Health systems, neoliberalism, and the end of growth: The World Health Organization in denial

The WHO (World Health Organization) has released its latest in a series of reports[i] on public health in 53 European nations, and presents this assessment through a focus on the social determinants of health[ii]. Rather than sounding an alarm or considering the possibility that epochal economic decline is underway which threatens the health of the public, it serves up tepid criticism of government policies that have resulted in surging poverty[iii] and high unemployment[iv], fiscal cuts to health and other social services, increases in suicide and a host of other declining health indicators deforming people’s lives in most –possibly all- of the countries examined. Put directly, the social determinants of health are being laid to waste in several European states and endangered in others, yet the report casts this as a few dark shadows on an otherwise bright picture.

I find the report psychologically dissociative, ethically compromised, and in an intellectual malaise. Sociologically, however, it makes sense: it is self-destructive to analyze or challenge[v] the political/economic system that funds your work, even if it is destroying what your organization was founded to analyze, protect and ensure. As such, this report represents a conflict-ridden and unstable posture of ignorance and subservience to political power.

Revealingly, the report takes virtually no notice of the portents of socioeconomic and political[vi]^,[vii]upheaval[viii] –like UKip and Golden Dawn- spreading through Europe.[ix]^,[x] Naïvely[xi], the report calls for slight reforms –like giving health ministers a “seat at the table” of austerity[xii] budgeting to make the case for “proportionate to need” funding cuts[xiii]– as sufficient to ensure, maintain or in some conceded instances restore a portion of the underlying fundamentals of the health of European populations now being sacrificed in the name of balancing budgets and debt repayment. The authors give every indication of having no inkling that their flaccid calls for a realization that too much austerity endangers the public’s health is too little too late and, in any case, will have zero influence on neoliberal policymakers.

Politically, then, this WHO[xiv] report offers no recognition, let alone opposition, to the class-based austerity imposed by neoliberal governments[xv]. Accordingly, this report personifies developing turmoil[xvi] in organizational mission and collective identity for health professions as the divergence between the imposition of neoliberal austerity measures and the mission of public health deepens. This compromised stance, of offering mild warnings about austerity while accepting it as a legitimate policy response, is part of a cultural phenomenon of an inability to democratically address genuine problems while offering rhetoric to reassure and soothe a public that is losing economic ground and its faith in government.[xvii]

Therefore, I suggest that the report illustrates the futility of relying upon the WHO to comprehend what is occurring, let alone to lead in protecting public health. This is important because the WHO is not just another think tank or academic institute; it is the appointed champion[xviii] of world health issues. If it will not speak truth to power[xix] for the European public –which means unequivocally rejecting austerity policies and growing inequalities in income and wealth as destructive of the social determinants of health- at this critical moment, there is no reason to expect it to do so as neoliberal governments continue to cannibalize their citizens to maintain a world politically ruled by a numerically tiny financial elite[xx].

Rather than dissect the report in detail, I want to use it as a springboard to talk to those in the health sciences, especially young professionals and those close to retiring[xxi], who will read it and other such reports and conclude, “This just doesn’t fit my sense of what’s going on in Europe, my workplace, or the world, for that matter.” They will be searching for explanations containing a ring of experiential truth. They also may feel, “If the WHO is incapable of defending the social determinants of health, who will do so as conditions continue to worsen? And, how can I contribute to much needed changes?”

My comments will be unsettling to most health professions readers, but I believe that they contain a kernel of truth to explain the economic decline, which I maintain is caused by class politics and reaching the limits to economic growth.

Before presenting why health systems will continue to be bludgeoned by economic contraction, there is the intricate matter of the question of sustaining oneself while trying to contribute to the greater good. To work in medicine, public health, nursing or a related health profession means your daily bread comes from a large complex system. (And in the United States it’s even worse because most health professional work for profit-driven intensely thought-regimenting corporations.) Raising ones voice in a bureaucratic workplace to address fundamental problems of mission and strategy runs the risk of being expelled or punished by your administrative superiors.

The classic questions of those who recognize organizational decline or malfunctioning are: Do I stay and raise my voice? Or do I leave and work for change from the outside (possibly starting my own organization?). Or, do I remain loyal? (This should not imply merely shutting up and can involve ingenious ways of sotto voce bending or subverting policies to introduce ground-level change to avert catastrophe).[xxii] So individual responses will vary with time and context and no one should be embarrassed to say, “I’m staying because I need this job and will work for change from within.”

