Chik Collins argues we must keep the politics in the political economy of health, in a review of Social Murder? by David Walsh and Gerry McCartney (Policy Press, 2024).
Just after the millennium, John Foster, as ever “keeping the politics in political economy”, described the three main phases of industrial restructuring in post-war Scotland. He also summarised their ‘disintegrative’ consequences, particularly in the deindustrialised core of the West of Scotland: “Young people in these areas have some of the lowest levels of educational attainment in Britain. The incidence of illness and morbidity is the worst in Western Europe”.1
Yet that was a time now described, in the title of a recent book, as A Time of Hope.2 There was then, it seems, a genuine belief that devolution, combined with the “end of boom and bust” and the rise of “evidence based policy making” would allow us to “make poverty history”, to “close the attainment gap” and to make meaningful progress with “equitable population health improvement” – “tackling health inequalities”, as they say. The founding of the Glasgow Centre for Population Health (GCPH) in 2004 was very much part of that climate of hope.3 Twenty years after its founding, two leading researchers associated with its work have written Social Murder? from a place of extreme frustration.
The key problematic for the GCPH in its first decade had been to explain the ‘excess mortality’ in Scotland, and especially in Glasgow. In 2016, with the assistance of this reviewer, an explanation was forthcoming.4 Foster had been right: the excess was largely explained by the political economy he had earlier described. Firstly, the wrong-headedness of the post-war industrial restructuring, which had been particularly catastrophic for Glasgow. Secondly, Thatcherism had a more damaging impact on a nation and region rendered especially vulnerable by the prior decades of restructuring. Archival research painfully evidenced the extent to which policy-makers in Edinburgh had, for fully four decades, been prepared to sacrifice Glasgow to a greater good of ‘modernising’ the Scottish economy in the new towns and other designated ‘growth areas’. To make matters worse, that modernisation proved ephemeral, as the collapse of ‘silicon glen’ in 2003 confirmed.
By 2016, when “the end of boom and bust” had gone the same way as New Labour’s earlier “ethical foreign policy” shibboleth and austerity had reigned for over half a decade, the belief in evidence based policy-making still persisted. Many continued to hope that if ‘the evidence’ was presented forcefully enough, policy-makers would be obliged to address the appalling health and other social consequences of all that post-war industrial restructuring, and also of the banking crisis, the ensuing great recession, and the impact of Westminster austerity too.
This history is helpful for grasping the content and tone of Social Murder? Austerity and Life Expectancy in the UK. Walsh and McCartney were initially somewhat sceptical that the adverse mortality trends that started to be reported in the middle of the last decade could really be caused so quickly by austerity. But they were soon convinced and duly played a leading role in charting the awful trends and signalling the need for action. They have done so in the face of much official disinterest and denial, and their frustration is very apparent.
The authors tell “the story of a scandal, of a tragedy on an enormous scale that did not need to happen” (p.8). After 2012, population health, as measured by mortality rates and life expectancy, broke from its long-prevailing trend of average (if often unequal) improvement. Improvement first slowed, then stalled, then for significant groups in the population entered decline. Between 2012 and 2019, 335,000 more people died in Britain, and another 10,000 in Northern Ireland, than would have been expected based on the projection of the pre-austerity trend. A society as wealthy as ours “simply shouldn’t be seeing these trends at all” (p.15). The cause was austerity (p.30), which had had to be massive to produce such unprecedented population health impacts so quickly. Worse, the impacts were highly regressive, socially and geographically. Thus, we also entered “a new era of health inequality in the UK” (p.26).
To illustrate the inequality in terms of local government, Glasgow, whose key social indicators were already ‘deranged’ by decades of mistreatment from Edinburgh, saw a 29% cut in spending between 2009/10 and 2016/17. East Renfrewshire, amongst the most affluent authorities in Scotland, saw increased spending. You don’t need to be an expert to know which of these was struggling more with the massive social security cuts of that period.
The authors lay out the causal pathways between austerity and health outcomes. Of course, the experience of poverty is central, including the “punitive, mean-spirited and often callous approach” developed by governments “to impose a rigid order on the lives of those least capable of coping” (in the words of the UN ‘special rapporteur’ despatched to Britain in 2018). The authors also review international evidence indicating that both the degree of austerity across states, and the lack of social provision for vulnerable populations, are associated with the extent of adverse trends in population health. The authors then turn their sights on the governments and agencies whose responsibility it should have been to respond to this unfolding disaster. They highlight the “startling … silence, misdirection, inaction and arguably ‘denialism’” (pp.93-4) and carefully detail a collective “dereliction of duty” (p.110).
