Abstract
Between May and August 2007, Bakersfield, California, reported 140 human cases in addition to numerous avian cases of West Nile Virus. Public health officials were perplexed. The preceding winter had been one of the driest on record and the summer had been exceptionally hot. Therefore, Bakersfield should have been devoid of the pools of standing water where infected mosquitoes normally breed. An aerial scan of the city revealed a possible answer: countless backyard swimming pools covered in bright green algal blooms. When the Kern County Mosquito and Vector Control Board went to investigate this case, they were not greeted by irresponsible homeowners. Instead, they found large “For Sale” and “Bank Owned Foreclosure” signs in the front yards of vacant homes. Bakersfield was not only the epicenter of a West Nile outbreak; it was also the center of the national mortgage lending crisis, reporting a 300 percent increase in mortgage delinquency and five thousand abandoned homes at the time.
Obviously, the public health repercussions of the financial crisis extend well beyond the relatively small outbreak of this rare disease. With the foreclosure crisis and the economic downturn also come the associated physical and mental health risks of homelessness and joblessness. In The Body Economic, David Stuckler and Sanjay Basu, both medical doctors with backgrounds in economics, public health, and statistics, go on to explore how national economic policies around the globe can either safeguard against or exacerbate these public health problems. While policy is by no means the direct agent of illness, Stuckler and Basu neatly demonstrate that it can contribute to the “causes of the causes” of illness (139). This message is particularly relevant for scholars and practitioners of urban planning, as it is our cities and communities that must deal with the unemployed and homeless populations, crowded hospitals, and the possibility of an epidemic when national economic austerity policy cuts spending for health, housing, and other social safety nets. This book challenges austerity as an empty ideology that both ignores the obvious public health benefits of stimulus spending directed at human well-being and the wealth of data that connects it to faster and more sustained exit from economic crises.
The book is divided into three parts, each examining natural experiments in public health responses to economic policies. Part I provides historical examples of these experiments, including the Great Depression, the dissolution of Soviet Russia, and the Asian Financial Crisis. Similar trends emerged across all three cases. As unemployment exploded and the social support networks of mono-industrial towns dissolved in Post-Soviet Russia, mortality rates among young men skyrocketed as they adopted high-risk behavior to cope with the stress. In Thailand, previous success in reducing HIV infection rates was reversed as cuts to public health budgets defunded one of the strongest HIV prevention programs in the region. Belarus and Malaysia in comparison favored gradualist approaches to rebuilding economic growth that included investing in public health programs to protect vulnerable populations. These two countries largely avoided the public health epidemics of their neighbors and also saw quicker return to positive economic growth in the long term. The same pattern was observed in the United States during the Great Depression when states like Louisiana decided to embrace the New Deal policy to expand public health programs. While Louisiana saw lower infant mortality rates and an increased control of infectious disease, states that neglected these investments, such as Georgia and Kansas, suffered worsening public health and prolonged economic depression.
Part II addresses contemporary versions of these natural experiments in Greece and Iceland, but essentially delivers the same message as Part I. For example, the Asian Financial Crisis and the recent recessions in Iceland and Greece were preceded by a precarious financialization of the economy. When these economies toppled, the countries diverged on their responses to advice and loan packages offered to them by the International Monetary Fund (IMF). Icelanders took austerity to a national referendum and the people uttered an emphatic “No!” In response, the Icelandic government postponed bailing out large private investment banks and instead increased National Health Service budgets and maintained its social protection systems. Reports indicate that Iceland not only maintained public health standards but also began to see positive economic growth by 2011. Greece, however, accepted an IMF bailout and attempted to cut health care spending to below 6 percent of the GDP. In response, southern Greece began to report outbreaks of malaria for the first time in thirty years because of the elimination of insecticide-spraying programs. Athens and other cities saw rising HIV infection rates. While politicians blamed this change on increased prostitution, Stuckler and Basu soundly connect it to high unemployment rates, especially among youth, and increased drug use in a country that slashed its safe-needle exchange and drug rehabilitation programs in order to meet IMF budget deficit targets.
In Part III, the authors examine what aspects of a country’s social safety net make its society resilient. A comparison of the U.S. and UK health care systems emphasizes the need for preventative care, which is much more likely to take center stage when health care is considered a universal right (as in the case of the United Kingdom) rather than a marketable commodity (as in the case of the United States). Next, an examination of the ties between unemployment and physical health across Spain, Italy, the United States, and the Nordic countries reveals the pressing need for active unemployment assistance programs. These programs are much more likely to prevent the suicides, hospitalizations, and incarcerations that can result from long-term unemployment. Finally, the authors argue that housing must be brought into the fold as an essential safeguard against the unnecessary health complications that arise from chronic homelessness.
Over the course of this book, several salient themes emerge. First, when deciding on policy options, we must distinguish between ideological myths and data-driven realities. The ideology purported by the IMF and other neoliberal institutions that decreased government spending leads to long-term economic growth is a myth based on the false assumption that the fiscal multipliers of social spending are less than one. Stuckler and Basu reveal that the multipliers for health and education are typically greater than three. Promoting these austerity policies through political rhetoric or loan packages actually does more harm than good. Based on the authors’ analysis, it is obvious that greater investments in public health and social assistance programs are needed. We should embrace this not simply as a humanitarian effort but as a practical investment in building a more resilient society and economy. Going forward, Stuckler and Basu make the bold claim that economic policy should be subject to the same kind of ethical review as medical practice.
The authors provide a compelling case for maintaining public health and social protection programs. Their grounding in medical research saves the piece from becoming a tirade against neoliberal economics and institutions like the IMF. The fifty-plus pages of meticulous notes that append the book, however, do plenty to justify their fiery language. While keeping this set of observations separate from the body of the work makes it more accessible to the general public, they will be of great interest to scholars and practitioners who wish to delve deeper into the academic evidence supporting Stuckler and Basu’s arguments.
While the structure of the book is repetitive and predictable after the first couple of chapters, it also serves its purpose of keeping the book publicly accessible. A major critique of this repetition, though, is its tendency to pit State versus Free Market solutions against each other as if there are no other options for service provision. It fails to acknowledge that governments are increasingly composed of a network of actors coordinated by a comparatively weak state. While the public services discussed in The Body Economic are essential, it is important to address how a decentralized system can provide such services. While answering this question is perhaps beyond the scope of the work, it is an important area of study for planners.
Despite this shortcoming, the book does provide us with something new and invaluable. By revealing the tangible consequences of austerity and stimulus, it departs from the often abstract justifications that surround economic development. Instead, it plainly illustrates the biopolitical realities of capitalism. The health crises presented in The Body Economic provide an uncomfortably literal depiction of the pathological response society generates to neoliberalism and its attempts to “integrally subsume life within the economy” (Rossi 2013, p. 1067). By cutting those social safety nets which maintain the physical and mental health of our communities, austere economic policy effectively debilitates both the human and economic body.
In this way, The Body Economic offers a fresh voice to the discussion on how public health and planning intersect. In laying out a broader public health agenda that links employment, housing, health, and economic policy into an integrated whole, the book goes beyond the well-loved and well-worn planning arguments for walkable physical design, active mode share, and healthy food systems. Instead, it strikes a chord that has much greater resonance in state, national, and international politics. Planners should duly take note.