What part do the values of growth and prosperity, freedom and justice, security and democracy play in social policy and human welfare? How can we judge the policies offered to us as the recipe for progress?
At a time of global ‘permacrisis’, Sebastian Taylor applies his extensive frontline experience working with health systems and healthcare in the Global North and South to assess the concrete impact of contemporary liberal values on our welfare, development and environmental survival.
Drawing on research from around the world, he uses health as an objective metric to assess how effective these policies are for individuals and society as a whole.
Economic growth is modernity’s religion – the centrepiece of political promise and policy making in countries across the world. Yet growth does not, on its own, result in a healthier or longer life. This chapter argues that an economic concept of progress unduly dominates policy thinking given the limited evidence of its benefit to our lives, and the extent of damage it poses for environmental sustainability. It argues that the key factor mediating between national wealth and human welfare is the quality of governance supplied by government – and that a better governance model is one which combines growth and health not as alternative priorities but as mutually interdependent components of a single social development strategy.
Coming out of the ‘lost development decade’ of the 1980s, global policy makers recognised that human development requires more than just economic growth. The Millennium Development Goals, however, continued to instrumentalise vertical investment in health as, in effect, an input to human capital and economic productivity. Using the example of food and nutrition systems, this chapter argues that, with the transition to the Sustainable Development Goals, the tension between growth, welfare and environmental survival has now become critical – a tension which the current architecture of global governance is unequipped to manage.
There is a strikinig parallel between our belief that the environmental effects of continual economic growth can be managed through technological mitigations, and the belief that biomedical care will furnish us with endless improvement in health and lifespan. Both are confronted by a ‘limits to growth’ problem – the realisation that both pathways lead to bankruptcy at best and extinction at worst. Drawing on income and growth data since the 1960s, and using the example of Japan since 1990, this chapter argues that a different model – of slower growth and more active wealth redistribution, within and between countries – is not only possible, but necessary and, potentially, beneficial.
Freedom is perhaps the most fundamental liberal value – yet one which is bitterly contested. What does freedom mean, for whom, and how do we achieve it? The contemporary idea of freedom focuses intensely on the liberation of individuals from the oppressions of society and government. The following three chapters draw on examples from health – the role of vaccines and immunisation, the problem of noncommunicable disease, and the nature of the healthcare system – to demonstrate that an individualist notion of freedom undermines some of our most valuable social functions and that an alternative concept – of freedom as reciprocal – is urgently needed if we are to optimise the relationship between liberty and welfare.
After clean water, vaccines constitute probably the greatest contribution to human health in history. Yet public faith in immunisation is declining around the world. This chapter argues that an intensive post-war focus on individual freedom, in the context of increasing inequality and collapsing trust between populations and their governments, is critically undermining popular willingness to support the premise of vaccines – that one of our most effective medical technologies, and the freedoms vaccines provide to us all, depends for its efficacy on the societal capability for reciprocity and collective action.
Noncommunicable diseases are now the dominant cause of mortality in countries at all levels of economic wealth. The causes of noncommunicable diseases, commonly characterised as ‘diseases of lifestyle’, are widely attributed to our consumption preferences and the behaviours we adopt. The dominant policy response is to increase individual freedom to make responsible choices – governments deferring in favour of market-led solutions, disregarding the evidence that these do not work. This chapter argues that individual freedom is too often simply overpowered by increasingly concentrated, globalising market forces. Using the example of obesity and diet, the chapter concludes that liberating individuals to make choices while failing to supply the conditions in which such choice is meaningfully possible is an ineffective, inefficient and in the end rather cruel form of freedom.
In almost all countries, health is assumed to depend on health care, delivered through systems which combine public and private providers. As the costs of care escalate, healthcare reform has become dominated by an emphasis on expansion of private provision – justified as the liberation of individual care choice from oppressive government monopoly. Using evidence from high-, middle- and low-income countries, this chapter argues that neither public nor private care systems perform conclusively better, and that the preference for privatised systems is ideological. It argues that almost all countries will, in the end, have a mixed system of public and private providers; that public healthcare systems based on universal entitlement offer significant sociological advantages by creating collective inclusion and security; and that excessive emphasis on freedom of choice can create fragmented and poorly governed public–private hybrids, characterised by uncertain and inequitable access. The chapter concludes that the freedoms available through universal healthcare require more, not less, government.
Justice is widely invoked as the basis of political legitimacy. Yet injustice remains entrenched within countries and between them. In the absence of a clear concept of social justice, policy has tended to focus on inequality as an economic phenomenon, on the problem of poverty as the core issue – and on the idea of fair opportunity and social mobility as the solution to unjust society. This chapter argues that poverty reduction and opportunity creation fail to address the deeper drivers of social inequality, and that this focus therefore offers a profoundly inadequate approach to advancing justice.
Inequalities in health and life expectancy are widely considered to be undesirable and even morally offensive. Yet no clear concept of ‘just health’ has emerged. Faced with the substantial potential costs of engineering the social conditions necessary for more equitable population health, governments tend to concentrate on improving fair provision of healthcare, included in the agenda for Universal Health Coverage (UHC) enshrined in the SDGs, and on remediating basic healthcare shortfalls among the poorest communities. This chapter argues that UHC, while admirable, will not deliver anything remotely resembling health justice – because the roots of health injustice lie in deeper problems of hierarchy, social status and inequality of power. It argues that UHC is a ‘supply-side’ model of justice, defined by what the prevailing systems of power are prepared to offer, not by what populations should demand.