Everyone has heard about the 1 per cent, and even the one per cent of the one per cent, but who knows what that means for the health and well-being of the 99 per cent?

Arne Ruckert and Ronald Labonte, two leading scholars in the field of health inequities, have just published a brief (5 pages) nicely-written and well-documented review of the global evidence of what these inequalities have meant over the last decade.

The last decade is a time slot when austerity, neo-liberalism and technological change (the latter not given much attention by the authors) have converged to erode social, environmental and food security protections in almost all countries in the world. The way these momentous policy shifts have happened so quickly in so many places is a forceful reminder of the globalized and interconnected world we live in.

I’ll share a brief summary of the authors’ innovative arguments about the pathways for disease opened up or widened as a result of the triple threat of neo-liberalism, austerity and technology. Then I’ll file my complaint (isn’t Wayne a broken record, some may say) that the authors miss the point about the role played by diets and food systems, which in my view are pivotal determinants of health and well-being, and which may prove empowering enough to resist negative forces.

As with most proponents of the “social determinants of health,” Ruckert and Labonte don’t see the pivotal role of the nutrients, the conviviality, or the agency that come with good food from a healthy food system — benefits that deserve to be regarded as social determinants in their own right, and that can be especially beneficial to disadvantaged people.

Arne Ruckert, with the conviviality of food not far behind, and TLC by the side

But first, I want to praise the article’s arguments about pathways from unequal economies and inequitable policies to declines in health and well-being.

WHY HEALTH INEQUITIES ARE OVERLOOKED

Income inequality gets a lot of public attention because the idea of so few people having so much money and power when so many people have so little money and power is both shocking and chilling. It just runs against the grain of what most people think of as fair or legitimate.

But the popular and populist resentment of upper class greed doesn’t automatically extend to empathy for the health problems of poor and working people. That’s because most chronic diseases are blamed on poor individual lifestyle choices, not poor incomes. So significantly different disease rates between rich and poor aren’t seen as shocking, unfair and unjustifiable as vastly different income levels.

Most public health professionals pay a lot of attention to the relationship between income and health. Food planning professor Lesli Hoey at the University of Michigan has a great way of putting it: “the postal code is more important to disease patterns that the genetic code,” I heard her tell a large class a few weeks ago.

The reason this link between inequality and disease matters so much for health planners is that disease burdens which can be attributed to low income are often the burdens that can be lifted most easily through cost-effective prevention — without a moment lost to unnecessary pain and suffering, or a penny lost to expensive medical operations, or a year of life lost away from work and family.

I’ll have an ounce of prevention

An ounce of prevention is worth a pound of cure, as the old saying goes, and it has the cost benefit ratio of prevention to cure about right.

Health planners also reason that this enormous potential for disease prevention should command the attention of everybody, because many of the runaway costs of curing chronic diseases are borne by taxpayers. Given that most societies provide some public support for life-saving medical care and post-operation recovery, much of the money saved from a prevention-based strategy is public money that could easily be freed up to go to truly necessary and productive expenditures.

So Ruckert’s and Labonte’s work of tracking health inequities is an important public service.

WHY GOVERNMENTS LACK MONEY

One pathway to disease is tax evasion, which reduces the ability of governments to fund programs that can overcome the inequities of the marketplace. In the neo-liberal era, government tax rates becomes competitive tools and a race to offer the lowest taxes to investors ends up as a race to the bottom of legislation that’s protective against inequity.

According to the authors, the global losses from tax reduction for the rich and tax evasion by the rich jumped from US$28 trillion in 2004 to US$58 trillion in 2012. That’s a big jump, done in record time, setting the stage perfectly for the austerity campaign launched around 2010, just after the big banks were rescued with public money. (For the salacious details, check this.)

Austerity + Neoliberalism = Robin Hood in Reverse

What they giveth with the right hand, they taketh from programs once funded with the left hand.

Ruckert and Labonte identify the following pathways as most important throughout the world: reductions in freely-available health services, including food formerly provided as one of these services; rising unemployment; rising homelessness; declining protection of vulnerable workers (aka the rise of the precariat); welfare reforms that have masked cuts in services.

They take care to note how each of these pathways is damaging to both the physical and mental health of people who’ve been disadvantaged. I think this linking of physical and mental health is a very important and praiseworthy addition to the ways impacts of cutbacks are measured.

THE PATHWAY NOT TAKEN

The missing pathway is the dominant food system, a major beneficiary of both neo-liberalism and government austerity.

Praise used to go to what is called “evidence-based” or “science-based” health policy, and responding to that praise, health workers built the case for the damage caused by salt, sugar, transfats, and other essential ingredients of a food system dominated by adulterated (aka junk) foods. Yet there’s been no hint of forceful legislation to have these ingredients taken off the market, and there’s barely a sign of effective and well-financed government-funded campaigns to educate consumers to take them off their shopping lists.

If ever there was a pathway to disease, food with damaging additives is one, yet the authors fail to give food this recognition. (To be fair, Labonte has written several items on how food fits in the neoliberal playbook, and could justifiably claim that space limits kept him from doing justice to food.)

Nor do they identify the potential of popular food customs to establish the conviviality, support, empowerment and agency that are critical to resilience and health, and that have been the mainstays of popular health (rude health, as it was known) over centuries, long before the rise of the modern medical system.

Control inequality, and people will control sweet tooths

Two scholars who don’t miss this issue are Hilary Seligman and Dean Schillinger, authors of an important article on hunger and social disparities in the July, 2010 edition of the prestigious New England Journal of Medicine. They show that the price gap between cheap unhealthy foods and more expensive healthy foods has “widened over the past two decades.”

They also describe how poverty, food security, seeming “poor self-control” and diabetes work in lock-step. “Adults with diabetes are 40 % more likely to have poor glycemic control if they have inadequate money for food than if they can afford a healthy diet,” they write.

I think it’s high time that people who promote social determinants of health emphasize the social side of food, and stop judging food as a strictly physical thing.

The article concludes with a nod to the Sustainable Development Goals adopted by the United Nations in 2015, a highwater mark for progressive social policy internationally. They refer to the totality of SDG goals as “a compelling anti-austerity agenda,” and I agree. We should all do more to promote awareness of these goals — a positive alternative to what governments are now doing.

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