Recession I

The business cycle today is characterised by periods of growth, or ‘booms’, and periods of retrenchment or ‘busts’. Booms can be worsened by over-confidence, producing a ‘bubble’; busts likewise can be worsened by over-reaction, producing a depression. Confidence, and its opposite, are psychological factors not rational ones.

One of the first recorded booms was the Dutch Tulip Mania, though there have been plenty of others, most recently the period of boom just before the great crash of 2007/08. The world-wide extent of this crash was unusual. The Great Depression, after the US stock market crash of the late 1920s is perhaps the best-remembered bust; events after 2007/08 again differ because of their worldwide reach.

Governments can respond to recession in two broad ways. They may choose a reduction in state spending, often encouraged as being to ‘balance the books’, with emphasis on health and social welfare programmes. Alternatively, they can choose to invest more in people’s health and social welfare, and to try to stimulate the economy through ‘public works’ programmes.

‘Balancing the books’ is often associated with a desire to reduce or eliminate the National Debt (and often a desire for a ‘small state’). On a personal level, eliminating our debts is a ‘good thing’. For a state, it’s not so clever. The central bank is able to issue money because people have deposited savings with it; it can use these savings as ‘collateral’ against which to issue money. If there were no savings in the bank (a ‘National Debt’), any money it issued would have no backing.

After the US stock market crash, the initial economic policies followed were what we would recognise today as ‘austerity’. However, in the 1932 presidential election Franklin Delano Roosevelt was pressurised by the unions and labour movements into offering a ‘New Deal’. This New Deal had elements of Keynesianism, a stimulus to the economy in bad times.

One curious ‘effect’ of the crash and the depression was an apparent increase in health, as measured by death rates.

(All data and diagrams from Stuckler and Basu, 2013, The Body Economic)

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Suggestions for this improvement included the idea that, because of poverty, many Americans were eating a much healthier, vegetable-based diet, and walking because they couldn’t afford to drive. However, other factors were lurking behind this improvement. This period is known as an ‘epidemiological transition’, a time when public health measures can be seen to be effective. Such measures included proper sanitation and the supply of clean, fresh water.

Prohibition of Alcohol, a significant ‘confounding’ factor, was lifted in 1933. In part, Prohibition was lifted because the supply of alcohol had become criminalised; it part because FDR reckoned it would be better to regulate and tax it. Deaths from alcohol-related disease immediately rose:

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Mental illness, depression and suicide usually rise during recessions, and fall when the economy recovers:

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What else changed? One major factor was a very significant reduction in death from road traffic collisions (‘accidents’). Many Americans simply didn’t have the money for petrol, and so couldn’t drive.

Suicide rates

I was reading David Stuckler and Sanjay Basu’s book The Body Economic; in their chapter about Russia they describe how the end of communism and the ‘Shock Therapy’ of very rapid privatisation had vastly increased mortality there, by comparison to the US:

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They illustrated this further:

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And then compared this with the 5-year moving average (using selected data points) given in The Economist:

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They commented, saying that The Economist had backed ‘Shock Therapy’, as did many economists; while these expected some minor, transient social and health pain, this isn’t what happened.

So, I was interested to see this Tweet from The Economist recently:

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Depression and suicide often, but not invariably increase with a recession and austerity: I haven’t seen the full article. Using the same numbers from the Office of National Statistics (ONS) I got this for suicides in men aged 30-49:

UK mortality.jpg

To which I added a 3-year moving average, reproducing their finding:

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And then tried a 5-year moving average (as in their Russian Example):

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Rather than a rise in mortality recently, this moving average shows a slight fall.

Hmmm.

Austerity II

For the last 30-plus years, the dominant politico-economic theory in the West has been ‘neo-liberalisation’. Roughly, this believes in the pre-eminence of the market, that the market is always right, that government should be small and not provide services.

The response of neo-liberalism to bad times is austerity. A retrenchment of state services, and an emphasis of debt reduction.

What effects does austerity have on health? It’s not so easy at this stage to be factually certain, for statistics often have a significant lag. However, some trends are quite clear.

There has been a reduction in social care recipients in England (Figure and data from Danny Dorling, 2014, Inequality and the 1%) :

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Lack of social care can be expected to increase loneliness, and loneliness is clearly associated with poor mental health.

There is a clear increase in poverty, as ‘benefits’ are reduced; poverty is associated with feelings of shame, and this too is associated with poor mental health.

At the same time, funding for the NHS in England is not keeping up with inflation, and it is expected that there will be a real 4% reduction in funding. This hasn’t been achieved before, but clearly can only be approached if there are significant reductions in provision. And mental health services have always been a ‘Cinderella’.

An extra 23,400 people in England and Wales died between 2012 and early 2013, equivalent to a 5% rise in mortality. While this was blamed on flu, this is very unlikely. (In the pea-souper for of 1952-53, there were 12,000 excess deaths, which were also blamed on flu. Again, incorrect.)

For the first time in many years, life expectancy for women in England now shows a decrease.

These can all be designated as ‘lead indicators’, and we can expect further data to show worsening levels of health as austerity continues.

All the UK political parties, except the Greens, are signed up to austerity. I’m not clear what the economic policies of SF and the DUP are—though for them, ‘flegs’ emblems, marches and bickering seem much more important that people’s health.

Austerity I

The dominant politico-economic theory in western countries has been, for the last 30 plus years, ‘neo-liberalism’. It was the work of the Austrian Friedrich von Hayek, and the subject of a symposium at Mont Pèlerin just after the end of WW2. It was also advanced by the Chicago school of economics under Milton Friedman.

