Austerity and COVID-19
A scientific paper published in the BMJ Open made international headlines by claiming that austerity policies led to 120,000 deaths in the UK (Watkins et al. 2017).
Death rates were falling in the years before the UK's 2010 election and then rose after the Conservative party came to power. University College London researchers found that there were 120,000 extra deaths between the start of the new government and 2017. They concluded that these had occurred because of the Conservative party's policies of austerity and, in particular, their significant cuts to health and social care (Watkins et al. 2017). The paper spurred a national debate. One criticism was that the authors may have gone too far; the study demonstrated an association between death rates and a change in government, but that did not mean one thing caused the other (Lee 2019).
Further support arose for the link between austerity and death rates when a study by another research group reported 130,000 preventable deaths in the UK between 2012 and 2017 (Hochlaf et al. 2019). These authors believed cuts to public health and preventive services could be implicated.
The magnitude of the impact may be up for debate, and the mechanism may not be clear, but many would find it difficult not to conclude that changes in medical services and social care can lead to changes in death rates. Having less access to evidence-based prevention and treatment services leads to increased mortality.
Work from the Canadian Medical Association takes the discussion further. It concludes that 25% of your risk for illness is linked to access to, and quality of, medical care. But this is dwarfed by 60% of your risk, which is linked to social determinants of health, such as poverty, housing, income, unemployment, early childhood development and discrimination (Canadian Medical Association 2013).
As austerity policies impact the social determinants of health, in addition to the provision of health and social care, it could have an impact on 85% of your risk for illness (Canadian Medical Association 2013; Stuckler et al. 2017).
We will see the social determinants of health play out in the COVID-19 pandemic. In the US, there already are early reports of race-based disparities in the risk of infection, and the subsequent risk of dying from COVID-19 (Eligon et al. 2020; Louisiana Department of Public Health 2020). We do not know whether this will be the same in Canada because we are not collecting the requisite data. But it is reasonable to suggest that, although COVID-19 may have been brought to our shores by those who can afford to travel and anyone can get infected, those with lower incomes are likely to be at more risk now that we have community spread (apart from health professionals and first responders). Low-income people are more likely to be in service jobs where they are in regular contact with the general public, such as grocery store workers or cleaners. They are also more likely to live in circumstances where self-isolation is difficult or not possible due to overcrowding, homelessness, living in institutions or less spacious long-term care homes. And racialized people are more likely to be in low-income groups in Canada.
The number of people at high risk of infection is related to government spending on social insurance and policies, and the spending to ensure that there are good jobs, working conditions, housing and social supports.
Those who are most at risk of dying from COVID-19 are older people and people who have underlying medical problems (Centers for Disease Control and Prevention 2020). And again, the risk of having an underlying chronic medical problem is directly related to the social determinants of health. The rate of chronic illness in a society is linked to social policy and prevention.
The shape of our pandemic curve, who is under the curve and who dies will be linked to the current and historic government spending and policies.
Ontario, the province that I live in, had the third lowest per capita spending on health in Canada in 2017 (Canadian Institute for Health Information 2020). It has struggled since taxes, hospital beds, social assistance and social care were cut by an austerity driven government in the 1990s (Wikipedia 2020). Governments since have not been able to return the sector to its previous levels (Ontario Hospital Association 2019). Hospitals have no spare capacity, and a lack of investment in housing, long-term care and social supports exacerbates the situation (Government of Ontario 2019). Hospitals have difficulty discharging patients who no longer need an acute bed. A minor surge in illness in flu season each year leads to long waits for beds and patients being treated, sometimes for days, in ER hallways (Government of Ontario 2019; Ontario Health Association 2019; Lederer 2020).
If a province goes into what the UN is saying is "the world's worst disaster since WWII" with insufficient hospital capacity, insufficient long-term care and an under-resourced social support sector, the outcomes are not going to be as good as they would be if there was existing capacity that can be used, and if there is a properly functioning health and social care sector (Government of Ontario 2019; Lederer 2020; Ontario Health Association 2019). Emergency plans may be able to produce beds and perhaps ventilators, but they do not produce quality medicine. Existing conditions cannot be remedied quickly either. For instance, it is difficult to get trained hospital staff and good-quality long-term home beds, build community capacity to support people and to improve necessary resources such as homeless shelters so that physical distancing is possible. And without these in place, the emergency plan quickly flounders.
