Health systems, neoliberalism, and the end of growth: The World Health Organization in denial
The WHO (World Health Organization) has released its latest in a series of reports[i] on public health in 53 European nations, and presents this assessment through a focus on the social determinants of health[ii]. Rather than sounding an alarm or considering the possibility that epochal economic decline is underway which threatens the health of the public, it serves up tepid criticism of government policies that have resulted in surging poverty[iii] and high unemployment[iv], fiscal cuts to health and other social services, increases in suicide and a host of other declining health indicators deforming people’s lives in most –possibly all- of the countries examined. Put directly, the social determinants of health are being laid to waste in several European states and endangered in others, yet the report casts this as a few dark shadows on an otherwise bright picture.
I find the report psychologically dissociative, ethically compromised, and in an intellectual malaise. Sociologically, however, it makes sense: it is self-destructive to analyze or challenge[v] the political/economic system that funds your work, even if it is destroying what your organization was founded to analyze, protect and ensure. As such, this report represents a conflict-ridden and unstable posture of ignorance and subservience to political power.
Revealingly, the report takes virtually no notice of the portents of socioeconomic and political[vi],[vii]upheaval[viii] –like UKip and Golden Dawn- spreading through Europe.[ix],[x] Naïvely[xi], the report calls for slight reforms –like giving health ministers a “seat at the table” of austerity[xii] budgeting to make the case for “proportionate to need” funding cuts[xiii]- as sufficient to ensure, maintain or in some conceded instances restore a portion of the underlying fundamentals of the health of European populations now being sacrificed in the name of balancing budgets and debt repayment. The authors give every indication of having no inkling that their flaccid calls for a realization that too much austerity endangers the public’s health is too little too late and, in any case, will have zero influence on neoliberal policymakers.
Politically, then, this WHO[xiv] report offers no recognition, let alone opposition, to the class-based austerity imposed by neoliberal governments[xv]. Accordingly, this report personifies developing turmoil[xvi] in organizational mission and collective identity for health professions as the divergence between the imposition of neoliberal austerity measures and the mission of public health deepens. This compromised stance, of offering mild warnings about austerity while accepting it as a legitimate policy response, is part of a cultural phenomenon of an inability to democratically address genuine problems while offering rhetoric to reassure and soothe a public that is losing economic ground and its faith in government.[xvii]
Therefore, I suggest that the report illustrates the futility of relying upon the WHO to comprehend what is occurring, let alone to lead in protecting public health. This is important because the WHO is not just another think tank or academic institute; it is the appointed champion[xviii] of world health issues. If it will not speak truth to power[xix] for the European public –which means unequivocally rejecting austerity policies and growing inequalities in income and wealth as destructive of the social determinants of health- at this critical moment, there is no reason to expect it to do so as neoliberal governments continue to cannibalize their citizens to maintain a world politically ruled by a numerically tiny financial elite[xx].
Rather than dissect the report in detail, I want to use it as a springboard to talk to those in the health sciences, especially young professionals and those close to retiring[xxi], who will read it and other such reports and conclude, “This just doesn’t fit my sense of what’s going on in Europe, my workplace, or the world, for that matter.” They will be searching for explanations containing a ring of experiential truth. They also may feel, “If the WHO is incapable of defending the social determinants of health, who will do so as conditions continue to worsen? And, how can I contribute to much needed changes?”
My comments will be unsettling to most health professions readers, but I believe that they contain a kernel of truth to explain the economic decline, which I maintain is caused by class politics and reaching the limits to economic growth.
Before presenting why health systems will continue to be bludgeoned by economic contraction, there is the intricate matter of the question of sustaining oneself while trying to contribute to the greater good. To work in medicine, public health, nursing or a related health profession means your daily bread comes from a large complex system. (And in the United States it’s even worse because most health professional work for profit-driven intensely thought-regimenting corporations.) Raising ones voice in a bureaucratic workplace to address fundamental problems of mission and strategy runs the risk of being expelled or punished by your administrative superiors.