Neo-liberalism is so-called because it harks back to the liberal economics of the 19th century, when a particular feature was laissez faire, the idea that the market knows best, and government should not interfere with its workings. At the start of the potato famine in Ireland, the prime minister, Sir Robert Peel, had to covertly buy ‘indian maize’ for distribution. (Unfortunately, Irish mills couldn’t process such maize, and the population didn’t know what to do with it.) Soon after, Peel was replaced by Lord John Gordon; he was very disinclined to interfere with the ‘market’, though, after a while, a series of public works measures were introduced. And, during this whole period, Ireland still exported grain to England; that was the ‘market’ at work.

Dr Ludwig Erhard was finance minister in the first governments in (West) Germany after the war; he joined the Mont Pelerin Society in 1950. Though credited with being the architect of the German economic miracle, he did have to distinctly compromise the ideas of the Society.

Neoliberalism believes in the market, and that government should not interfere with them, nor should governments provide services; rather this is the preserve of private enterprise. Unfortunately, the originators  of neo-liberalism didn’t foresee just how much instability and inequality would come from the application of their ideas. In the US, the Republican party, and their ‘Tea Party’ elements are the major mouthpieces for neo-liberalism. But then Americans think that ‘socialism’ and ‘communism’ are pretty much the same thing.

Since the 1980s, with Thatcherism in the UK and Reaganism in the US, governments have ‘privatised’ state holdings, sold off council houses, deregulated financial services and banks, and markedly reduced taxation on the rich.

We all know what happened; sub-prime mortgages, strange financial products that no one seemed to fully understand, the ‘greed is good’ mentality; and a very marked rise in income and wealth inequality. Even after the market crash, when recovery began, the rich, the 1% (and less) still claimed around 95% of this recovery.

The neo-liberal response to an economic downturn is austerity; a further retrenchment by the state, a reduction in government spending, though not increased taxation for the rich. The neo-classical approach would be state intervention in a downturn; Keynesians would do likewise, but (attempt) to save when times are good.

In the UK, this reduction in state spending is justified by reducing the ‘deficit’, the difference between government revenue and spending; the national ‘debt’ is what the state owes. This deficit reduction is seen as a ‘good thing’ by comparison to individuals. If you or I outspend our income, the bank will want their overdraft back, and want it back soon—certainly before we die. This is a major flaw in reasoning; governments don’t die. They may not be eternal, but they are very long lasting. In England, and later in the UK, the state has been borrowing for a millennium; and if it takes a century to pay back a loan, so what? We accept that a century from now there will still be government in the UK, even if we can’t really say what sort of government it will be, or what sort of place the UK will be.

To further justify austerity, scapegoats have to be identified; clearly, the poor are benefit scroungers, people who can’t be trusted with managing their own finances (the poor are usually very good at managing); immigrants who flood in from eastern Europe, not only to benefit scrounge, but for ‘NHS tourism’. Even the obese are vilified. None of this is correct; and the real rascals, the villains whose activities precipitated the present position—bankers and the ilk—aren’t penalised, taxed or jailed; their activities are supposedly so important as drivers and creators of wealth. Of course, the wealth that they create goes mostly into their own pockets.

Perhaps it’s me, but I hear so many politicians these days saying things like, ‘but the truth is such-and-such’ as if they all have knowledge of exact truth, rather than positions; often such ‘truth’ is partial and incomplete. So, if we hear that the 1% pay a quarter of all income tax (or whatever the fraction is today), this statement is correct; but what isn’t said is that they don’t pay nearly enough income tax, and they don’t pay any wealth tax. The poor certainly pay income tax; but all classes pay taxes on ‘consumption’ such as VAT. The poor pay a much higher percentage of their income on all these taxes, the rich a much smaller proportion of their ‘earnings’. I say ‘earnings’ for much of their rents are capital gains, and these are taxed at lower rates than income; how many of the poor have vast capital gains, do you suppose?

We’ve all heard of people on benefits where these have been reduced (the ‘bedroom tax’), people with major disabilities, the seriously ill and the dying who have been ‘sanctioned’ and told they are fit for work. You might think that education of the young (and even the not so young) is important for the future, for their future earnings and the future of the country. But the educational maintenance allowance was discontinued; university fees were raised, even though it’s realised that a very sizeable proportion of graduates won’t (can’t) ever fully repay them. And for those graduates who do get a good job, such that their income is taxed at 40%, will have to pay an additional 9% to repay their fees. At 49% their tax rate will be higher than the 1% who are only paying 45% (if they are paying, that is). Is that reasonable or fair?

Even the churches are having a say about the effects of austerity on the poor; increasing numbers of kids going hungry because the money isn’t there to feed them. The Trussell Trust now has 14 food banks in N Ireland. Not, surely, an ‘achievement’ to be proud of.

Yet the government proudly claims success because of its policies; in reality, it might just be despite their policies—for, except in tiny countries, austerity simply doesn’t work. You cannot shrink the state and the economy and expect debts to be repaid. But, they tell us, private enterprise has produced so many thousands of new jobs; but how many of these are people now self-employed, or employed on the minimum wage on a zero hours contract. Even a full time worker on minimum wage will have earnings well below the poverty level.

Does austerity have any effects on health outcomes? I’m not thinking about Greece, where the health service barely functions, where HIV infections have risen, but the UK. Here, it’s clear that there has been a (slight) reduction in life expectancy. (If you are really cynical, this is to be welcomed, for it means a saving on ‘benefits’, for the state pension is classified as a benefit, albeit one that most people have paid for.)

What’s to be done? All political parties, except the Greens, are for neo-liberalism, austerity, debt reduction and so on. (Cynically again, you could say that we have a government of the 1%, for the 1% and by the 1%.) It will take a major culture change before policies alter; a major change in viewpoints. And, if you’ve ever tried to do a culture change, you’ll know just how hard this is. I’m not sanguine at present.

