The Body Economic – Why Austerity Kills

By David Stuckler and Sanjay Basu

Allen Lane: 2013

240 pages (hb)

ISBN 978–1846147838

Reviewed by Matt James

We are living in austere and tough financial times. It’s the message that appears to ring out from every news bulletin.  The pressure is on to make savings at the same time as finding the solutions to key problems with fewer resources. Crucial to this challenge is the question of values and ethics which will shape how government, industry and civil society go about making strategic long term decisions. Good practice, trust and accountability are terms which have taken on new importance in recent years, not least because of the drop in public confidence and trust in leadership in general. From the banks to the board room and from the press to Parliament.

It is within this context that David Stuckler and Sanjay Basu’s book “The Body Economic: Why Austerity Kills” seeks to make a contribution to the ongoing discussion as to how we respond to economic contraction in the presence of significant deficits. In fact to use the word “contribution” is a polite way of describing it. Their book helps to blow open the discussion and cut straight to the core of some of the thinking and ideology which is behind many of the deficit reductions and budget slashing approaches. Their motive is not to argue for which approach (cuts vs spending) will, in their opinion, lead us back to economic recovery in the shortest amount of time; that aspect of the conversation is left for others to fight over. Rather Stuckler and Basu assume a more human–oriented perspective. In a similar vein to Naomi Klein’s seminal book No Logo on branding and globalisation, The Body Economic addresses the matter of health in austere times and the effects of policy decisions on the health and well–being of the citizens of countries struggling with major economic crises. With a little less of Klein’s activism, but with no less passion, the book calls for evidence based policies to protect and meet health needs, thus avoiding attempts to provide care on a person’s ability to pay for it. Succinctly, the message from the book can be summed up in no better way than “recessions can hurt, but austerity kills.”

The book’s key strength lies in the extensive research which under girds the comprehensive thesis. Not only that but the fact that the same research has been published in well respected peer review journals such as The Lancet and BMJ only serves to add to the credence of the argument being put forward. Critics may try and argue against the book’s main ideas, but the one thing that no one will find easy is to say the authors have come up with their ideas from a quick survey of data which they have chosen to spin in a certain way so as to support their claims. For this reason, it is not that often you come across a book which has an extensive list of Research Publications given at the end of it.

Structure

Divided into three parts, the book consists of eight chapters. The style of the book is engaging and makes easy work of mixing narrative, statistical analysis and argument. That is not to say that the book is ‘light’ in rigour. This is certainly not the case; having undertaken rigorous analysis and research, the points the authors wish to make are made in a clear and nuanced manner. The first part assumes a historical perspective and reviews the events of the Great Depression. President Roosevelt’s New Deal of the 1930 is reviewed and praised for what the authors seek to demonstrate as the link between healthcare spending and productivity and how channelling investment into health can play a significant factor in helping to provide the conditions for a recovery.

The focus then switches to the post–Communist mortality crisis and the rapid disappearance of men from the Russian population. In my mind it remains one of the most horrific social catastrophes that in the space of three years, the life expectancy of Russian men fell by seven years, from 64 to 57. This can be attributed to a significant surge in alcoholism and in associated heart disease during this period. Ten million men just disappeared from the Russian population in the early 1990s. 

A Greek Trajedy

The times in which we live form the second part of the book which takes two contrasting case studies: Greece and Iceland. Both countries are experiencing economic crises but they have pursued crucially difference paths. The Greek tragedy needs no explanation as we are all too well aware of the events which have sadly unfolded in the country. Suffice it to say life is not good: Having experienced fifteen years of consecutive growth, Greece is now in its fifth year of recession.  Suicide rose by 17% in 2009 from 2007 with the Minister of Health reporting a 40% rise in the first half of 2011 compared with the same period in 2010. In contrast to this, Iceland’s story is one of democracy in action and putting the crucial decision of whether to bail out the banks back into the courts of the public to decide. Public referenda confirmed a clear majority were in favour of not bailing out the banks but to invest in health and social welfare instead. The result: social welfare increased with no loss to healthcare.

Back to work

Part III of the book is all about resilience. Here the authors make the case for what, in my opinion, is the real take away message for those in the policy community. Using case studies and statistics from Sweden and Spain, the authors argue that the dismantling of the social safety nets that prove such a vital role in protecting those in need, directly leads to increased sickness and death within the general population. Efficient and successful models of back to work programs implemented in Sweden have really encouraged people to return to work, but crucially these programs have motivated, supported and guided them along the path to this final outcome.  News of the UK government’s attempt to do something like this have hit the headlines in recent weeks and no doubt will be used as an example of what Stuckler and Basu call for. However, I think considered more carefully, the models exemplified in the book highlight subtle yet significant differences which are the real reasons for their success. Simply giving people literature, paying them something as they are told to ‘keep at it’ is not the hallmarks of these more successful Swedish active labour market programs (ALMPs). Investment in a guided programme for those unemployed and those who are not yet but think they may be in that position soon, have helped to prevent rates of depression and suicide escalating, I can see that investing money in well developed schemes such as this could be regarded as a luxury during tough economic times, but as the authors ably demonstrate, health, education and social programs actually have higher fiscal multipliers (ratio of a change in national income to the change in government spending that causes it). In profound contrast, bank bailouts are often negative.

The role, actions and influence of the World Bank and International Monetary Fund (IMF) come under criticism throughout the book in circumstances where countries have followed its advice and ended up in worse circumstances than before. As someone who studied the IMF in detail, particularly with regard to Argentina’s experience in the late 1990s–early 2000s, I tend to echo the authors’ sentiments. There is something wrong with an approach which takes steps to reduce the power of democratically elected leaders of nation states to regulate investments of multi–nationals and insist on basic social and environmental standards. Nevertheless, Stuckler and Basu avoid straying too much into an ideaological critique or discussion but instead put forward a strong case for calling for evidence–based policy making as opposed to the keen desire to pursue austerity, believing “short term pain for long term gain” will pay off, when there is a lack of evidence to support such an approach.

Statistics to tell a story

The book is not just about statistical analysis and graphs. True, there are many graphs dotted throughout the book but they are easy to understand, compliment the text well and do not distract. I recall when I read sociology at undergraduate level, my statistics lecturer steadfastly drilling into us the mantra, “Make the statistics tell a story”. Stuckler and Basu clearly heard the same series of lectures or something very similar. Compelling real life accounts are offered throughout the book, which help to put a human face to the statistical analysis and the impact of the decisions taken by various governments around the world. In citing the stories, the authors do not descend to emotionalism but they do powerfully demonstrate the profound effects which cuts on public health have had on ordinary members of the public.

Conclusion

Naturally, there will be those who read the book who may remain resolute that cuts and deficit reduction is the correct way of dealing and managing a financial crisis. Nevertheless, I am not aware of such a compelling and well researched opposing view to that position as the one laid out by Stuckler and Basu. Ideology has helpfully been put to one side in favour of providing a rich and robust tour de force of the impact on human health and well being. The lessons uncovered by Stuckler and Basu make for uncomfortable reading in places but they must be heeded and considered not only by policy makers but by us all, for it affects us all. It has been said that a health system can help serve as a means by which to symbolise and promote the values of the wider society which it serves. Times of economic crisis allow us the chance to refocus on what really matters and the kind of people we want to be and wish to become. The decisions which we make as a result really will affect the health of us all – the body economic. 

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