The classic questions of those who recognize organizational decline or malfunctioning are: Do I stay and raise my voice? Or do I leave and work for change from the outside (possibly starting my own organization?). Or, do I remain loyal? (This should not imply merely shutting up and can involve ingenious ways of sotto voce bending or subverting policies to introduce ground-level change to avert catastrophe).[xxii] So individual responses will vary with time and context and no one should be embarrassed to say, “I’m staying because I need this job and will work for change from within.”
A further note on this: As late as the hour is, the probabilities of rationally convincing the WHO and other health leadership to challenge neoliberalism –or recognize the ecological/thermodynamic issues I will raise below- are virtually nonexistent. Nevertheless, it does not follow that it is futile to remain inside health systems articulating –as best we can for no one knows precisely what is coming- the need for vast change. The fact that the status quo of health leadership is ignorant yet powerful is a dangerous combination. They are virtually cybernetically designed to “go down with the ship” and can be expected to make a series of rote and arrantly wrongheaded and damaging decisions as the crises in the larger society and health systems deepen. Suffice it to say that voices -or loyalists- on the inside with an ability to articulate what is happening MAY find opportunities in this volatile context to affect the course of their organizations[xxiii]. This is particularly true as the legitimacy and power of administrative leadership dwindles, which it will.
On the other hand, health professionals in austerity-eviscerated nations like Greece[xxiv], Spain, Italy, Latvia, Ireland and Portugal may find my thoughts tame, trite or passé, given the devil’s choices and steadily degrading circumstances in which they are being forced to do their work. They are past the stage of anticipating decline and need no convincing that their governments are less concerned about the health of citizens than the pocketbooks of bankers–they are deeply experiencing these realities. They are likely to provide the world with models and ideas[xxv] for how to protect the health of the public in an era of thermodynamically and ecologically induced degrowth coping –for now- with the added burden of their governments working to save the rich by plundering the rest of society.
I suggest that one major lesson of Greece, et al. for a health professional is that neoliberalism’s priorities and abandonment of citizens are on display in these nations.
After confronting the class-based nature of public policy, I ask them to rethink their taken-for-granted understanding of how health systems are sustained[xxvi]. For many this combination of requests will be much like the disorientation that occurs when viewing the world through inverted glasses[xxvii].
So what do health professionals who intuitively grasp that something is fundamentally amiss need to know? First, they should examine the larger systems –or cultural- context that supports the delivery of health care and public health. By this I mean that the institutions upon which health systems rely for social, political and economic support are themselves caught up in a multi-layered set of ticking-clock crises, dilemmas and problems[xxviii] that spans the political/economic/financial, the ecological/thermodynamic, and the psychological/cultural/social dimensions.
To reiterate, these master institutions[xxix] as presently designed cannot respond to this set of crises in an egalitarian manner because 1) they are organized in terms of serving a) economic growth that benefits b) class-based interests; 2) they are unaware of the unfolding dynamics of ecological/thermodynamic realities bringing economic growth to a halt and 3) anthropologically, institutions in crisis automatically operate to repeat mistakes –as the only way forward- while not perceiving or merely dismissing as absurd information pointing to the necessity of taking radically alternative courses of action.
In sum, health professionals must see that austerity is a chosen policy stance of neoliberal governments serving narrow economic elite interests, not an unfortunate oversight or misguided mistake of politicians acting for the common good. Again, I stress that this will be extremely difficult and threatening for health professionals to perceive and act upon.
In tandem with this they need to understand that resource scarcity –especially the end of cheap energy[xxx]- and a host of ecological crises are coupled to –and worsened by- the inherent social, political, fiscal, and economic invidiousness of neoliberalism. This amounts to more and more of the 99% being sacrificed to preserve and further enrich the 1%. Simultaneously, the actual size of the economic pie is contracting. What is occurring in Europe, the United States and other nations is, therefore, a class-based upward redistribution of the income and wealth produced by a dwindling flow of natural capital.