There’s another view of economics and economists, as a newspaper correspondent observed:

In the 1980’s when I was student at the LSE, I recall attending a lecture from the late Dame Ragnhild Hatton, the intellectually intimidating Emeritus Professor of International History. She was commenting upon the fact that even in times when devotion to religion was overwhelming, such as in Cromwell’s New Model Army, policy makers and senior officers remained convinced of the value of Astrology to inform their decisions. Dame Ragnhild then paused, looked over her glasses at the students before her and said, “Is anyone here studying Economics as their core degree subject?” About half the students in the hall put their hands up. Addressing them she said, “Well, ladies and gentlemen, Astrology in those days was viewed in the same way that we view Economics today. It was seen as a way of divining the future, whereas of course, as centuries of research have shown, both Astrology and Economics are pseudo-sciences with no basis in logic at all. They are the incoherent ramblings of third and fourth rate academics who falsely claim they can predict the future. They are the intellectual equivalent of the Fortune-Teller in a tent at a fair. Now, let us return to Cromwell”.

Poverty, illness, inequality III

It was, perhaps, the ‘Occupy’ movement that brought income and wealth disparity into public consciousness. They split society into the 99% and the 1%, with the latter branded as the ‘elite’. It’s a simple message, but not quite correct. To be in the 1% you need an income of £150k, something that many professionals achieve without feeling themselves to be ‘super-rich’. The really rich, the mega-rich are a much smaller subset of the 1%, perhaps 1% of them. But Oxfam publicised this recently at the Davos Economic Forum.

Be that as it may, the idea that there is marked wealth and income equality in much of the western, developed world has certainly taken hold, though the consequences of poorer outcomes in health and social problems isn’t nearly so clear, even if there has been a lot of publicity about the effects of ‘austerity’ on the poor. How did we get to be so unequal? Can anything be done about it?—for improving monetary inequality can be surely expected to reduce health and social problems. And if we as a society really want to do something about this, isn’t this the way to do it?

Certainly, there have been many very rich people in the past, though the absence of data about what other people (the ‘proles’) earned makes it difficult to be sure of the level of inequality, though it was probably very high. The Sun King and his court at Versailles financed their extravagance through taxes on the ‘common people’, the aristocracy and the church (the ‘elite’ of their time) didn’t pay tax; the French Revolution ended that line of the Bourbon monarchy. The French economist Thomas Piketty in his recent book ‘Capital in the Twenty-First Century’ goes far back into historical records both in France and in the UK.

The UK, and the US, were very financially unequal countries just before the Great War. In the UK, people were either rich because they were ‘landed gentry’, and lived off the income their capital produced; or they were successful businessmen and entrepreneurs who made their money in ‘trade’. The really rich in the US at that stage were the ‘robber barons’, giants of industry. The war changed the position of the rich; taxes were significantly increased to pay for the war, and though they recovered somewhat in the 1920s and 1930s, still taxation was very high. During the second World War, the incomes of the poor increased, while those of the middling class declined; there was full employment, and a sense of common purpose.

After this war ended there was what the French call les trente glorieuses (thirty glorious years), characterised by full or nearly full employment and gradually increasing levels of prosperity and living standards, characterised by Supermac’s phrase, ‘you’ve never had it so good’.

Taxation remained high during this time, with the highest rate of UK income tax on earnings being 83%; if your income was unearned, there was a 15% extra levy, taxation until ‘the pips squeaked’. Some would call a taxation rate of 98% ‘confiscatory’. There was tight control on credit and what banks and stock markets could do.

This approach changed in the late 1970s and early 1980s. Such tax rates and control of business were felt to be a hindrance to the country’s economic growth. Reaganism and Thatcherism were the new ideals, the concepts taken up avidly in the Anglo-American world, but to a lesser extent elsewhere. These ideas were based on the theories of the Austrian economist, Friedrich von Hayek, and were also called ’neo-liberalism’ or the Austrian model. They included the idea of a ‘free market’, that is one which is untrammelled by Government regulation, together with the ‘privatisation’ of government or state assets; and lower taxation. By contrast, the previous model, based on the theories of John Maynard Keynes included an active fiscal policy, with income redistribution. In good times, when there was growth in the economy, the government should save, and use these savings to stimulate growth during economic downturns.

In the UK, privatisation began with the sale of council houses, and has continued with the sale of utilities—as Supermac, in one of his last speeches, said it was ‘selling off the family silver’.

Likewise the stock market ‘modernised’, with transactions done electronically, by computer rather than face to face. Controls over banks were relaxed, both in the UK and the US.

Banks, particularly in the US, developed some remarkably complex financial ‘products’, such as collateralised debt obligations (CDOs); some of these were so complicated that more senior bankers didn’t understand what they were, or their potential for loss—for risk, it was felt, had been (almost) eliminated from the system.

At the start of the 1980s, the pay differential between senior executives of large firms and the pay of the ‘average’ employee was about 40:1. Average pay showed little, if any real growth over the next 30+ years; yet at that time, differentials had increased to perhaps 300:1, or even more. In some companies, the best paid executive could ‘earn’ more in a day than the average worker in a year.

What happened in 2008, the crash, and why it happened are well known—CDOs based on sub-prime mortgages, the ‘greed is good’ mentality growing the economy on the back of debt, and lending to borrowers who in reality could never pay back. Once in the UK, most of us rented out homes; this gradually changed, and ‘property’ was seen as a safe long-term investment, and a ‘right’. Banks were seen to be ‘too big to fail’, and were bailed out, though this is hardly letting the market do its work—that logic would imply that the banks should have been allowed to go bankrupt—as indeed were a very few, such as the Islandic banks, and Lehman Bros. Rather governments took on the extra debts that the banks had accumulated, which the ordinary taxpayer is now expected to pay for, through ‘austerity’, the idea that saving and financial retraction by the state will effect a cure. Yet, even the crash of 2008 was only a temporary setback to this apparently inexorable rise in pay inequality; the 99% are still worse off than they were beforehand. The effects of this austerity are clearly seen in Greece, where the economy is 25% smaller than previously, and 25% are unemployed. How can a country in such a position repay its debts. In the UK, we are seeing the emergence of an ‘hourglass’ economy; a squeezed middle, with an increase in the super-rich, and also those icing close to the margin of survival.