Austerity policies that cut back health and social care services to the bare minimum in the name of efficiency do not allow spare capacity for emergencies. So when emergencies occur, more people die than is needed. But, austerity also impacts health indirectly through the social determinants of health. If over 100,000 people died in the UK during times that were more normal than these, I worry what the impact of past and current austerity measures will be on death rates during the COVID-19 pandemic in Canada.
About the Author(s)
Kwame McKenzie, MD, is the CEO of Wellesley Institute, the director of health equity, CAMH, and a professor at the Department of Psychiatry, University of Toronto, Toronto, ON. He can be reached via Twitter at @kwame_mckenzie
Canadian Institute for Health Information (CIHI). 2020. Your Health System. Retrieved April 6, 2020. <https://yourhealthsystem.cihi.ca/hsp/inbrief?lang=en#!/indicators/014/age-adjusted-public-spending-per-person/;mapC1;mapLevel2;/>.
Canadian Medical Association. 2013. Health Equity and the Social Determinants of Health: A Role for the Medical Profession. CMA Policy. Retrieved April 6, 2020. <https://cma.ca/sites/default/files/2018-11/PD13-03-e.pdf>.
Centers for Disease Control and Prevention (CDC). 2020, April 2. Coronavirus Disease 2019 (COVID-19) – People Who Are at Higher Risk for Severe Illness. Retrieved April 6, 2020. <https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher-risk.html>.
Eligon, J., A.D.S. Burch, D. Searcey and R.A. Oppel Jr. 2020, April 7. Black Americans Face Alarming Rates of Coronavirus Infection in Some States. The New York Times. Retrieved April 8, 2020. <https://www.nytimes.com/2020/04/07/us/coronavirus-race.html>.
Government of Ontario. 2019, January. Hallway Healthcare: A System under Strain. 1st Interim Report from the Premier's Council on Improving Healthcare and Ending Hallway Medicine. Retrieved April 6, 2020. <http://www.health.gov.on.ca/en/public/publications/premiers_council/docs/premiers_council_report.pdf>.
Hochlaf, D., H. Quilter-Pinner and T. Kibasi. 2019. Ending the Blame Game: The Case for a New Approach to Public Health and Prevention. IPPR. Retrieved April 8, 2020. <http://www.ippr.org/research/publications/ending-the-blame-game>.
Lederer, E.M. 2020, March 31. UN Chief Says COVID-19 Is Worst Crisis Since World War II. US News. Retrieved July 14, 2020. <https://www.usnews.com/news/world/articles/2020-03-31/un-chief-says-covid-19-is-worst-crisis-since-world-war-ii>.
Lee, G. 2019, September 20. Did Austerity Kill 120,000 People? 4 News. Retrieved April 6, 2020. <https://www.channel4.com/news/factcheck/factcheck-did-austerity-kill-120000-people>.
Louisiana Department of Public Health. 2020, April 8. COVID-19. Retrieved July 14, 2020. <http://ldh.la.gov/Coronavirus/>.
Ontario Hospital Association. 2019, December. Ontario Hospitals – Leaders in Efficiency. Retrieved April 6, 2020. <https://www.oha.com/Documents/Ontario%20Hospitals%20-%20Leaders%20in%20Efficiency.pdf>.
Stuckler, D., A. Reeves, R. Loopstra, M. Karanikolos and M. McKee. 2017, October 10. Austerity and Health: The Impact in the UK and Europe. European Journal of Public Health 27(4-1): 18–21. doi:10.1093/eurpub/ckx167.
Watkins, J., W. Wulaningsih, C. Da Zhou, D.C. Marshall, G.D.C. Sylianteng, P.G.D. Rosa et al. 20175. Effects of Health and Social Care Spending Constraints on Mortality in England: A Time Trend Analysis. BMJ Open 7(11):e017722. doi:10.1136/bmjopen-2017-017722.
Wikipedia. 2020, April 3. Mike Harris. Retrieved April 6, 2020. <https://en.wikipedia.org/wiki/Mike_Harris>.
Originally published as a Longwoods Insight on April 14, 2020 (https://www.longwoods.com/content/26198/austerity-and-covid-19).
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