Jean Adams from Newcastle University, UK reviews “The Body Economic: why austerity kills” by David Stuckler & Sanjay Basu
In early 2009, a few short months after Lehman Brothers filed for bankruptcy, an interesting debate broke out on the Health Equity Network electronic mailing list: What effect would the global recession on have on public health? Would mass unemployment with loss of income, homes and status have catastrophic effects on the physical and mental health of ex-workers and their families? Or would people respond to contracting household budgets by quitting smoking, giving up their car in favour of walking, and cutting back on fast-food ‘treats’?
The main thesis of David Stuckler and Sanjay Basu’s well written and engaging new book, The Body Economic: why austerity kills, is that the health consequences of recession are almost entirely dependent on the political response to it. It is austerity, they argue, that is harmful to public health – not recession per se.
Although Stuckler & Basu use personal anecdotes to introduce and illustrate their topics, the main bulk of the text makes reference to peer-reviewed research. Unfortunately, it isn’t always clear whether all of the analyses presented have been subject to peer-review. As the authors point out, given the health impacts of economic policies, they “ought to pass the same rigorous tests that we apply to other things that affect our health, like pharmaceuticals”.
There are growing calls for wider use of randomised controlled trials (RCT), considered the gold-standard methodology of clinical trials, in the social policy arena. Notwithstanding the many cogent responses to the same old anti-RCT arguments, conducting true experiments of economic policy really would be near-impossible. Instead, Stuckler & Basu draw on a number of natural experiments where ‘natural’ variations in how programmes are implemented can be used to study effectiveness.
Roosevelt’s New Deal in response to the Great Depression of the early 1930’s included a range of social protection programmes focussing on, amongst other things, work creation, home loans and food assistance. As individual states decided how much money to devote to New Deal programmes, Stuckler & Basu were able to use this ‘natural’ variation to explore the effect of anti-austerity New Deal spending on markers of health and wellbeing. Each additional $100 per capita spent on New Deal programmes, they found, was associated with 18 fewer deaths from pneumonia and four fewer suicides per 100,000 people, as well as 18 fewer infant deaths per 1,000 births. Their conclusion that “the New Deal was in effect the biggest public health programme ever to have been implemented in the United States” seems well justified by the data they present.
In 1997, the East Asian real estate bubble burst. The Thai baht lost 75% of its value and the Indonesian rupiah lost 80%. The International Monetary Fund (IMF) stepped into help – on condition of harsh fiscal austerity. Thailand, Indonesia and South Korea accepted the terms, cutting government spending by up to 20%. But Malaysia refused, preferring to maintain and grow social support programmes and providing the ‘control’ group against which the experience of the austerity nations could be compared. Again Stuckler & Basu report remarkable effects. Whilst Thailand and Indonesia reported substantial increases in malnutrition, infant mortality, and HIV, Malaysia saw no such public health disaster.
Sometimes it can be hard to disentangle hot-blooded ideology from cool-headed evidence. Politicians are not alone in interpreting the evidence in the light of their personal ideology – finding evidence to fit the preferred intervention, rather than vice versa. Stuckler & Basu make a convincing case that the austerity currently being implemented around the world is driven more by a political ideology that rejects the very notion of ‘big government’ than any particular evidence. Indeed, the evidence they present almost universally supports their conclusion that austerity is bad for economic recovery and bad for public health.
As others have argued for social policies, Stuckler & Basu conclude by demanding that economic policies are robustly interrogated and evaluated – particularly in terms of their impact on health. Without understanding the health impacts of policy, they argue, we can never make informed choices about what to implement. Who could argue with that?
But even when we have the evidence, it can remain frustratingly difficult to get the right people to act on it. Politicians are motivated by ideology, personal anecdote and the ballot box as much as, if not more than, by scientific ‘evidence’. Stuckler & Basu seem to know this implicitly, recounting a number of occasions when they were invited to present their results to policy makers who then chose quietly to ignore them. As so often in public health, exactly how to ensure that this evidence-based call to action is implemented is left unsaid.
“The Body Economic: why austerity kills” by David Stuckler and Sanjay Basu is published by Allen Lane: 978-1846147838
The author declares no conflict of interest.
Books reviewed in Speaking of Medicine are independent of the book’s publisher. Reviewers do not receive a fee but are allowed to keep the review copy of the book.