While health and longevity are matters of social justice and fairness, they are also cornerstones of economic productivity

This weeks news that the UK has officially entered a recession will have left many people deeply concerned. Chancellor Rishi Sunaks Dickensian announcement that hard times are here will have felt a particularly poorly chosen phrase to the millions for whom hard times have never gone away since the last recession in 2008-9.

Massive cuts to local authority budgets and a fall in health spending as a proportion of GDP in the last decade have been associated with poorer population health and increased child poverty. It has been estimated that the austerity measures introduced in the UK following the 2008 crash might have resulted in up to 150,000 excess deaths (excluding those relating to the covid-19 pandemic).

The 2008 crash prompted renewed political attention to the impact of poverty on health. The World Health Organizations Commission on the Social Determinants of Health was published in 2008, and Michael Marmots landmark review, Fair Society Healthy Lives two years later. Both laid bare the brutality of health and wealth inequalities both globally and in the UK. Today, such inequalities result in a massive 16-year disparity in the average life expectancy between Africa and Europe and, even more starkly, a 30-year difference in healthy life expectancythe number of years lived in good healthbetween the highest country (Singapore) and the lowest (Central African Republic). A similar picture is seen between different areas of the UK: the difference in healthy life expectancy between the highest and lowest areas is currently at 21.5 years for women and 15.8 years for men.

The pandemic has forced us to watch the impact of neoliberal economic policy on health as if on fast-forward. Deaths and morbidity from covid-19 have been on a steep socioeconomic gradient, and black and minority ethnic people have been particularly badly affected. An underfunded, marketised and fragmented NHS has only been able to cope with increased demand by cancelling almost all elective surgery and sidelining cancer care. Alfred Saad-Filho at Kings College London has argued that economic policies accelerated by post-2008 governments have directly resulted in the UKs unenviable pole position for highest covid-19 mortality rate in Europe.

Both the WHO Commission and the Marmot review set out a course to reduce health inequalities, a plan which they argued had economic as well as social benefits. While health and longevity are matters of social justice and fairness, they are also cornerstones of economic productivity.

However, a decade of austerity in the UK has shown governments since 2008 took a dim view of the recommendations from WHO and Marmot. In the 10 years on follow-up to the Marmot review, the team at the Institute of Health Equity has drawn a stark picture of the UK governments economic policy choices. Gains in life expectancy began stalling in 2011, and in some areas of England both life expectancy and healthy life expectancy have started falling.

But while the deleterious effect of a decades worth of austerity on public services and public health were predictable (and indeed predicted), they were not inevitable. Economist Jonathan Portes has shown that claims made during pandemic that there is a trade-off between health and negative economic growth are based on a false premise, arguing that it was not the recession that resulted in the terrible outcomes unearthed in Marmots follow-up review, but rather the political choice to disinvest in the welfare state. In their 2013 book The Body Economic, Stuckler and Basu argue:

Conventional wisdom holds that recessions are inevitably bad for human health. Thus, we ought to expect a rise in depression, suicide, alcoholism, infectious disease outbreaks, and many other health problems. But this is false. Recessions pose both threats and opportunities for public health, and sometimes can even improve health outcomes.

Philip Alston, United Nations Special Rapporteur on extreme poverty and human rights made a similar point after a visit to the UK in 2018: the driving force [behind increasing levels of poverty] has not been economic but rather a commitment to achieving radical social re-engineering.

The tenacity of those who have fought in the anti-austerity movement over the last decade has meant that the argument against austerity as a response to a recessionwhich many Conservatives, including George Osborne, would like to rerun after the current downturnnow has high levels of public support. A 2018 UK poll found that a 66% majority thought austerity had gone too far and the British Social Attitudes survey in the same year found 60% were in favour of raising taxes, compared to only 31% when the same question was asked in 2010.

Marmots 10 years on report concluded that health is getting worse for people living in more deprived districts and regions, health inequalities are increasing and, for the population as a whole, health is declining. The report was published in February of this year, just before the devastating impact of covid-19 on the UK became apparent. The challenge is now even harder, the stakes higher, and the fight even more important.

JosephFreeris anNIHR Academic Clinical Fellow,Institute of Population Health Sciences, Queen Mary University London. He worked at The BMJ as the editorial registrar and Clinical Fellow, Faculty of Medical Leadership and Management, 2016-17.

Competing interests: None declared.

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The recession should remind us that health and wealth are political choices - The BMJ - The BMJ