Finally, the authors ask, “What do we need to do?”. Interestingly, they report that this is “a remarkably easy question to answer” because “all the evidence shows that health inequalities are entirely political in nature and they therefore require entirely political solutions”. Our responsibility as citizens is “to wield our collective power as a population … to ensure that people who make decisions do so to benefit us all” (135-8, emphases added). We need an end to austerity, then a society which ensures more equitable access to the key social determinants of health: income, wealth, power, good work, housing, education, transport, and so on. Nor, the authors insist, is this “impossibilism”. It would represent a switch to an entirely affordable menu of policy choices, albeit a radically different menu than the one we are currently offered. Most importantly, “the question is whether those with the autonomy to act [elected politicians] will do so”, especially those at Westminster. Poverty could be abolished: “It is not only within the gift of our political leaders to achieve this: it is surely their moral obligation” (144-5).
Social Murder? is a meticulously researched, skilfully presented tour de force of a book, and something of a moral ‘crusade’. Its power is increased by the inclusion of seven short “stories” used “to illustrate the impacts … of the UK Government’s austerity policies on individual people” (p.xiv). Governments and others that have variously perpetrated great harms and failed to address those harms are undoubtedly culpable. But, based on the authors’ logic, the rest of us are probably culpable too, for failing appropriately “to wield our collective power as a population”, because the questions are “remarkably easy to answer” and politicians, as “autonomous” actors, can easily enough be directed to make decisions that “benefit us all”.
Readers of this journal will be getting the drift of my criticism. Unlike Foster, intent on “keeping the politics in political economy”, the authors of Social Murder? take a view of the political economy of health in which the ‘political’ is somewhat impoverished. The attachment to ‘evidence based policy making’ still seems to loom large in their argument. Of course, basing policy on evidence is a worthy aspiration. But it is evidently not how politics currently works or how policy decisions are made. Failing adequately to account for that, one might find oneself shouting ever louder, and in increasingly frustrated and condemnatory tones, at the policy makers and others who have failed in their duties – and hoping that this time the population will awaken and ensure that politicians’ “autonomy to act” is used “to benefit us all”.
In fact, there are many in our population and abroad who are very sure that the policies Walsh and McCartney advocate would not benefit them at all. They are organised to varying degrees, and many are powerful, in terms of voices and resources. These days, some would prefer fascism over a return even to mild social democracy. And in general, they do rather a lot, with varying degrees of overtness and covertness, to constrain and eliminate the “autonomy” of politicians, or even to prevent them from gaining formal power to make policy at all.
So the question “what do we need to do” is unfortunately not “a remarkably easy question to answer”. It raises all of the inevitable further questions about achieving sociopolitical change against great opposition. It requires understanding in detail the shifting coalitions of power and interest as our world changes, and how to build the kind of class-based movements which can intervene intelligently and effectively in the politics of “who gets what, when and how”. Only in the hands of such a movement might evidence become the basis of the kinds of policy that the authors rightly crave.
Walsh and McCartney, then, have given us a massively powerful political economy of health, but one that will benefit from an enriched conception of the politics of the changes they seek to see in the world.
One test of those changes must involve addressing the continuingly appalling treatment of Glasgow. After 25 years of devolved institutions pledging commitment to equality and social justice, getting off the train from Glasgow in Edinburgh can still feel like arriving in a different country. Our focus on austerity should not occlude our perspective on the decades of prejudice against and mistreatment of Glasgow, or dampen our call for restorative justice to be delivered to the city.
Chik Collins was until recently Director of the Glasgow Centre for Population Health. Previously, he worked at the University of the Faroe Islands and the University of the West of Scotland
- John Foster, “The Economic Restructuring of the West of Scotland, 1945-2000”, in G. Blazyca (ed), Restructuring Regional and Local Economies, Ashgate 2003. ↩︎
- Carol Craig, A Time of Hope: The Story of Scotland’s Centre from Confidence and Well-Being, Argyll Publishing, 2024. ↩︎
- Its creation was part of a broader initiative in Jack McConnell’s time that created also the Centre for Confidence and Well-Being mentioned immediately above. ↩︎
- David Walsh, Gerry McCartney, Chik Collins, et al, History, Politics and Vulnerability, GCPH, 2016. ↩︎