Conditionalities attached to loans from the World Bank and IMF were among the key negative influences on health and its social determinants between 1980 and 2000 in many of the more than 75 low- and middle-income countries in which they were applied. Best available evidence suggests that this 'neoliberal epidemics' era is not over. In the future, neoliberalism is likely to reflect the erosion of territorial divisions between core and periphery, or the global North and the global South, in the world economy
by Ted Schrecker, professor of Global Health Policy
and Clare Bambra, professor of Public Health Geography
Durham University, England
‘Neoliberal Epidemics’ in Global Context
An aid-funded Canadian team that sought to rebuild Tanzania’s health system on a pittance wrote in 2004 that: ‘The era of structural adjustment may be over, but the effects of earlier damage continue to cast a long shadow’. The length of that shadow became apparent a decade later, when the Ebola outbreak in Africa in 2014 dramatised the fragile state of national health systems – attributed by commentators writing in The Lancet and Foreign Policy to the damage done by long periods of expenditure restraint mandated by the International Monetary Fund. (The IMF, predictably, contested these claims.) The specifics of the Ebola response aside, conditionalities attached to loans from the World Bank and IMF were among the key influences on health and its social determinants between 1980 and 2000 in many of the more than 75 low- and middle-income countries in which they were applied, and the best available evidence is that the era was not over at least circa 2007.
Structural adjustment programmes involved a relatively standard neoliberal package of privatisation, deregulation, reduced subsidies for consumer goods including food, economic restructuring that prioritised export sectors, and what would now be called austerity – demanded in exchange for loans that enabled countries to reschedule their external debts. At least as early as 1987, a major UNICEF study warned of the destructive human consequences. Similar consequences are now being experienced in Greece in the context of analogous demands by the ‘troika’ of the IMF, the European Commission and the European Central Bank. As in the 1980s and the 1990s, primary beneficiaries are commercial banks that hold the country’s debts. (The ‘debt crisis’ that ushered in the era of structural adjustment became part of the US foreign policy agenda in the early 1980s mainly because of threats to several of the country’s major banks.)
In a book published last year, we used the term ‘neoliberal epidemics’ to describe the spread of overweight and obesity, austerity (expenditure cutbacks), inequality and insecurity in the United States and the United Kingdom – the large, high-income countries that have travelled farthest down the road of neoliberal or ‘market fundamentalist’ policies. These are epidemics in the sense that they exist on such a scale and have spread so quickly across time and space that if they involved pathogens they would be seen as of epidemic proportions; indeed, references to the epidemic of overweight and obesity are now commonplace. They are neoliberal in that they are direct consequences of neoliberal economic and social policies.
The example of structural adjustment programmes and their contemporary European analogues shows that in global context, the concept of neoliberal epidemics is even more relevant. In another example, references to the epidemic of overweight and obesity, now convincingly linked to the neoliberal transformation of food systems and the increasing unaffordability of healthy diets, have become commonplace in the high-income world. The connection is evident, as well, in many low- and middle-income countries where rapid transitions to a diet that is conducive to obesity have been connected with trade liberalisation and the growth of foreign investors, to the point where one article described a pattern of ‘exporting obesity’ from the United States to Mexico, notably in the form of (subsidised) high-fructose corn syrup for use in fizzy drinks. Predictably, the prevalence of obesity in the two countries is now comparable. Neoliberalism is also implicated in the spread of precarious and insecure work, which is increasingly recognised as a social determinant of (ill) health. One author, Guy Standing, has argued that it has generated a new global class – the precariat – as ‘flexible’ labour market regimes become the price of attracting and retaining foreign investment. In an especially striking illustration of the consequences, in 2012 The New York Times revealed that not long before a disastrous fire at a Bangladeshi garment factory, Walmart had resisted an initiative to improve fire safety in such factories.
In the future, neoliberal epidemics are likely to reflect the erosion of territorial divisions between core and periphery, or the global North and the global South, in the world economy. William Robinson, a leader in the emerging field of critical globalisation studies, pointed this out more than a decade ago when he argued the need to move from a ‘territorial’ to a ‘social cartography’ in understanding development. More recently, social theorist Nancy Fraser has made a similar point, noting not only the spread of austerity programmes to Europe but also phenomena like ‘the terrible impoverishment of the old industrial cities, of the global north, which are starting to look more and more like the periphery’, and the fact that ‘the conditions of working class people in the global north are converging with the conditions of the global south’. On one estimate, 1.4 million UK workers are on zero-hours contracts, which do not guarantee them even a single hour of work in a given week. Trends like this help to explain the widening of health inequalities in the UK, such that in the small municipality of Stockton-on-Tees where one of us (TS) lives and works, the 17-year gap in male life expectancy between the most and least deprived neighbourhoods is comparable to the difference in national average male life expectancy between the UK and Senegal.
This analysis is not a counsel of despair, but it does suggest that the success of efforts to fight neoliberal epidemics and reduce health inequalities will depend on blurring boundaries: between the global and local frames of reference, and between public health practice and the politics of health. This last blurring means a return to the wisdom of Rudolf Virchow, to the effect that ‘medicine is a social science, and politics is nothing else but medicine on a large scale’. As Martin McKee and colleagues wrote in a 2012 commentary on the failure of austerity policies, ‘Virchow’s words are as relevant today as they ever were’. Understanding how to translate that insight into political action will require the development of a comparative political science of health inequalities – a critically important project that remains in its infancy.