Ted Schrecker and Clare Bambra
London: Palgrave Macmillan, 2015, 167 pages, £16.99/$30.00 (Pb)
ISBN 978 11 3746 306 7

Few would dispute that pro-market neoliberal ideas have heavily influenced the politics of the United States and the United Kingdom over the last thirty-five years. It began with the efforts of Reagan and Thatcher to reduce taxes and dismantle the welfare state, gained steam with the fall of the Soviet Union, and crested with the ascendancy of “The Third Way” political movement of Bill Clinton and Tony Blair.  It was a time when the traditional adversaries of neoliberalism, the center-left political parties, cosied up to the laissez faire economic and social policies of financial deregulation, labour market flexibility, and welfare state reform.

Yet, increasingly, neoliberalism now appears to be out of fashion. Bernie Sanders, a little known American politician, challenges the establishment of the Democratic Party by running a competitive presidential campaign deploring income inequality and advocating for expansion of the welfare state. Jeremy Corbyn, a Democratic Socialist like Sanders, is elected Leader of the Labour Party in the UK. Donald Trump, the next President of the United States, advocates against neoliberal orthodoxy, calling NAFTA, the free trade agreement with Canada and Mexico, a “disaster.”  And the British electorate’s dramatic decision to exit the European Union, and to incur the heavy economic costs of that decision, suggests that economic nationalism has now replaced neoliberalism as the central organising idea of the political right.

So, now that the neoliberal era has lost some steam, what can we learn about the policies of that period. And can understanding the effects of those policies explain neoliberalism’s fall from grace? In How Politics Makes Us Sick: Neoliberal Epidemics, Ted Schrecker and Clare Bambra provide a provocative critique of neoliberal policies and how they have affected our physical and mental health. They identify four so-called “neoliberal epidemics” – obesity, insecurity, austerity, and inequality. And each of these epidemics, they argue, is spreading much like a disease with negative health effects and a common causal agent: neoliberal politics. Schrecker and Bambra are thus the odd kind of public health scholars who do not study pathogens or viruses but the political determinants of health.

Their book begins by considering why the US, despite its economic dominance, has one of the lowest rates of life expectancy and one of the highest rates of infant mortality among the rich economic countries. Schrecker and Bambra favour a political economy explanation and focus on the relationship between a country’s welfare state regime and the health of its population. For example, they point out that in Denmark, a social democratic welfare state regime, where old age pensions are more generous and healthcare more accessible than in the US, a liberal welfare regime, life expectancy is also longer. Schrecker and Bambra thus conclude that “population health is enhanced by the relatively generous and universal welfare provision of the social democratic countries.” They concede, of course, that different behavioural patterns (e.g. rates of smoking and exercise) may also explain cross-national differences in health. As epidemiologists, Schrecker and Bambra do not dismiss the relevance of such factors, yet they clearly seek to elevate the significance of the political economy variable as a determinant of health.  Their story, presented in succinct chapters, follows a familiar pattern: the retreat of the state through the adoption of neoliberal policies and the resulting failure of the regulatory system of consumer protection (Chapter 2), the loss of labour market stability (Chapter 3), the weakening of the social safety net (Chapter 4), and the widening disparity of income distribution (Chapter 5) all having a detrimental effect on public health.

Obesity is the first neoliberal epidemic explored in the book. Schrecker and Bambra argue that, “neoliberalism is a critical upstream influence” and is responsible for the rising obesity rates in nearly all the advanced economies. Neoliberal economic and social policies, they argue, have increased economic insecurity making it difficult for poor people to afford nutritious food; at the same time, multinational food companies, in the absence of food-labeling regulations, intensely market their unhealthy products to an unwitting public. That low-income people have few affordable healthy food options and are bombarded with ads for unhealthy products is indisputable. Yet, the reader is also left wondering if there is a role for demand and what part it may play in driving the supply of unhealthy foods across the globe.

