Health and politics for 2015 and beyond

The important 2014 report of the Lancet-University of Oslo Commission on Global Governance for health1 was organized around the ‘political origins of health inequity’, political determinants of health and power asymmetries. Its focus was on global processes and mechanisms such as the demands for austerity imposed on several European countries by the troika of the International Monetary Fund, the European Central Bank and the European Commission, and the impact of investment treaties on health equity and the ability of governments to control the activities of transnational corporations. The Commission's emphasis on politics is highly relevant within national borders, as well. In advance of the 2015 UK General Election, the Faculty of Public Health's manifesto2 sets out a 12-point action plan that is described in a companion guest editorial.3 It includes such measures as a tax on sugar sweetened beverages, debated in this issue by Mytton4 and Cornelsen and colleagues;5 lower speed limits in built-up areas, for which an early access article in the Journal reports solid evidence;6 renewed commitment to universal tax-funded health care free at the point of use; minimum unit pricing (MUP) for alcohol; and investments in public transport and zero-carbon energy systems. These are all the stuff of politics, requiring various forms of government action and activism, and likely to face opposition from various powerful and entrenched interests. Patterson and colleagues7 describe industry resistance to MUP but focus on another dimension of politics: the way in which mass media ‘frame’ public health issues. Given the media's importance to our understanding of events and policy choices, this area remains under-researched. Also in this issue, Smith and Kandlik Eltanani8 report agreement among researchers they surveyed on the importance for reducing health inequalities of ‘more progressive systems of taxation, benefits, pensions and tax credits that provide greater support for people at the lower end of the social gradient’. Support for this set of measures was more consistent, in fact, than for any other measure identified. This prescription contrasts dramatically with the effects of post-2010 UK public expenditure cuts, which have had a disproportionate impact not only on lower income households, with the poorest groups losing the largest percentage of their incomes,9 but also on lower income regions like those reported on in this issue by Copeland and colleagues.10 Areas with the highest prevalence of economic deprivation have lost and will lose the most from combinations of benefit cuts and reductions to local authority budgets.11 The impact on public services and poverty in cities like Liverpool12 and Newcastle,13 where one of us (E.M.) works, has already been devastating. Against this background, the Chancellor of the Exchequer's autumn 2014 economic statement presaged post-2015 expenditure cuts that, according to the Office for Budget Responsibility14 and the Institute for Fiscal Studies,15 will be considerably larger than those already implemented. The effect, they say, will be to roll back public expenditure as a proportion of GDP to the levels of the 1930s, ‘taking the size of the state to its smallest in many generations’.15 There is no right answer to the question of how large or small government ought to be, but given the findings of Smith and Kandlik Eltanani8 and the accumulated body of evidence for negative health effects of austerity,16 the absence of any serious conversation in mainstream politics about the short- and long-term consequences for health, and health equity, is truly remarkable and disturbing. Some would claim that the evidence that redistributive policies will reduce health inequalities is insufficiently strong or equivocal. In fact, more of the researchers interviewed by Smith and Kandlik Eltanani considered such policies ‘strongly supported by available evidence’ than thought the same for fluoridating water or increasing tobacco taxes, but their pre-existing interest in health equity means they were hardly a random sample. Some epidemiologists tend to dismiss all such inferences that are not supported by experimental or quasi-experimental studies as ‘ecological correlations’.17 At least by implication, this issue's article by Threlfall and colleagues18 offers a counter-argument. They point out that ‘there are many health interventions for which the outcome is beyond reasonable doubt based upon evidence other than that from intervention trials’,1,8 based, for example, on the robustness of available knowledge about the underlying mechanisms of causation. Threlfall et al. argue, instead, for a more theoretically informed approach to how interventions work, based on a range of available evidence. We would add that many policies and interventions are impossible to test using experimental methods, for reasons of ethics, logistics or both.19 That said, decisions about when evidence is strong enough to justify inaction, or to render inaction on social determinants of health unjustifiable, cannot be made on scientific grounds. Such decisions are driven by values and are also the stuff of politics.