These realizations require a giant leap of consciousness and will almost assuredly be accompanied by a crisis in collective and personal identity as institutions begin to fail, and possibly collapse. Preserving the social determinants of health in these dire circumstances goes beyond restoring or even increasing –which simply will not happen- funding for health services to involve building a society that shrinks energy-consumptive institutions, respects and comprehends the power of nature and, as a necessity, eliminates deeply embedded socially parasitic patterns of wealth accumulation and economic exploitation.
I am not much for prognostication, yet it appears clear to me that fissures will expand and rupture in the health professions as –probably slowly and then in a torrent- awareness spreads that the WHO and other “official” protectors of health are incapable of recognizing or responding to the crises touched upon above. This crisis of health systems, of course, will not happen in a cultural vacuum, as the master economic, financial and political institutions that health professionals take for granted also enter extreme crisis due to energy scarcities and the financial and economic chaos this will create.
Offering specific goals or detailed policy agendas beyond those cited above -shrinking energy-consumptive institutions, respect and comprehend the power of nature and eliminating deeply embedded socially parasitic patterns of wealth accumulation and economic exploitation- is, paradoxically, not likely to succeed at this moment. First comes an awakening, brought on by crisis, to the class-based nature of public policy and the thermodynamic impossibly of perpetuating economic growth[xxxi].
[i] Review of social determinants and the health divide in the WHO European Region: final report. Marmot, Michael lead author.
[iv] Ewing, Jack. “Jobless Rate in Euro Zone Stays at Record.” New York Times, October 31, 2013. http://www.nytimes.com/2013/11/01/business/international/jobless-rate-in-europe-stays-at-record-12-2.html?_r=0.
[v] It is also the case that awareness is constrained by one’s location in society to the extent that an organization and the individuals within it can literally not consider, easily dismiss, or fail to recognize issues, facts and circumstances germane to their institution’s operations and survival. For a vivid example of this phenomenon see this account of Lawrence Wilkerson, assistant to Colin Powell when Powell, as Secretary of State, delivered his now infamous and debunked speech to the UN “proving” that Saddam Hussein has biological and chemical weapons and was hotly pursuing a nuclear bomb with which to intimidate the world and possibly attack the United States. In sum, Wilkerson says in this interview he was unaware –at that time- that Powell’s “evidence” was in fact untrue. See: Democracy Now, “Decade After Iraq WMD Speech at UN, Ex-Powell Aide Lawrence Wilkerson Debates Author Norman Solomon.” Amy Goodman, interviewer. http://www.democracynow.org/2013/2/6/decade_after_iraq_wmd_speech_at.
[vi] Quijones, Don. “Law And Disorder In Spain.” Testosterone Pit, December 15, 2013. http://www.testosteronepit.com/home/2013/12/15/law-and-disorder-in-spain.html.
[vii] Clark, Tom and Rowena Mason. “Fury with MPs is main reason for not voting – poll.” The Guardian, Thursday 26 December 2013. http://www.theguardian.com/politics/2013/dec/26/fury-mps-not-voting-poll.
[viii] It is important to highlight the absence of democratic processes in guiding European austerity policies. The most glaring example concerns the removal of the Greek premier, George Papandreou, in 2011, as a response to his call for a vote by Greeks on the question of whether to accept massive governmental spending reductions as the concession for loans to repay loans –yes loans to repay loans- coming due on Greek debts. Here is how “The Troika” (the term used for the European Union, the European Central Bank and the International Monetary Fund.) responded to his call foe a plebiscite:
Chancellor Angela Merkel of Germany and President Nicolas Sarkozy of France, apparently caught off guard by Mr. Papandreou’s call for a referendum … said they would hold emergency talks on Greece with euro zone leaders on Wednesday.
The chairman of the euro zone finance ministers, Jean-Claude Juncker, warned that the plan to hold a referendum endangered an $11 billion loan that Greece was to receive under the bailout deal, and that Greece urgently needed to avoid a default.[viii]
In the United States National Public Radio put the best spin it could on this display of raw and panicked tyranny: “Papandreou tried to build public support by asking for a referendum on the bailout… But the referendum never happened; terrified European Union leaders, as well as many Greeks, rejected that idea.” (NPR, May 1, 2012: “George Papandreou: Greece Had To Make Changes.” http://www.npr.org/2012/05/01/150804420/george-papandreou-greece-had-to-make-changes.)