A further note on this: As late as the hour is, the probabilities of rationally convincing the WHO and other health leadership to challenge neoliberalism –or recognize the ecological/thermodynamic issues I will raise below- are virtually nonexistent. Nevertheless, it does not follow that it is futile to remain inside health systems articulating –as best we can for no one knows precisely what is coming- the need for vast change. The fact that the status quo of health leadership is ignorant yet powerful is a dangerous combination. They are virtually cybernetically designed to “go down with the ship” and can be expected to make a series of rote and arrantly wrongheaded and damaging decisions as the crises in the larger society and health systems deepen. Suffice it to say that voices -or loyalists- on the inside with an ability to articulate what is happening MAY find opportunities in this volatile context to affect the course of their organizations[xxiii]. This is particularly true as the legitimacy and power of administrative leadership dwindles, which it will.

On the other hand, health professionals in austerity-eviscerated nations like Greece[xxiv], Spain, Italy, Latvia, Ireland and Portugal may find my thoughts tame, trite or passé, given the devil’s choices and steadily degrading circumstances in which they are being forced to do their work. They are past the stage of anticipating decline and need no convincing that their governments are less concerned about the health of citizens than the pocketbooks of bankers–they are deeply experiencing these realities. They are likely to provide the world with models and ideas[xxv] for how to protect the health of the public in an era of thermodynamically and ecologically induced degrowth coping –for now- with the added burden of their governments working to save the rich by plundering the rest of society.

I suggest that one major lesson of Greece, et al. for a health professional is that neoliberalism’s priorities and abandonment of citizens are on display in these nations.

After confronting the class-based nature of public policy, I ask them to rethink their taken-for-granted understanding of how health systems are sustained[xxvi]. For many this combination of requests will be much like the disorientation that occurs when viewing the world through inverted glasses[xxvii].

So what do health professionals who intuitively grasp that something is fundamentally amiss need to know? First, they should examine the larger systems –or cultural- context that supports the delivery of health care and public health. By this I mean that the institutions upon which health systems rely for social, political and economic support are themselves caught up in a multi-layered set of ticking-clock crises, dilemmas and problems[xxviii] that spans the political/economic/financial, the ecological/thermodynamic, and the psychological/cultural/social dimensions.

To reiterate, these master institutions[xxix] as presently designed cannot respond to this set of crises in an egalitarian manner because 1) they are organized in terms of serving a) economic growth that benefits b) class-based interests; 2) they are unaware of the unfolding dynamics of ecological/thermodynamic realities bringing economic growth to a halt and 3) anthropologically, institutions in crisis automatically operate to repeat mistakes –as the only way forward- while not perceiving or merely dismissing as absurd information pointing to the necessity of taking radically alternative courses of action.

In sum, health professionals must see that austerity is a chosen policy stance of neoliberal governments serving narrow economic elite interests, not an unfortunate oversight or misguided mistake of politicians acting for the common good. Again, I stress that this will be extremely difficult and threatening for health professionals to perceive and act upon.

In tandem with this they need to understand that resource scarcity –especially the end of cheap energy[xxx]– and a host of ecological crises are coupled to –and worsened by- the inherent social, political, fiscal, and economic invidiousness of neoliberalism. This amounts to more and more of the 99% being sacrificed to preserve and further enrich the 1%. Simultaneously, the actual size of the economic pie is contracting. What is occurring in Europe, the United States and other nations is, therefore, a class-based upward redistribution of the income and wealth produced by a dwindling flow of natural capital.

These realizations require a giant leap of consciousness and will almost assuredly be accompanied by a crisis in collective and personal identity as institutions begin to fail, and possibly collapse. Preserving the social determinants of health in these dire circumstances goes beyond restoring or even increasing –which simply will not happen- funding for health services to involve building a society that shrinks energy-consumptive institutions, respects and comprehends the power of nature and, as a necessity, eliminates deeply embedded socially parasitic patterns of wealth accumulation and economic exploitation.

I am not much for prognostication, yet it appears clear to me that fissures will expand and rupture in the health professions as –probably slowly and then in a torrent- awareness spreads that the WHO and other “official” protectors of health are incapable of recognizing or responding to the crises touched upon above. This crisis of health systems, of course, will not happen in a cultural vacuum, as the master economic, financial and political institutions that health professionals take for granted also enter extreme crisis due to energy scarcities and the financial and economic chaos this will create.

Offering specific goals or detailed policy agendas beyond those cited above -shrinking energy-consumptive institutions, respect and comprehend the power of nature and eliminating deeply embedded socially parasitic patterns of wealth accumulation and economic exploitation- is, paradoxically, not likely to succeed at this moment. First comes an awakening, brought on by crisis, to the class-based nature of public policy and the thermodynamic impossibly of perpetuating economic growth[xxxi].