Piketty’s analysis produced a formula to show when wealth inequality will increase; the rich derive much (or all) of their income from invested capital, rather than through work:

r > g

Where r is the ‘rent’ or interest received on invested capital, and g is the rate of growth in the economy. This is what’s happening now, and what happened in the past when inequality rose.

High taxation did produce less wealth inequality, but is seen now as offensive, almost ‘morally’ wrong. There has been growth, if that’s an appropriate expression, in tax avoidance (which is legal), and tax evasion. Tax evasion is generally illegal, though in some jurisdictions, such as Switzerland, the illegality is less than in others. Elaborate schemes have been devised to ‘protect’ income from the tax man; such causes aren’t helped by anecdotes such as, ‘only the little people pay tax’ and, ‘I pay less tax than my cleaner’.

The Laffer curve describes, in theory, what happens, or is supposed to happen, as tax rates rise; there is a point beyond which increasing tax rates reduces taxation return:

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This is said, by some, to be the justification for the recent Coalition government’s decision to reduce the top rate of income tax from 50% to 45%.

Piketty suggests that some form of taxation is required to reduce inequality; perhaps a tax on the millions of daily share transactions. Alternatively, a tax on wealth rather than increases on taxation of income and expenditure; these are seen as ‘regressive’. Further, it’s probable that even if government were to take on board the evidence that inequality is a bad thing, and attempt to correct it, this would take more than one parliament. Yet governments must keep an eye on the short term, if they are to win the next election. Significant change comes from a change in culture, yet such a cultural change is slow, needing one or two generations to be realised. Think about the introduction of seat-belts, or the appreciation that ‘drink-driving’ was irresponsible. How long did it take for these societal, cultural changes to happen.

Finally, recall that a suggested title for The Spirit Level was Evidence-based Politics. In the same vein, there is a small insert in Ha-Joon Chang’s excellent book Economics: the User’s Guide:

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Poverty, illness, inequality II

The relationship between wealth inequality and health outcomes and social problems has been known to researchers for some time, but only more recently to the public at large. If at first the idea was that rich countries had better measures of health and social problems, it became apparent that this wasn’t the case. Consider this diagram of average incomes to an index of health and social problems in developed countries in the Western world. (These diagrams all come from Wilkinson & Pickett, The Spirit Level, 2009, or from the associated website.)

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There’s clearly no pattern here, nothing to indicate that some rich countries, such as the US, do better than relatively poor ones, such as Portugal—which they very clearly don’t.

Now, look at the income distributions in these countries:

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It’s clear here that there are very wide variations in income inequality between countries. Some of them are a lot richer than others, but none is poor in absolute terms, no country is ‘developing’.

If we take the Health and Social Problems Index in the diagram above, and rather than using average income we take the inequality of incomes, measured as between the bottom 20% and the top 20% of earners we get something quite different:

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The line up the graph measures ‘regression’; this is a statistical device showing the best fit between ‘Income inequality’ and ‘Index of Health and Social problems’. It is a measure of how likely the results are to be due to ‘chance’; here, the results here are very unlikely to be due to chance.

‘The index of health and social problems’ is a composite of all the factors shown on the right side of the graph; all are given equal weight. Note that some diseases are not measured directly; there is no association between breast and prostate cancer and Income inequality. Yet, increasing wealth inequality directly correlates with health and social problems.

Wilkinson and Pickett also compared this index with all 50 states of the USA, with similar results. They also presented graphs and further background information for each of the problems, finding similar patterns. There are occasional ‘outliers’—Finland has a higher homicide rate than would be otherwise expected. I say ‘expected’ because the position of any country on a graph of the individual problems will predict where that country will lie in respect of other problems. There are more such graphs on their website, here.

There was a mixed reception when The Spirit Level was published a few years. Some critics, mostly it seems from the ‘right’ questioned the data and the methodologies, those on the ‘left’ felt that their views were justified. Some of the data are a bit outdated now, though the general conclusions remain valid.

However, the diagrams do not explain just how income inequality could lead to such differences in health and social problems. There must be more going on, but what are these factors?

Recall the Whitehall I and II studies, where those in the lowest grades of the civil service had more heart attacks, and more of a whole range of problems. The researchers’ conclusions were that job stress and peoples’ sense of self-control over their work seemed to make the most difference. Low social status has a clear influence on physical health; but, more than this, there is a gradient across society, affecting all members. All these findings have been backed up by further research.

There is an interaction between the psyche, the mind,  and the soma, the body. Multiple associations have been described, and the whole can seem really complex at times. A rise in anxiety levels has been observed in a long-term study of American college students; anxiety is often associated with depression. Likewise, there has been a rise in ‘self-esteem’, though this has two components. There is ‘healthy’ self-esteem, people with a generally positive attitude, the ability to make friends and accept criticism. But there is also ‘unhealthy’ self-esteem, people who are defensive and who deny any weakness, described as an attempt to maintain self-esteem in the face of threats. Such people react badly to criticism, and this ‘insecure’ self-esteem can be called narcissism. A rise in this narcissism has also been found in US college students, that is, in the young.

Stress’ is a more complex, multifactorial concept, and is associated with ‘social-evaluative threats’ which damage self-esteem. Low social status, lack of friends and stress in early life (including as a foetus) are all sources of stress in general. Pride and its psychological opposite, shame have also been incriminated.