So here we are asked to believe that the will of the Troika and “some” of the Greek people was legitimate, whereas the discovery of the collective will of the Greek people through a plebiscite was destabilizing.
[ix] Evans-Pritchard, Ambrose. “Italy’s president fears violent insurrection in 2014 but offers no remedy.” The Telegraph, December 20, 2013. http://blogs.telegraph.co.uk/finance/ambroseevans-pritchard/100026297/italys-president-fears-violent-insurrection-in-2014-but-offers-no-remedy/.
[xi] Perhaps the word strategically should be used here, but I’m not in a position to say this with certainty.
[xii] “Political Economist Answers: What’s So Dangerous About Austerity?” interview of Mark Blyth (author of Austerity: The History of a Dangerous Idea. Oxford University Press, 2013) by CJ Polychroniou. Truthout, February 16, 2014. http://truth-out.org/opinion/item/21880-mark-blyth-discusses-austerity.
[xiii] In fact, what has been going on in policymaking is an inversion of this “shared sacrifice” suggestion. The wealthiest are gaining wealth and income while those beneath them are losing the same.
[xiv] “WHO is a United Nations specialized agency concentrating exclusively on health by providing technical cooperation, carrying out programmes to control and eradicate disease and striving to improve the quality of human life.” WHO: http://www.who.int/trade/glossary/story096/en/.
[xv] Bourdieu, Pierre. “The essence of neoliberalism.” Lemonde diplomatique, English edition. http://mondediplo.com/1998/12/08bourdieu. ”Thus we see how the neoliberal utopia tends to embody itself in the reality of a kind of infernal machine, whose necessity imposes itself even upon the rulers. Like the Marxism of an earlier time, with which, in this regard, it has much in common, this utopia evokes powerful belief – the free trade faith – not only among those who live off it, such as financiers, the owners and managers of large corporations, etc., but also among those, such as high-level government officials and politicians, who derive their justification for existing from it.
“For they sanctify the power of markets in the name of economic efficiency, which requires the elimination of administrative or political barriers capable of inconveniencing the owners of capital in their individual quest for the maximisation of individual profit, which has been turned into a model of rationality. They want independent central banks.
“And they preach the subordination of nation-states to the requirements of economic freedom for the masters of the economy, with the suppression of any regulation of any market, beginning with the labour market, the prohibition of deficits and inflation, the general privatisation of public services, and the reduction of public and social expenses.”
[xvi] Parley, Thomas I. “Europe’s Crisis without End: The Consequences of Neoliberalism.” Contributions to Political Economy, Volume 32, Issue 1, 2013. Pp. 29-50 http://cpe.oxfordjournals.org/content/32/1/29.short.
[xvii] In the United States polls regularly show that 10% or less of the public trusts the Congress; and a recent pool found recorded 64% of Americans favor firing all members of Congress.
[xix] This slogan is, to coin a phrase, the faint tribute vice pays to virtue. Anyone who really speaks truth to power must anticipate an aggressive and threatening response. “Real resistance has real consequences. And no salary.” “Public Power in the Age of Empire: Arundhati Roy on War, Resistance and the Presidency.” Democracy Now, August 23, 2004. http://www.democracynow.org/2004/8/23/public_power_in_the_age_of.
[xx] Konczal, Mike. “Who Are the Top 1 Percent and How Do They Earn a Living?” Rortybomb, http://rortybomb.wordpress.com/2011/10/14/who-are-the-1-and-what-do-they-do-for-a-living/.
[xxi] Ahmed, Nafeez. “Former BP geologist: peak oil is here and it will ‘break economies’. The Guardian, “http://www.theguardian.com/environment/earth-insight/2013/dec/23/british-petroleum-geologist-peak-oil-break-economy-recession.
[xxii] Hirschman, A.O. Exit, Voice and Loyalty: Responses to Decline in Firms, Organizations, and States. Cambridge, MA: Harvard University Press. 1970.
