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American institutions are in decline and rife with corruption brought on by a combination of hitting the limits to growth while under the control of neoliberal capitalism[i]. To the extent one deviates from the appearance and demeanor of staid white middle or upper class norms, an encounter with the police in many localities[ii],[iii],[iv] can be dangerous to ones person and pocket[v]. The government’s reaction to the “the most destructive epidemics of elite financial frauds in history”[vi] has been to further enrich[vii] –rather than jail- financiers,[viii] and protection of the banks continues to harm and ruin the lives of millions of citizens. Higher education is embroiled in several scandals, from encouraging students to take out usurious loans few will able to retire, to the exploitation of adjunct professors, to covering up campus rape cabals. Many Americans are trapped in debt with virtually no possibility of paying it off; trust in government and corporations[ix] is at all time lows; and in fashions too lugubrious to list the federal government –and the two major political parties- do not promote the public interest,[x] preferring instead to serve political/economic elites.[xi],[xii]

In the obscure yet critical institution of public health organizational leadership and academic researchers either blithely ignore or erroneously frame these indicators of cultural decline and corruption as the unfortunate fallout from “The Great Recession.” I suggest these leaders are trapped in a tightening contradiction between the field’s mission, protecting the health of the entire public, and acquiescence to social policies that serve the private interests of the 1%. This stance of Loyalty inexorably places the health of the public at risk. For example, on the front lines health departments across the nation are absorbing funding cuts[xiii] leading to service reductions as mounting socioeconomic inequality erodes the nation’s collective health. For good measure, stir in hitting the aforementioned limits to growth and the recently demonstrated lack of preparedness for Black Swan events, such as an Ebola outbreak[xiv], and you have a recipe for system breakdowns and, eventually, the collapse of the current health system. (As dysfunctional and unsustainable as it is, it still ambles along.)

In early 2009 I conducted interviews with public health directors from several states to assess how they were dealing with declining governmental funding.[xv] Not surprisingly, the central issue they faced was how “to resolve the contradiction between diminishing [public health] funding in a time of growing need and the consequent threats to the social determinants of health[xvi]…” They reported that budget cuts had been occurring for several years prior to the financial crash of the fall of 2008. Further, they felt that these reductions would continue for an indeterminate period which would require them, these public health directors, to contract or substantially rework their operations until their funding situation could, if possible, return to previous higher levels. Only one of those I interviewed entertained the idea of collectively lobbying -using the Voice option, see discussion below- for government to increase support for public health.

In my summary of the report on these interviews I wrote,

Albert O. Hirschman’s pioneering work (Exit, Voice and Loyalty: Responses to Decline in Firms, Organizations and States, 1970) examines the logical array of responses to organizational decline. Exit is the economic option: quit, boycott, or in some way withdraw economic support [to stimulate needed changes or establish another organization to provide the needed services/goods]. Voice aims at political reform [from inside the organization or from the outside in the form of protests movements]. Loyalty is the psychological dimension that complicates use of the Exit and Voice options.[xvii]

Since public health is not a competitive market but a government subsidized public good, the Voice option is the reasonable response.

A year later I wrote a follow-up to this report and observed, “To the extent that the crisis has garnered attention public health professionals cast it as a ’weather the storm’ condition.”[xviii] This is a Loyalty reaction to decline.

At the beginning of 2013 I wrote an article outlining what I saw as the central challenges facing public health: the commencement of thermodynamically induced socioeconomic degrowth in a context of the havoc wrought by a neoliberal capitalist[xix] system of government simultaneously unwilling to and incapable of acting in the public interest. In this article I concluded:

Thermodynamics explains the physical basis of how energy is needed to make things happen –to do work- in the natural world; it describes the physical limits of growth and the loss of low-entropy energy inputs involved in extracting natural resources from the earth and transforming them into goods and services for a human economy. The Cat Food Commission metaphor informs us that the (contingent) way humans have arranged the political/economy [neoliberalism] of the modern world in the early 21st century is invidious and unsustainable in a world at the end of growth. Henceforth, neoliberalism “works” only if more and more groups –classes of people- are pauperized. In sum, “Cat Food Commission” embodies social inequality… This is the turbulent context in which public health must first locate itself and then (explicitly) answer the question … Which side are we on?

Let me rephrase this for emphasis: if an economy stops physically growing –not piling up “paper wealth” for a few through the creation of debt for many and calling it growth- the only way for the top 10% to continue to become “wealthier” is by cannibalizing the bottom 90% -and eventually the 1% will seek to devour those below them. This is now occurring[xx] –and public health remains silent or clueless despite the portentous implications for the social determinants of health and the functioning of a public health system.