If the increases in these ‘bad’ psychological measures are increasing, and the evidence does strongly suggest that they are, how and why did this happen? It’s suggested that this is related to the fairly modern trend for communities to be disrupted; where once several generations of a family lived close to one another, people are more geographically mobile now, and perhaps lack a sense of community identity. Think of the difference between a nuclear family and a stem family; the latter lacks the wisdom gained from experience from senior members of the former, even if this isn’t always welcome. Greater inequality is also associated with greater distrust of other people, and there is certainly a replacement of judging people not by who they are, but by what they have—material ‘stuff’, and ‘conspicuous consumption’—and perceived ‘status’, based on possessions.

This is all getting overly complicated, and it is rather complicated, but the over-arching message is that greater income inequality in developed countries is clearly associated with greater levels of health and social problems, and these are strongly influenced  by our psychological responses. I’m trying to present a ‘broad brush’ approach, to see the underlying patterns, even at the extent of ignoring some complexities.

The Nordic countries and Japan have low levels of income inequality and health and social problems. But their low income inequality comes from two different mechanisms. In Japan, there is a small gap between the gross pay of the lowest earners and the highest. In the Nordic countries, this relative equality is achieved by a combination of heavy taxation on high earners, and a generous range of benefits. It’s hardly a coincidence that the Nordic countries not only have high standards of living, but in global surveys, also have high levels of happiness. And the educational system in Finland is seen as the best in the world.

The conclusions of The Spirit Level have been repeated and expanded in several recent publications, listed on the website.

Finally, the authors of The Spirit Level originally considered calling it Evidence-based Politics.

Poverty, illness and inequality I

We often think that poverty is inevitable, and many people (think that they) know by itself that poverty is a cause of illness and social problems. The poor are always with us, they say, rather misreading Deuteronomy and St Matthew. Attitudes today are rather different from Victorian times, when the poor were seen as either ‘deserving’ or ‘non deserving’, groupings which were subjective and moralising. If you were ‘deserving’, you got into the workhouse; too bad if you were deemed ‘undeserving’. You only have to think of Fagin, Nancy, and Bill Sikes in Dickens’ Oliver Twist (poverty, theft, murder), or Mimi in Puccini’s La Bohème (poverty, TB); for a mid-20th century view, try watching the BBC series Call the Midwife.

Poverty is classified as absolute or relative. Absolute poverty is an income of less than $1.25 per day, and refers to what are usually called developing countries; in such countries the problems are of starvation, disease and survival. The improvements that public health efforts in the western world have brought aren’t common in such populations. Relative poverty, in the UK, is defined as an income less than 60% of the median income. In the UK, the median income is £26664, so that the ‘poverty line’ is about £16,000 per annum. In N Ireland the respective  figures are £21836, and £13100. A worker, on 40 hours per week at minimum wage of £6.50/hour, and working for 52 weeks, can expect a gross income, before any benefits, of £13250. (It also follows from this definition of relative poverty, that such poverty per se cannot be eradicated.)

Before settled agriculture, people lived as hunter-gatherers, in groups of up to 150. There are still ‘primitive’ tribes who live like this, yet such tribes have remarkable social integration, an absence of crime amongst the members; children are entirely safe, and are treated as precious by all—perhaps because their paternity is uncertain.

Before the industrial revolution, most people lived and worked in the country, in agriculture. The revolution brought mass production of material goods, or “stuff”, mass migration to cities, slums, overcrowding, very long working days. The exploitation of children and child labour, sending little boys up chimneys. And thus poverty, overcrowding, foetid atmosphere, rampant infection, and the inevitability of disease. Hardly an improvement from life in a rural hovel. Like the agricultural revolution, the industrial revolution has been called simultaneously both the greatest and the worst of all human innovations. The concept of “childhood” is a Victorian invention, concatenated with increasing education and ideals of purity and innocence.

Poverty in the mid-Victorian times and in the bourgeois mind was certainly associated with disease and criminality; the major improvements in health then (as they still do) came not from the treatment of individuals, but from improvements in public health. These included a clean, safe supply of drinking water, proper sanitation, food hygiene, refuse removal, and immunisation against smallpox. (Immunisation against other diseases came much later.) Even though the Victorians at this stage didn’t know about ‘germs’, some of them realised that some diseases, such as cholera, were water borne, rather than being caused by bad air and miasmas. The anaesthetist John Snow is said to have halted an outbreak of cholera in London’s Soho, by removing the handle of a communal water pump. A little earlier, Semmelweiss realised, from the results of a simple epidemiological study, that doctors coming directly from post mortems on maternity patients who had died of childbed fever were infecting the patients they then examined; he insisted that the physicians should wash their hands in disinfectant. He didn’t really in convincing his colleagues; perhaps calling them ‘murderers’ wasn’t tactful. Semmelweiss died in an insane asylum.

The next major health improvements came with immunisation against common infectious diseases, such as polio, measles, rubella, and pertussis, together with antibiotics. These great improvements in the control of infectious diseases are known as an ‘epidemiological transition’. The grossly polluted air in cities wasn’t addressed until after the London ‘pea-soupers’ of the 1950s and the recognition that they were associated with a very marked increase in deaths from respiratory illnesses.

Attention then turned to the diseases of “affluence” such as heart disease and cancer—though the apparent increase in these diseases was also related to greater longevity. What are called “life style choices” were implicated in these diseases, with the “usual suspects”, as Captain Renault might have called them, including smoking, poor diet, lack of exercise , stress, and alcohol. (Professor Sir Richard Doll originally thought that the great rise in lung cancer was related to tar and road works; the totally unexpected link to cigarette smoking took him by surprise.)

Heart disease was long felt to be a disease of executives, the rich, and somehow related to or caused by ‘stress’. To confirm this, investigators began a long-term study of civil servants—the Whitehall I study. (Its results were confirmed by the later Whitehall II study, which included women.) The expectation was that men in the highest levels of the civil service would have the biggest rates of heart attacks; but, to their surprise, investigators found exactly the opposite. Men in the lowest grades, such as messengers and door keepers had rates of heart disease and death three times higher than men in the highest grade.

