] do not have high levels of control” (Quoted in Anjana Abuja’s FT comment, 25th May 2017 – paywall).
Nevertheless, the number of workers on part time contracts because unable to secure full-time employment has risen steadily by 53% since 1984 to 7.7 million in 2010.
- Oligarchic rule
Finally, we come to oligarchy. Oligarchy – the rule of a country by a small number of people – most accurately describes the political system in which we live. The champagne glass graphic with which prompted this post is one way of visualising oligarchy – seen through a glass darkly. Robert Cox described the condition thus: it’s a “nebuleuse” or “a loose elite network of influential agencies, sharing a common set of ideas, that collectively perform the governance function” (Chapter 3 of Anthony McGrew’s Transformation of Democracy?) To give you just one example: over an 18 month period in 2015-16, executives from American multinational, multi-media company NewsCorp had 20 meetings with senior UK government officials, 18 of which were with either the prime minister, chancellor, or culture secretary (Jackson 2017). As noted above, it is a truism to note that the economically powerful also command a high degree of political power. Economic expansion requires power inequality. If presented with a meaningful choice, few would voluntarily choose to work in a Lancashire cotton mill any more than they would choose to work in a Peruvian gold mine. But if that labour is required, then labourers must be compelled, either through necessity or force.
The existence of democracy may present a conundrum for critics of capitalism. Why would democracy exist in an economic system characterised by profound economic inequality? The idea of democracy pre-dates capitalism by millennia, and because it is desired, because people want their voices to be heard, it is demanded. It is more efficient, therefore, to create and then manage a political system that satisfies a political need, but within heavily circumscribed parameters. Capitalism has been particularly effective at denuding individuals of their critical faculties. As Dowd observes:
“If there is any difference between the past and the present, it resides in the existence of populations in the politically democratic countries who have been so mesmerized – or trapped or lost – in the jungles of consumerism that force is no longer necessary to gain their acquiescence in an exploitative and otherwise harmful social system” (p8).
Modern democracy is the denouement of a long process of depoliticisation. Democracy has the potential to be active and participatory, providing an opportunity for inclusive decision-making and encourage responsible action. But that potential lies on the distant horizon rather than in the foreground. Critiques of democracy tend to focus on the struggle for inclusion of minority (and majority) groups excluded from the democratic process. Much less attention focuses on the quality of the process, which is currently reduced to choosing a government led by candidates with converging, centrist, political identities. In the UK, direct political action has, over the years, been criminalized by successive governments, notably through the Public Order Act 1986, the 1994 Criminal Justice and Public Order Act, the 2000 Terrorism Act, and the 2005 Serious and Organised Crime and Police Act. Through such legislation, political action has been heavily circumscribed to the point of passivity.
The sense of powerlessness, and the effect that that can have on mental health has been described more recently in Smail’s The Origins of Unhappiness, the thesis of which is that in order to understand unhappiness one needs to focus on the distal causes – the social institutions, politics, and the ‘establishment’ of a society. Others have argued that levels of violence, trust and social capital are all demonstrably lower in unequal societies, noting that “violence is more common where there is more inequality because people are deprived of the markers of status and so are more vulnerable to the anxieties of being judged by others”.
So, we’re back where we started: inequality. You’ll recall Wilkinson and Pickett’s book The Spirit Level in which the authors document extensively how inequality impacts negatively on a whole range of social determinants. Utilising UNICEF data on children’s wellbeing, they found that adolescent pregnancy, violence, poor educational performance, mental illness and imprisonment rates were all higher in more unequal countries and in more unequal states within the USA.
Note the book’s subtitle: why more equal societies almost always do better. In the 2017 Oxfam report cited at the beginning of this post there are some truly disturbing stats. Here are two to ponder:
The incomes of the poorest 10% of people increased by less than $3 a year between 1988 and 2011, while the incomes of the richest 1% increased 182 times as much.
In the US, over the last 30 years the growth in the incomes of the bottom 50% has been zero, whereas incomes of the top 1% have grown 300%.
In other words, to the extent that one can talk of a global society (which I confess it is hard to do, but let’s try and be optimistic for a minute), inequality globally is increasing exponentially. That can only be bad news for a healthy life.
Ok, let’s wrap up. I think it’s fair to say that critiques of capitalism have remained at the margins of global health and given a forum in very few academic journals (the pre-eminent example is the International Journal of Health Services). Stephen Gill and Solomon Benatar’s recent critique (not in IJHS but in another excellent, open access, journal The International Journal of Health Policy and Management) of global health governance gives you a flavour of how gosh darned frustrating global health scholarship can be:
“In this context, we would argue that current frameworks of multilateralism are ultimately constituted and shaped by the fundamental economic and political structures, forces and knowledge frameworks that configure the global political economy, namely those of actually existing neoliberal capitalism”.
Realising the unsustainable logic of capitalism, doyen of critical global health Ronald Labonté asks: “How can we tame capitalism and the predatory market logic to support human equity and (now) a livable planet? Or, if it cannot be tamed, how might capitalism be transformed into something better fit for human social and ecological survival into a 21st century?”
Labonté asks the question we all need to be asking right now: how can we make economics (rather than just one specific model of economics) fit our social and ecological needs? The central argument presented by Raworth and others is to reconceptualise the idea of economic growth and, in the process, de-link it from the standard, current, measure of Gross Domestic Product. Raworth describes the challenge thus:
“The over-riding aim of global economic development must be to enable humanity to thrive in the safe and just space, ending deprivation and keeping within sustainable limits of natural resource use. Traditional economic growth policies have largely failed to deliver on both accounts: far too few benefits of economic growth have gone to people living in poverty, and far too much of GDP’s rise has been at the cost of degrading natural resources. The critical economic question is whether or not global GDP growth can be harnessed as a tool for moving into the doughnut – or whether a different approach to economic development is needed” (p.20)
Raworth’s analysis is not explicitly anti-capitalist in its approach, indeed there is no mention of capitalism per se in her book Doughnut Economics. But it is hard to see how the imperatives of capitalism can possibly align with an economics that is driven by priorities such as sustainability and social justice. Capitalism is the antithesis of both. “A different approach” will entail developing an economics that is not capitalist in design.
However, if capitalism is more than just economics, and Dowd’s analysis suggests that it is as much social and political as economic, then a sustainable and just economics will also require a safe and just politics in order to ensure a safe and just society. Efforts to radically alter one imperative, would require change in the other two. To be continued…
* Yes, I am aware of the difference between income and wealth.