I want to offer three examples –from the foundation world, academia and government- to illustrate public health’s inability to exercise the Exit or Voice options and its obsequious Loyalty to the 1% worldview. To reiterate, continued Loyalty to neoliberal government as the world enters degrowth constitutes a deepening contradiction with the mission of public health.

Our nation’s current political/economic situation is not a “new normal” mandating long-term austerity, as some in public health imply.[xxi] The pace of decline will increase and worsen the institutional crisis now emerging. This crisis may –not will– sow the seeds for –amidst tumultuous cultural change- a public health system capable of earnestly pursuing its mission.[xxii] The alternative of system breakdown is utterly chaotic, but barring a deus ex machina, it will be necessary to break the hold of neoliberalism and make us realize we now live in a world of degrowth.

This new system must be a decentralized, low-tech, less complex one that is in line with thermodynamic and ecological realities while simultaneously overcoming the corrupting[xxiii] class-based neoliberal “social” policies now dominant in society. At this time it is hard to imagine how we get to this system in anything approaching a consciously designed and orderly fashion.

Taking my cue from A.O. Hirschman, I want to highlight the organizational forces that place institutional public health in this dilemma between pursuit of its mission and obedience to a government aiding and abetting the predations and depredations of the 1%. This analysis shows –I hope- why not more than a tiny number of current leadership in public health will use their collective Voice to struggle to fulfill public health’s mission (Exit is virtually impossible at this moment, except for those who follow the path of localization). Also, my commentary should remind readers that Loyalty to the status quo among leadership is typical of how massive social change unfolds. As time passes these leaders will be redefined as irrelevant myopic obstructionists; but in the meantime they have power to ignore, resist and suppress collective impulses for change.

For our three examples, let’s examine the views of two public health policy thought leaders and agenda setters, first, the deep-pocketed Robert Wood Johnson Foundation, RWJ; and second, the Harvard’s School of Public Health, HSPH, and then follow with a third example from local government. HSPH recently published, “Failing Economy, Failing Health: The Great Recession’s Toll on Mind and Body.”[xxiv] The abstract reads:

Five years after the Great Recession officially came to an end, the United States has yet to fully recover from the economic devastation sparked by the collapse of an $8 trillion housing bubble and the ensuing turmoil that saw global financial systems teetering on the brink of collapse. But while the economic costs of the downturn have drawn the lion’s share of attention, the damage to our bodies could end up far surpassing the damage to our bank accounts.

This abstract begins with a 1% talking point, “the Great Recession officially came to an end.” Really? What kind of “recovery” –and more generally, economic system- is it when the bottom 90% is losing ground while the top 10 is doing well, the top 1% very well, and the top 0.1% spectacularly so? Similarly, this report avoids assigning human agency, referring to, “economic devastation sparked by the collapse of an $8 trillion housing bubble and the ensuing turmoil.” It seems we have encountered our old acquaintance, Mr. Passivity, voicing a version of, “Mistakes were made.”[xxv],[xxvi],[xxvii] This avoidance of assigning responsibility is akin to Chomsky and Herman’s[xxviii] well-known criticism of mainstream media propaganda: Report “war has broken out” -as if it were an act of Nature- rather than analyzing who initiated the aggression and for what gains. Finally, the reference to “damage to our bank accounts” betrays a social class bias since millions of citizens have lost their jobs and homes, have no savings and are deep in debt.

Below is an excerpt from the RWJ companion piece to the above Harvard article. It describes the relevance of several Harvard School of Public Health faculty members’ research to the public health issues flowing from the “Great Recession.” RWJ titles this, “Harvard School of Public Health Special Report: The Financial Crisis as a Public Health Crisis.”

…HSPH faculty are exploring ways to buffer people from the health impacts of economic downturns. Laura Kubzansky, for example, is looking at the biology of resilience. “What are the resources that would mitigate the impact of stress?” she asks. “What are the assets that enable people to meet life’s demands in a hardier way? Wouldn’t it be great if we knew the answers and put some proven protections in place before the next recession?…

“What drives resilience in some individuals? What leaves others more vulnerable?” asks [Michelle] Williams [Chair of Harvard’s Department of Epidemiology]. “Those are the public health questions we need to answer.”[xxix]

This professor went on to offer this risible ivory tower observation:

“You can ask and answer a lot of research questions when what we call a natural experiment—like the Great Recession—happens on a population scale.”

The causes of the Great Recession are unexamined in both documents; I suppose because economic crises are viewed as merely part of “life’s demands.” Rather, the reports focus on such non-boat-rocking topics as how to mitigate stress and develop “resilience” in individuals so that they can better cope with the next round of economic misery. (This framing, of course, ignores that for many Americans their economic suffering is ongoing). Tellingly, there is nary a word about the social determinants of health from the Harvard faculty or RWJ in these documents.