Since the oil shock of the 1970s, there has been a well-documented decline both in the quantity and quality of jobs in the advanced economies. For those with low skills, long-term unemployment and precarious employment are now commonplace. There are competing explanations for this rise in economic insecurity. Some blame technological change.  Others blame globalisation. Schrecker and Bambra blame neoliberal policies. For example, they argue that neoliberal attacks on the rights of workers to unionise have led to steep declines in union membership. That corporations, spurred on by neoliberal policies and more concerned with shareholder value than in a living wage for workers, created offshore manufacturing plants in low wage countries. These arguments will not convince all readers yet Schrecker and Bambra provide compelling evidence. Though all countries were exposed to the same forces of globalisation and technological change, the authors point out union density rates and median wages have decreased the greatest in the liberal welfare regimes of the US, UK, and Canada, where neoliberal politics have most dominated.

Schrecker and Bambra further attribute the austerity that followed the last financial crisis and the cuts to public services to neoliberal economic and social ideas. Again, the comparative evidence is telling. In countries that responded to the financial crisis with economic stimulus measures, their economies tended to recover faster than those that relied on the model of austerity. The authors also address the epidemic of inequality. Although careful not to attribute a causal relationship between neoliberal policies and inequality, they emphasise the role that tax and benefit policies can play in decreasing inequality. Using case studies, neoliberal policies are blamed for health inequities in the UK, the epidemic of incarceration in the US, and the creeping privatisation of the National Health Service in the UK.  Though the analysis is thorough, the message here is a bit jumbled because so much ground is covered. For example, the review of the effects of the marketisation of medical services on health equity in the UK serves as a powerful indictment against the neoliberal preference to privatise health care. But this seems rather loosely connected to the problem of economic inequality.

So how exactly do these neoliberal epidemics of obesity, insecurity, austerity, and inequality affect our health? According to Schrecker and Bambra, stress is a major consequence of the neoliberal era, is brought on by economic insecurity, and is associated with the risk of cardiovascular diseases and other negative health behaviors, such as alcoholism. Long-term unemployment is also associated with chronic health problems both because of the loss of income and the psychological damage of feeling worthless when one is unemployed. As Schrecker and Bambra demonstrate, being long-term unemployed is essentially a risk factor for developing a work-limiting disability. Indeed, mental health problems now account for a third of all disability benefit claims in OECD countries. The financial crisis, moreover, is shown to have had negative effects on health with the damage felt most acutely in the liberal welfare regimes that provide the least protection from market instability. Schrecker and Bambra also associate negative health effects to income inequality. Although this is a much-disputed relationship empirically, as noted in the book it has received considerable recent support in the literature. Yet, the suggestion that the “chronic stress” of being in a lower social position is the mechanism by which income inequality affects health is unpersuasive. Many people may not be aware of their lower economic position and may covet the wealth of their neighbours more than the billionaires driving rising inequality. Thus, one still wonders how exactly income inequality affects health and whether the recent surge in academic research on inequality detracts from the problem of poverty.

Ultimately, Schrecker and Bambra provide a stimulating, if not entirely convincing, case against neoliberal policies and their detrimental effects on our health. Their argument helps explain the recent fading of neoliberal ideas. Donald Trump’s appeal to the working class can be better understood when taking into account how neoliberal policies have affected economic security. In the final pages of the book, Schrecker and Bambra consider alternatives to neoliberalism and present a vision for a “re-invigorated welfare state.” Hillary Clinton appeared to be channeling that same spirit in calling for a “New New Deal” for the US.  The total reversibility of neoliberal policies, however, seems unlikely. It is hard to imagine large-scale manufacturing returning to the US and UK. Minimum income guarantees and greater regulation of precarious work arrangements could provide much needed security but will also require increased taxation. As Schrecker and Bambra conclude, a sufficient response to the failure of the neoliberal era will require a “politics of collectivism and solidarity.” Yet, it is precisely that kind of politics that our societies seem to lack the most at present.