[xxiii] This requires another essay to explore but the point to make here is to not condemn those who remain “inside” but to challenge them to find the best ways available to offer a comprehensible vision of the radical future now emerging.
[xxiv] “Open Letter on Greek Health Care Crisis.” http://tacd-ip.org/archives/926. “The Government has imposed a brutal and self-defeating fiscal austerity; in a confiscatory manner, it tries to collect extra revenue from an already impoverished and afflicted populace, while it neglects its main role, as specified by the Constitution: The Protection of the Rights and the Welfare of the Citizen Body.”
[xxv] Ostrom, Elanor. “Beyond Markets and states: Polycentric Governance of Complex Economic systems.” Nobel Prize in Economics Lecture, December 8, 2009. http://www.nobelprize.org/nobel_prizes/economic-sciences/laureates/2009/ostrom_lecture.pdf. Ostrom describes the received wisdom view of policymaking, which she challenges in her work as often empirically false. That is to say, it is creative people in extremis who come up with solutions, not distant policy analysts and their political patrons. She writes:
“When analysts perceive the human beings they model as being trapped inside perverse situations, they assume… scholars and public officials – are able to analyze the situation… Then, external officials are expected to impose an optimal set of rules… it is assumed that the momentum for change must come from outside the situation rather than from the self-reflection and creativity of those within a situation to restructure their own patterns of interaction.”
[xxvi] Bednarz, Dan and Allana Beavis. “Neoliberalism, Degrowth and the Fate of Health Systems.” Resilience.org, September 14, 2013. http://www.resilience.org/stories/2012-09-14/neoliberalism-degrowth-and-fate-health-systems.
[xxvii] “Psychologist Made Glasses that Turned The World Upside Down: In 5 Days, He Saw Everything as Normal.” Techyville, http://www.techyville.com/2012/10/social-media/psychologist-made-glasses-that-turned-the-world-upside-down-in-5-days-he-saw-everything-as-normal/.
[xxviii] In the United States, for example, The 2008 financial and meltdown, the BP deepwater horizon blowout and subsequent –and little reported- efforts by government to signal an “all clear”, hurricanes Katrina and Sandy, Government bailouts of financials institutions (instead of criminal prosecutions), the NSA surveillance on citizens, the refusal of Congress and the Executive Branch to address unemployment, energy, climate, the secret negotiations of the Trans-Pacific Partnership, and a host of other issues, have all served to heighten the lack of trust in government.
[xxix] Leaders and high-level managers are supposed to act strategically, to scan the environment so as to anticipate problems, to analyze them soberly, act responsibly, and so forth. In the real world few act this way because they are not rewarded to do so and their information acquisition and processing is non-consciously done so as to misunderstand or ignore signals that call standard operating procedures and power arrangements into question.
[xxx] We are in the beginning phase of the post-peak oil era, a fact that is dismissed in mainstream media and misunderstood by many who grasp that neoliberal governments serve class interests.
See: Cunningham, Nick. “Big Oil Sheds Assets to Fix Balance Sheets.” Oilprice, February 14, 2014. http://oilprice.com/Energy/Oil-Prices/Big-Oil-Sheds-Assets-to-Fix-Balance-Sheets.html. Cunningham writes: “The oil industry may be in the midst of entering a new phase of high costs and slower growth. New oil discoveries are harder to come by, and the scramble to replace depleting production is costing more and more.”
See also: Swann, Richard. “’Big oil’ getting smaller as production keeps falling.” Platts, February 14, 2014. http://www.platts.com/news-feature/2014/oil/western-oil-production/index.
This decline in extraction due to rising costs is one of the central predictions of the consequences of peak oil. Another is a series of crises in financial markets; a t5hird is high unemployment. (These were made by Colin Campbell and Kenneth Deffeyes, both are petroleum geologists, among others.
[xxxi] We should take seriously the phenomenon Thomas Frank pointed out in What’s the Matter with Kansas?: How Conservatives Won the Heart of America. New York: Henry Holt. 2004. Frank writes, many Kansans are living “Like a French Revolution in reverse — one in which the sans-culottes pour down the streets demanding more power for the aristocracy.”
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