However, we can turn to economist Bill Black, who borrows a health concept for metaphorical purposes, to assign human agency to The Great Recession:

…fraud epidemics hyper-inflated the housing bubble and drove the financial crisis and the Great Recession. The best estimate is that the U.S. GDP loss will be $21 trillion and that 10 million Americans lost their jobs. Both numbers are far larger in Europe. The elite “C Suite” leaders of these fraud epidemics were made wealthy by those frauds through bonuses that measured in the billions of dollars annually.[xxx]

Put differently, as far as RWJ and HSPH indicate in these reports there’s no widespread socioeconomic exploitation and oppression in America threatening the health of the public. Rather, the “Great Recession” has revealed an opportunity to do research on a public lacking sufficient biological resilience and coping skills to deal with the vicissitudes of modern life. By implication, investigating the larger context of a political/economy where a neoliberal government serves corporate masters as we enter the end of growth would call for activation of Exit (again, highly improbable today) or Voice to protect the health of the public from a predatory elite as the economic pie shrinks. So RWJ and HSPH dare not respond to decline with the Exit or Voice options and by default have taken the road most traveled -to irrelevance- through their response of Loyalty.

My third example is government. Here is Tom Wheeler, former Multnomah County (Portland, Oregon) Commission Chair, in a video accompanying a RWJ[xxxi] essay on how public health departments need to “innovate” and “evolve” to adapt to funding cuts: “The way to reduce our costs over the long term is to reduce the dependence on the services we provide.” Wheeler’s remarks were made in reference to an approximately $15 million budget cut to the Multnomah County Health Department, which resulted in the loss of 50 full-time positions. For him, government is about “reducing costs” and pretending that no protections or services offered to the public have been compromised.[xxxii] And remember that this was done during a time of increasing socioeconomic inequality.

Presently, only the Voice[xxxiii] option has any chance of reforming the nation’s public health system. The reasons for the failure of the Voice option to be taken up have to do with the great personal and professional costs and burdens of exercising it, especially as the Exit option –except as noted in regard to localization above- is virtually unavailable as it is tied to the implausible notion of building and funding a parallel public health system.

[i] Zephyr Teachout. “The Anti-Corruption Principle.” Cornell Law Review, Volume 92 Issue 2, January 2009. “Half of Americans are convinced that Congress is corrupt; strong evidence indicates that many members of Congress are enriched by their service; no-bid contracts and earmarks are regularly rewarded to people who use their wealth to affect public policy. According to Transparency International, the United States ranks eighteenth in its Corruption Perceptions Index. The revolving door of corruption between staffers and lobbyists, the lure of powerful contacts, the seductions of what {Alexander] Hamilton called “the business of corruption.”

[ii] : Barry Donegan. “Nashville Police Chief Refuses to Crack Down on Ferguson Protesters, No Violence Ensues.”, Nov 28, 2014.

[iii] Robert Rogers. “Richmond police chief a prominent participant in protest against police violence.” Contra Costa Times, December 9, 2014.

[iv] Steve Early. “Real Police Reform Takes Root in One California City.” Counterpunch, December 2, 2014.

[v] I refer to the use of physical violence and also the laws that make it “legal” for the police to confiscate property and money from those they define as criminal suspects.

[vi] Bill Black.New York City: Aggressive “Broken Windows” Policing but Carte Blanche for Banksters.” New Economic Perspectives, December 6, 2014.

[vii] Nomi Prins. “From J.P. Morgan to Jamie Dimon: The inside story of how banks and bankers control our politics.” NEW YORK DAILY NEWS, Thursday, April 10, 2014.

[viii] Yves Smith. “The Fed’s Ever-Burgeoning Market Manipulation Support.” Naked Capitalism, June 20, 2014.

[ix] Neil King JR. “Americans of All Stripes Agree: The System Is Stacked Against Them.” Wall Street Journal, Nov. 20, 2014.

[x] Chris Cillizza. “The remarkable collapse of our trust in government, in one chart.” Washington Post, December 4, 2014.

[xi] Martin Gilens and Benjamin I. Page. “Testing Theories of American Politics: Elites, Interest Groups, and Average Citizens.” Perspectives on Politics / Volume 12 / Issue 03 / September 2014, pp 564-581. “Our lawmakers create policy based on the desires of monied elites while “mass-based interest groups and average citizens have little or no independent influence.’”

[xii] Sahil Kapur. “Scholar Behind Viral ‘Oligarchy’ Study Tells You What It Means.” TMP DC, April 22, 2014.