Further analysis of these studies also showed that the lowest grade workers had not only more heart disease, but also more of some cancers, lung disease, digestive disease, depression, suicide. Was this difference the result of lifestyle, poverty or ‘low status’? Remember that all the people surveyed were employed, and weren’t in poverty. Researchers concluded that obesity and lack of exercise in the low status jobs were not enough to explain the differences; what else was going on?

Why Brexit?

I’m a Remainer; naturally, I’m unhappy about the Brexit vote. How did we, collectively, get to vote for Brexit? Let’s look at some of the issues.

People voted because of ideology, thinking that the EU was just a ‘bad thing’, and that Britain would be better ‘Leaving and Taking Control’. Others voted because they believed the deliberate untruths they had been told; that the borders would be closed to foreigners, though the Brits would be free to move anywhere in the EU; and that there was a financial bonus from leaving – £350 million a week for the NHS. (Almost immediately after the result, these promises were shown, by the Leave campaign themselves, to be false.) Others registered a protest, saying in effect that the EU needed reform. Some voted because of the effects of austerity, and continuing unemployment and poor job prospects. It’s clear enough that, in England, the economically disadvantaged areas voted to leave.

And things just got worse; the Prime Minister resigned, the Tory party began a process of selection only for some potential candidates to withdraw before their application had been lodged; there was blood on the floor, and many knives in many backs. And the Opposition front bench resigned, though the leader didn’t, leaving the Labour party in an existential crisis.

What we never had was any real clarity about what Leave meant; posters on billboards and on buses, and a leaflet implying that Turkey was poised to join the EU – along with Iraq and Syria. By contrast, during the 2014 referendum on independence for Scotland, that government produced a 650 page White Paper on the implications of independence. And once the Leave vote was announced, the leaders then appeared looking crestfallen at the result – as well they might, for they didn’t really want it. And now, nobody seems to have any clear or comprehensive idea what leave actually means, how this inchoate idea can be achieved, or even how we are going to get somewhere that we don’t know where it is.

And then, not unexpectedly, the Scottish National Party talked of another independence referendum. In the first, voters in Scotland were assured that the only way to remain the the EU was to vote to remain in the UK. Meanwhile, in N Ireland the First Minister talked of the vote across the UK as a whole, while the Deputy First Minister talked of another border poll. Unable to formulate a common, agreed policy on what’s best for NI, the leaders have left it to senior civil servants and gone off of 9 weeks holiday.

What is the United Kingdom? Originally, there were several kingdoms in what we now recognise as England. Gradually, this country was unified, and then conquered Wales to form Britain. After a disastrous foray in colonialism, Scotland – up till then an entirely separate and independent country – joined a union with Britain to form a country called Great Britain. Ireland had long been a quasi-independent place, with its own parliament, but because of Poyning’s Law, Britain, later Great Britain, always had the final say. At the beginning of the 19th century, Ireland too joined a union with Great Britain, forming the United Kingdom of Great Britain and Ireland. Finally, in the early 1920s, 26 counties of Ireland acquired ‘Home Rule’ and later full independence as a republic. The UK was renamed as the United Kingdom of Great Britain and Northern Ireland. Throughout these changes, it’s clear that England was always the strongest part, the place where real power and control lay; and the idea that in a union of countries England remains the most important player – the only player – still persists in the collective unconsciousness of the English. The Secretary of State for N Ireland is quite clear; the UK as a whole (translation: England) must collectively leave the EU, the wishes of NI or even Scotland are of no account, there will be no special pleading for the regions. Even getting the regions to the negotiating table might be difficult.

So when we talk of ‘British’ values, or of ‘Britain’ leaving the EU, those in England think it’s England which is leaving. The Scots are more nationalistic, unwilling to blindly accept the imposition of a Brexit which they neither sought or desired. And in N Ireland, the political parties, as usual, are split; unionists stress the totality of the vote across the UK, others stress that N Ireland as a whole voted to remain.

So, if there is confusion about who exactly wants to leave the EU, what of the reasons? Already, some protest voters are expressing ‘Bregret’; ideologues aren’t likely to listen to reason or counter-arguments. Look at the geographical spread in England, by far the most populous part of the UK. London and some other metropolitan areas voted to stay; but the disadvantaged north-east, east Anglia and so on voted to leave, along with the leafier parts of the ‘green and pleasant land’. What did these leavers think the EU had or hadn’t done for them?

They probably saw a ’swarm’ of immigrants, people prepared to work even if categorised as work-shy scroungers who only came to the UK to claim benefits. Never mind the facts – these people aren’t scroungers – it’s the perception that counts. Likewise, places such as the north-east of England and much of the industrial heartlands have seen their manufacturing industries decline and fail. Partly, this came through the Thatcher government taking on the unions and winning; but Thatcher’s mistake, if it was a mistake and not deliberate policy, was simply to ignore such regions, for after all they didn’t vote Tory so they didn’t matter. More recently, we have had ‘austerity’, a gradual reduction in benefits and welfare generally, and in the last 30 years average earnings have barely increased. What happened to the ’thirty glorious years’ after the end of the second world war? Why has the pay of managers greatly increased so that some of them earn in a day what the average worker gets in a week?

These effects are the neo-liberal economic model in action. This model was born around 1947 from the work and ideas of Hayek and the Austrian school, and encouraged by Friedman and the Chicago school. They believed that the market was always right and that business should operate almost unfettered by regulation; that government should be small, and not really be a service provider. Their ideas were put into action in the Thatcher and Reagan years, and indeed, provided early economic growth and wealth creation. Such wealth, we were told, would ‘trickle down’ to enrich all. It hasn’t worked out like that. Rather, the managers of banks and business saw opportunities to enrich themselves, and did so enrich themselves while seeking cost-cutting measures from their staff; zero-hours contracts and unpaid internships are just two examples of neo-liberalism in practice. Outsourcing is another; workers in China and Asia, having had little in the past, could have slightly more by working for global corporations, even the conditions of their work were such that no western government would accept them – but of course, business must operate unfettered. No matter that so many workers try to take their own lives, no matter that 1,000 women in a garment sweatshop can be crushed to death; business must be free to operate.

