Socioeconomic inequality has been rising almost everywhere in the OECD over the last 30 years, to the dismay even of hardened supporters of capitalism. COVID-19 has revealed a less familiar type of inequality: death rates that differ widely across socioeconomic and racial/ethnic groups, as well as across countries. This comes as no surprise to social epidemiologists, who have been documenting social inequalities in health and mortality for centuries, and have concluded that inequalities in socioeconomic status (including those generated by racial hierarchies) are powerful underlying determinants of inequalities in health. Indeed, deaths from COVID-19 are occurring disproportionately among people who, by virtue of their position in class, racial and gender hierarchies, are more exposed to the virus that causes COVID-19, have less ability to protect themselves from it, and who experience more severe symptoms as a result of their previous exposures to risk factors for cardiovascular disease and diabetes.
At one level, then, the story of COVID-19 is a familiar, albeit extreme, one: social inequality is causing health inequalities. But I think we need to take a step back and think about why we are hearing this story yet again. Given all that we know about how bad extreme inequality is, including for health, why don’t governments do more to confront the problem of health inequity generated by underlying socioeconomic inequalities? It turns out that many do try – and fail. My book just out from Cambridge University Press, Regimes of Inequality: The Political Economic of Health and Wealth, explains why, and what we can do about it. The book is based on exhaustive case-based research of policy-making in England, France and Finland from roughly 1980 to 2014. Here’s the thumbnail summary, for those who might find themselves too busy, distracted, or just plain exhausted to read right now.
Starting in the 1990s, center-left politicians began to fear openly talking about the structural inequalities generated by neoliberal capitalism. This was partly strategic, and party because they came to truly believe that, in Margaret Thatcher’s words, “there is no alternative” to neoliberal policy solutions. But it was still important for the center-left to signal that they support greater equality — just without appearing to be against the market or in favor of radical redistribution. And it turned out that the issue of social inequalities in health, which had been brewing in European policy circles for some time, was the answer to the center-left’s prayers: a way to talk about inequality without talking about redistribution, public spending, or market regulation. This should have been good news: left governments could work to reduce inequality by acting quietly on inequalities in the social determinants of health, and avoid getting punished electorally for being too tough on capitalism. But it didn’t work. Even the most robust, sustained efforts to reduce health inequalities through multi-sectoral action on SDOH were disappointing, in large part because they didn’t address upstream inequalities in income and power.
Why did medicalizing inequality make it harder to reduce BOTH health inequalities and the underlying socioeconomic inequalities that produce them? The main policy response pursued by European governments to try to reduce health inequality has been coordinated, simultaneous, cross-sectoral action on multiple social determinants of health — but there is accumulating evidence that it’s extremely hard to pull off such a “Health in All Policies” approach to reducing health inequalities. As I argue in short pieces here and here, when politicians reframe inequality as a problem of health, rather than of a fundamental maldistribution of power and resources in society, it shifts the Overton Window around inequality in ways that make the problem harder to solve. Health inequality is a paradigmatic “wicked problem”: causation is complex and distal, policy remedies are unclear and often very complicated. Meanwhile, attacking socioeconomic inequality directly, by contrast, may be politically harder, but it’s technically a lot easier. Redistributive taxation, regulation and the like can be done by a single ministry, and with relatively predictable consequences for the underlying distribution of resources in society.
So: If you’re a center-left politician and you want to reduce inequality, including health inequality, what should you do? My first advice is to avoid complex, multisectoral Health in All Policies-style remedies. European governments have tried this, and the results have been very limited. My second advice is to avoid talking about inequality as if it’s a technocratic problem, which reduces the salience of class in voting behavior, and can push former left voters into the arms of right-populist parties. In other words, “social investment,” including investing in health, is a wonderful thing — but if politicians try to reduce inequalities without acting directly on the fundamental inequalities in social and economic life, they are likely to fail.
Julia Lynch (Socio-Economic Review editor)