[xiii] NACCHO. (National Association of City and County Health Officials). “LHD (Local Health Departments) Budget Cuts and Job Losses.” “Since 2008 local health departments shed nearly 44,000 jobs…”

[xiv] Mary Logan has a series of enlightening articles on the threats Ebola poses to the United States overly-complex health systems as they face peak oil and, overall, ecological overshoot.

[xv] Dan Bednarz.. “The economic crisis impacts on public health.” Health after Oil, March 13, 2010.

[xvi] World Health Organization. “The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.”

[xvii] I have since learned that Loyalty itself can be a subversive mechanism for change inside an organization. This is done, for example, by members of the organization simply reinterpreting their roles, job descriptions or the rules and regulations that guide their work in such a way as to promote change while being loyal to the organization and never taking up the Exit or Voice options. I learned this from an article I read in a law review essay on Hirschman in 2012: Heather K. Gerken, “EXIT, VOICE, AND DISLOYALTY,” DUKE LAW JOURNAL [Vol. 62:1349, 2013].

[xviii] Dan Bednarz, “Impacts of the economic crisis on public health, part II: Paradigms and the right questions,” Energy Bulletin, March 28, 2010.

[xix] Dan Bednarz. “Public health, thermodynamics and the cat food commission.” Resilience. February 20, 2103.

[xx] Steve Ludlum. “Oil Shock.” Economic Undertow. December 10, 2014. “Since 2008, the world has become poorer; what remains of purchasing power has been diverted away from ordinary customers toward elites. Monetary- and fiscal policies around the world have amplified this flow making it difficult for customers to buy industrial goods including oil. By catering to crony ‘friends’ the central banks and governments have been working against their own stated interests, precipitating the very crisis they have been working so hard (?) to avoid.”

[xxi] Kim Krisberg, “Budget cuts straining capacity of public health departments: Services in demand.” The Nation’s Health, Nov/Dec 2014.

[xxii] This will not take place in a socioeconomic vacuum; rather, expect a context of cultural upheaval.

[xxiii] Zephyr Teachout. “The Anti-Corruption Principle.” Cornell Law Review, Volume 92 Issue 2, January 2009. “Broadly put, corruption is the use of public forum to pursue private ends. It can affect citizens and societies as well as public officers.”

[xxiv] Robert Wood Johnson Foundation. “Harvard School of Public Health Special Report: The Financial Crisis as a Public Health Crisis.” April 30, 2014.

[xxv] Jezera Kaye. ‘“Mistakes Were Made”: The Passive Voice.’ Speak Up for Success,

[xxvi] Wikipedia. “Mistakes Were Made.”

[xxvii] Fusion Net. “Obama on torture report: ‘Terrible mistakes were made,’ but declines to directly blame Bush.”

[xxviii] Noam Chomsky and Edward Herman. Manufacturing Consent: The Political Economy of the Mass Media. New York: Knopf Doubleday Publishing Group. 1988.

[xxix] Amy Gutman. “Failing Economy, Failing Health: The Great Recession’s Toll on Mind and Body.” Harvard School of Public Health.

[xxx] Bill Black. New York City: Aggressive “Broken Windows” Policing but Carte Blanche for Banksters.” New Economic Perspectives, December 6, 2014.

[xxxi] Tom Wheeler quoted in: Robert Wood Johnson Foundation, “Persevering in Tough Budget Times: How one county’s health department is expanding its reach through efficiency and innovation.”

[xxxii] One wonders, however, what the reaction would be if Wheeler’s advice of “innovate” and “evolve” to make up for funding cuts would be applied to the Pentagon. Likewise, this logic could have been applied in 2009 when the Secretary of the Treasury, Timothy Geithner, worked to “foam the runway” for banks.” See:

To hammer this point one more time, this advice could have been given to Goldman Sachs when government officials made sure that AIG paid out 100 cents on the dollar to Goldman:

After the federal government stepped in to rescue the teetering insurance giant [AIG] in the fall of 2008, the New York Fed, then led by current Treasury Secretary Timothy Geithner, directed AIG to pay its counterparties 100 cents on the dollar on their complex derivatives deals. More than $27 billion of taxpayer money went into the coffers of firms like Goldman Sachs and Deutsche Bank. The firms were also allowed to keep $35 billion in collateral previously posted by AIG. Source: Shahien Nasiripour. “Goldman Sachs Told It Was Getting 100 Cents On The Dollar From AIG, Top Exec Says.” Huffington Post, June 27, 2010.

[xxxiii] See: Yves Smith, “The Skunk Party Manifesto,” Naked Capitalism, November 20, 2013, for a discussion of collective political action.