And austerity is just another child of neo-liberalism; some of the effects are remarkable. The idea that imposing austerity, for which read poverty, on a country permits that country to pay off its debts is, well, strange thinking. (In the past, debtors were sent to prison in the UK; this didn’t allow them to work to pay off their debts.) And if countries had debts, well the lenders had to be protected from their bad decisions; the bailouts that such countries receive may well go to the country, only to immediately find their way into the lender banks; banks, unlike you or me, are ‘too big to fail’. Even the IMF has form in this; in the past they decided that health care fell into the category of ‘luxury goods’ and could therefore be reduced. The didn’t reckon on increased outbreaks of disease. At least, there is now evidence that the IMF has recognised that their ideas on austerity were wrong.

The neo-liberal economic theory has a firm hold throughout most of the western world; there is no sign of any successor or better or fairer policy. Economic policy in the EU will continue, as it will in the UK; there is no evidence that lessons have been learned. Neo-liberalism reigns supreme, even to the extent that universities don’t teach or suggest alternatives. Economists who don’t agree don’t get positions in departments of Economics, rather the few gravitate to others where then can disguise their ideas under the heading of, say, ‘social geography’.

 

So, Brexit is the symptom but neo-liberalism is the disease. Why don’t we cure the disease?

A Case of Appendicitis

London was abuzz with excitement and expectation in late June, 1902. The coronation of the new king, Edward VII was to take place on the 26th in Westminster Abbey where monarchs had been crowned for a millennium. Vast swathes of the crowned heads of Europe were to attend; not for nothing was Edward known as the ‘uncle of Europe’. Edward had reinvented the role of the monarchy after the dreary years of Victoria; he reimagined all the pomp and ceremonial associated with the coronation; and every ceremonial we see today is very much his legacy. All sorts of souvenirs of the day were available; flats overlooking the processional route were being rented out for extortionate sums, and all traders were expecting a bumper time.

Meanwhile, in a room not far from the Abbey, a conclave of physicians and surgeons was discussing the illness of a patient with him. The patient was middle aged, distinctly obese, a heavy smoker and a known glutton and heavy drinker. Despite these considerable handicaps, the advisability of an operation was being taken seriously—but not by the patient.

His illness had begun 10 days previously. He had had abdominal pain which seemed to settle low down on the right side of the belly. He felt rather better soon enough, well enough to go for a drive in his carriage. However, although a mass had later developed in the belly, his medical advisers were against an operation, and the mass seemed to resolve, and his condition similarly improved. But, after a particularly gargantuan banquet on the evening of the 23rd—eight large courses, each with their own wine—his condition markedly worsened, leading to the consultation on the morning of the 24th June.

Despite their entreaties, the fat patient refused to change his mind; tempers began to rise. The king—for it was he—felt he knew his responsibilities, his duty. “I must keep faith with my people,” he said, “I must go to the Abbey”. Frederick Treeves, well known for his association with the ‘Elephant Man’, was one of the surgeons in attendance. Treeves was not a man to suffer fools or monarchs gladly; he was not a man to be cowed into silence by the majesty of the vast imperial presence. He replied,

Then, Sire, you will go in your coffin.

The king acquiesced. A room was made ready in Buckingham Palace for the procedure, an operating table was sourced, and later that morning the king was anaesthetised and prepared. Treeves, assisted by Lord Lister, a septuagenarian who had suffered a stroke, drained an appendix abscess; the king’s appendix was not removed. During the procedure the king had a respiratory arrest; his airway became blocked and he stopped breathing. The anaesthetist, Sir Frederick Hewitt, grabbing the king’s beard and pulling mightily upwards on it, reopened the airway. (The operating table, after much use in the RVH, is now in the Department of Surgery at QUB.)

The following day, the king was able to sit in bed and smoke a cigar; he made an uncomplicated recovery. The coronation, inevitably postponed, was held on 9th August. It was a much more muted affair; the king was well enough to be able to support the totally decrepit Archbishop of Canterbury during the ceremony.

***

The king’s illness and operation was widely publicised; appendicectomy subsequently became very popular, almost fashionable, even if the king’s—or what was left of it—remained inside him.

Though certainly known for centuries, appendicitis was first scientifically described in the latter part of the 19th century. Operations at this time were rare; Treeves was the first surgeon in England to perform an appendicectomy. Whether the publicity given to the king’s illness meant that appendicitis was more often correctly diagnosed, or whether there was a real increase in incidence is unclear.

The primary reason for appendicectomy is to prevent peritonitis, the infection and inflammation of the lining of the abdomen; untreated, this is fatal. The appendix is a blind ended, hollow, worm-like appendage at the start of the large bowel, and lies in the lower right side of the belly. The natural history of appendicitis isn’t clearly known, as operation is advised when the condition is diagnosed, but probably follows these courses. Inflammation begins inside the appendix, and gradually spreads through the walls of the organ. Central, crampy abdominal pain moves to the right iliac fossa as the inflammation involves the whole organ and the local peritoneum in the area. There is usually a low-grade rise in temperature; it is at this stage that the organ is removed. This inflammation may resolve over a period of a few days, or persist and worsen so that the appendix ruptures, either directly into the peritoneal cavity, or locally forming an abscess. The abscess may resolve or settle, or it may rupture into the abdomen. In retrospect, it seems probable that the king suffered an episode of appendicitis 10 days before his operation, which initially improved, only then to worsen as a localised inflammatory mass. This too settled, until the banquet on the evening of the 23rd when it was reinvigorated, at which stage it was clearly an abscess.

