On September 28, 2012, the postgraduate students of the Dalla Lana School of Public Health at the University of Toronto organized a conference on the theme of Health, Austerity and Affluence. It brought together academics, health-care professionals and public policy makers in a forum to discuss effective health care delivery at a time when the gap between wealth and poverty appears to be increasing while, at the same time, governments are imposing austerity measures on public spending—not least in the field of public health. The following remarks by Dr. Blake Poland are of direct importance not only to college students and teachers in Nursing and related health-care programs, but also to anyone those educators who understand that education is an inherently moral and political practice: moral because it is deeply infused with values, and political because those values are essentially contested. Most obviously in vocational pursuits involving the creation and distribution of public services and private commercial enterprise, but even in the most instrumental and technical fields, education involves a continuing dialogue about what knowledge is for and how the use of knowledge adds to or detracts from the common good. (HD)
Thank you to the conference organizers for the invitation to join this panel, and to Steini Brown for the kind introduction.
On the question of “what can we do to improve health and health inequities?” I think we first need to remind ourselves that the most powerful determinants of health lie well outside the healthcare system. Issues of gender equality, racism, the gap between rich and poor, access to affordable education, the social safety net and the quality of the social fabric (or conversely the erosion of community) are powerful determinants of health in their own right. These social determinants have been shown to have a bigger impact collectively on population health than what often gets focused on in health education, although I don’t want to dismiss the importance of diet, exercise and smoking and the ways in which these too are unevenly socially distributed. And yes publicly funded health care does matter, given its capacity to level the playing field in an unequal society, where those impacted by the inequitable distribution of the costs and burdens of progress, can be cared for by the body politic, as it were.
There are also many outstanding examples of public health and health professionals working with community groups and organizations to address determinants of health beyond the institutional walls, in the community. I could easily devote the rest of my allotted time, and then some, on these and other examples of innovative practice that mobilizes people in different sectors, is informed by community development principles, and addresses the upstream determinants of health. The Urban Issues team at Toronto Public Health, Street Health, Anishnawbe Health, PARC, the West End Urban Health Alliance—there are so many great examples of this kind of work right here in Toronto that I urge you to become familiar with and engaged in.
However, on a topic such as the one the students have put before us today (austerity), I think we need to step back, make a forthright examination of basic concepts, and unpack the broader socio-political context in which this so‐called Age of Austerity is unfolding. To start with, could it be that “Austerity” Is not quite what we’ve been told it is? Is it, as we’ve been told repeatedly, ‘short‐term-pain‐for‐long‐term-gain’, a temporary belt‐tightening until the public debt is paid or the next tide of economic growth washes in and lifts all boats? Or is it possible that, for many different reasons, sustained economic growth is and will remain a thing of the past, that economic stagnation is the new normal? Really, is Austerity about a shortage of money?
I submit that any Comparison of military vs. social spending suggests otherwise. According to a recent Human Development Report, for example, global spending on arms and military is roughly thirty-five times the estimated $28B that would be required to provide clean fresh water, sanitation, education and food for everyone alive today everywhere in the world. Another example that the money is there when it’s ‘needed’ is the trillions of dollars used since 2008 to bail out big banks and investment firms that had grown reckless because they were “too big to fail”.
York University Professor Dan McNally, among others, has urged us to remember that the bailout needs to be understood as a historically unprecedented transfer of public resources into private hands. That bail out is still happening, by the way. I don’t know if you caught the announcement a few weeks ago that the US Federal Reserve is prepared to inject, if I remember correctly, $40B a month into the US economy “for as long as it takes”. Please also note that this is public money that we have been told all along was unavailable for universal health care in the US and numerous social programs here, from the very modest Special Diet program for poor people with health problems (that was slashed in 2010 Ontario budget) to social housing and Metrolinx to more ambitious proposals such as universal day care or the replacement of our complicated welfare system with a guaranteed annual income In other words, there are reasons to question the notion that the Age of Austerity reflects a lack of resources that prevent a society for caring for fellow citizens in the way it would like. It would appear that scarcity is a distributional issue. At the same time, let us be clear about the ways in which the future is unlikely to be an extension of the past.
By many accounts, we are entering a period beset by multiple emerging threats to health equity and where efforts to politically, economically or socially ‘kick the can down the road’ (i.e., defer consequences) are proving less and less effective. Each of these, whether we’re talking about economic instability, climate change, resource scarcity, or environmental degradation, has the potential to exacerbate inequality.
In its 2008 annual report, the UN flatly stated that climate change alone has the potential to undo twenty-five or more years of anti‐poverty and health equity work around the world. There are many indications that we are entering a period of irreversible decline—economic and ecological—even as we (or at least our political leaders) cling to a fiction of renewed growth. What does this mean for us in public health? We’ve barely started to have the conversation about what it means to be thrust into the role of ‘managing decline’ (to borrow the title of a workshop Trevor Hancock and I organized at The Urban Health conference in New York two years ago). Nor have we seriously grappled with what it means to do health equity and poverty reduction work when the pie is not growing and maybe even shrinking, when we bump up against really challenging issues of wealth redistribution.
To summarize, as the financial, social, political and ecological systems we’ve relied on are showing unprecedented signs of stress and vulnerability to collapse, it would seem an opportune moment for rethinking the foundations of contemporary society. In other words, the real question here, in my opinion, is not how we get through the age of Austerity as best we can. If we and our children are to have a future worth aspiring to, we need to seize the opportunity of crisis to reinvent the future in terms that work for everyone rather than for the one or two percent. If that sounds unapologetically radical, it was meant to be. Whether the public is quite ready for this is another matter, although if current trends persist that could be said to be just a matter of time. At the moment, however, it seems easier for most people to imagine the end of the world than the end of capitalism. And yet the future of capitalism is more hotly debated now than at any other time in human history, and rightly so. If I can make one last point, think back over the past century to the remarkable accomplishments of the black emancipation movement, the women’s movement, the gay rights movement, the environmental movement. Yes these are works in progress. But history shows repeatedly that the concerted will of the people is unstoppable. In the words of Margaret Mead, “Never Doubt that a small group of committed citizens can change the world. Indeed that’s all that ever has …”
Occupy is an interesting example. In a few short months it accomplished what over twenty years of earnest liberal discourse, political hand-wringing, NGO think tanks and left‐wing politics was unable to do: it catapulted issues of inequality squarely into the mainstream political and civil discourse. Even as the encampments in Zuccotti Park and elsewhere have been forcibly disbanded, the notion of a ‘99%’ endures on the lips of politicians and in the mainstream media as one of the defining issues of our time, or at least of the current US presidential campaign.
And so it should—rates of inequality in the US have not been this high since the Great Depression. So in closing, if there is one strategy for public health that is too often overlooked it’s this: we need to get better at learning from the successes of recent and contemporary social movements and cultivate relationships with social movement leaders to leverage change in the major determinants of health. Because history shows that where political resolve falters and studies fail to sufficiently persuade, the concerted will of the people is unstoppable.
Blake Poland Associate Professor of Social and Behavioural Health Sciences and Public Health Policy at the Dalla Lana School of Public Health at the University of Toronto. He can be reached at email@example.com.