Although operation is the gold standard method of treatment, a report from US navy submarines included a description of 100 sailors who had symptoms of appendicitis and who were treated with antibiotics; all survived without complications. Clearly, some of the seamen may not have had appendicitis. Whether antibiotic treatment is superior to operation in more normal practice in a properly equipped hospital remains unclear (here); overall, opinion still favours operation over antibiotics, in part because there cannot be recurrent episodes. Such conservative management will still require observation in a hospital for a few days; the overall cost savings are likely to be imaginary. And, of course, the diagnosis of appendicitis may be wrong. The appendix can be removed at an open operation, or by keyhole (laparoscopic) surgery. Recovery after keyhole surgery is quicker, but specialised equipment is needed. Whether, after an appendix abscess has been drained, the appendix should be removed at a second operation is uncertain; some experts think that the inflammation has destroyed the appendix, others fear a further attack.

There’s a further very clear lesson from the king’s story; that no matter how elevated the person may be, no matter how deep the purse of a private patient may be, no matter if the patient is the humblest peasant in the land, they should all be treated equally on the merits of their illness. The patient should be able to make an informed judgement about the benefits and drawbacks of any operation. And if this demands the telling of brutal ’truth to power’, well, so be it.

Alcoholism

Charles Kennedy, the former leader of the LibDem political party died recently. There have been lots of tributes to him, such as Gerry Lynch’s (here) on Slugger, which also references Alistair Campbell’s. Remarkably, while a certain ‘reading between the lines’ is usually necessary with obituaries, I haven’t read anything about Charles Kennedy that wasn’t straightforward, or other than complimentary about him, while recognising his ‘problem’. Alistair Campbell, you will recall, was Tony Blair’s ‘spin doctor’ and much reviled for his activities; I can’t say that I’ve ever been a fan of his. And yet, his blog piece is surely one of the most humane pieces of writing from one politician about another. And he isn’t afraid to talk about the ‘problem’ that they shared.

The problem was the demon they both shared, alcohol; it lead to Kennedy’s downfall as LibDem leader.

The association between alcohol and politicians and artistic celebrities is well known; is there a link between their drive and ambitions and their problems, or are they self-destructive prisoners of their fate?  In the UK, the Labour politician George Brown was frequently ‘tired and emotional’; Reginald Maudling wasn’t any better; what about Churchill or Pitt the younger? What of Brendan Behan, Amy Winehouse, George Best, Dylan Thomas, Truman Capote, F Scott Fitzgerald and many, many more. Is there a connection between the creative artist and alcoholism? And if so, what is it?

Alcohol and humans have a long history; alcohol has been found in prehistoric remains. It’s not at all clear when alcohol was recognised for what it is, or when it was first deliberately produced. It’s suggested that the natural fermentation of rotting fruit, or compressed grain in a granary might have been the initial source. Be that as it may, alcohol whether as beer or as wine is well recorded in ancient texts. And with this, there are recognitions of the problems that can ensue.

The ancient Greeks drank alcohol at their evening meetings; it’s use was widespread in the Roman Empire. The early Christians had diverging views; some saw alcohol as a ‘gift of God’, others saw the evils that it could produce. Early protestants such as Luther and Calvin weren’t so against alcohol as some of their successors certainly are. In those times, wine or ‘small beer’ was commonly drunk throughout the day, with rations given out to nuns and others. ‘Small beer’ contained only about 1% alcohol, much less than beer today; it’s suggested that it was safer to drink than water which could be contaminated. It’s wasn’t just the alcohol that killed the bugs; rather it was the boiling required before fermentation that ‘sterilised’ the liquid, and the alcohol prevented later contamination. This was certainly the view of my grandfather, who always drank beer when touring around Ireland decades ago; it was simply safer than the local water.

The problems surrounding drunkenness lead to the emergence of temperance organisations, both in Ireland with Father Theobald Matthew and later James Cullen and the Pioneers; and elsewhere, usually within religious movements. Though the word ‘temperance’ implies ‘moderation’, such movements were really about total abstinence.

The concept of ‘alcoholism’ as a disease began to emerge in the late 19th century, being more formalised in the 20th. Medically, it can be seen as a physical addiction, and it is often associated with depression. (Alistair Campbell has certainly suffered with depression.) A marked rise in vodka consumption has been seen recently in Russia, and is often related to the miserable socio-economic conditions there after the fall of communism; Russian men have seen a marked decline in their life expectancy in the last two decades, almost certainly related to their alcohol consumption. There can be a genetic disposition, suggesting that some people cannot ‘help themselves’. As students, one psychiatrist taught us that alcohol addiction was a response to ‘internal pain’, alcohol acted as an analgesic, a pain killer. Part of the treatment was to try to discover what caused the patient’s pain, for without getting to the ‘root cause’ we would be unsuccessful in our therapy. I’m not sure if this view ever gained widespread acceptance. But there is also a ‘social’ view of alcohol consumption, one of society and the role we play within it; alcohol as a social lubricant, easing conversation between strangers though lowering of our defences, perhaps we even reveal too much, ‘in vino veritas’. And of course, it ‘provokes the desire but takes away the performance’.

Not only are there alcoholics in the classical sense, but also others who might be ‘heavy social drinkers’ or even ‘high functioning alcoholics’. Is excess alcohol consumption related to the stresses of life and the need for relaxation—a learned behaviour, a coping mechanism for life’s vicissitudes; or is it primarily a medical illness, or a bit of both? Whatever your view, it can be remarkably destructive.

If you think that someone you know might be an alcoholic, you should seek advice and help:

The Samaritans are on:  08457 909090 (UK) and 116 123 (Ireland)

Alcoholics Anonymous are on: 0845 769 7555   The Irish group is here.

Al-Anon (support for those affected by another’s problem):  020 7403 0888   In Ireland, (01) 873 2699