Narratives of inevitability or pragmatic action radically limit political discourse that’s both false and prevents social transformation.

What if, within the constraints created by the global economic environment, there are (some) alternatives at least under conditions of formal democracy – in other words, what if the policy space (Koivusalo et al., 2009) available for redistributive action is more extensive than implied by the preceding discussion? In particular, the account just provided fails directly to confront the possibility that domestic competition state polices are not pragmatic responses to a global environment that leaves few options available, but rather elite initiatives designed to use globalization as a justification for their own agendas, or actively to accelerate integration into global flows of production and finance on terms that would later be difficult if not impossible to reverse.6

The account presented in the preceding section has other shortcomings. For example, although convergence of tax rates is widespread, the pattern is stronger with respect to corporate taxation (Genschel and Schwarz, 2013) than it is with respect to personal income and wealth taxes. This is to be expected given the relative ease with which transnational corporations can shift profits within the corporate structure in order to minimize tax liabilities (see e.g. Tanzi, 2001; Kar et al., 2015; Clausing, 2016). It is hard to make a credible argument that the massive reductions in personal income taxes for the rich in the UK under Thatcher and later the post-2010 Conservative-led coalition, which took place alongside growing fiscal deficits and social policy retrenchment, were motivated by anticipated tax competition. Still less can this be claimed with respect to tax cuts for the rich in the US under Presidents Reagan and later G.W. Bush. Similarly, it is difficult to see the high interest rate policies of the US central bank post-1979, which had worldwide ramifications, as a response to globalization rather than a proactive effort to transform the economic policy landscape. Yet both sets of policies, i.e. high interest rates and tax cuts for the wealthy, are implicated in the rise of public debt (Streeck, 2014, p. 149). And the consolidation state argument is much more persuasive with respect to countries of the Eurozone, which creates distinctive limits on economic policy space (Streeck, 2016, p. 113–141), than with respect to others.

These observations imply that the choices in question could have been made differently by governments with a different set of priorities – whether responsive to different domestic constituencies or driven by different elite agendas. Similar inferences can be drawn from differences in the prevalence of poverty after taxes and transfers, and of low-wage employment (Schrecker, 2016), in countries that have “all been exposed over the last several decades to the same increases in globalization, technology, and competition within national product markets” (Appelbaum et al., 2010, p. 5). Such contrasts reflect broader divergence across a range of indicators of social justice (Schraad-Tischler, 2011), and arguably lend weight to Göran Therborn's (2006) assertion that “[n]ational rulers have no global alibi for national privileges and inequalities” (p. 49).

That said, within specific national contexts such phenomena as tax resistance, tax revolt and the erosion of commitments to social solidarity may reflect powerful path dependencies associated with patterns of structural economic change, and with past policies that facilitated these, limited policy space, or increased economic inequality and other forms of stratification. The consequences of joining the Eurozone are an obvious example. In the case of the UK, after the transformations initiated under Thatcher and continued under New Labour and then the post-2010 Conservative restoration, transition to something like a Nordic model of social policy may simply not be electorally feasible because of the changed class structure of the society, and the corollary shifts in political allegiances. A powerful version of this argument, organized around class coalitions and the electoral process, explains the politics of austerity post-2008 in the US and the UK with reference to a “constituency of the ‘squeezed but basically safe’” (Clark and Heath, 2014, p. 213), holding that “in hard times the exposed are more desperate for help than ever, but the majority … have come to calculate that it is better to throw their lot in with the haves, than to risk being saddled with tax rises to provide assistance to the have-nots” (p. 202).

If calculations like those posited by Clark and Heath underpin the allegiances that drive electoral outcomes, are they accurate?7 What influences the way in which this constituency, and others, frame the relevant risks and probabilities? Here we move into the discursive or ideational realm, and the focus of inquiry shifts to the possibility of altering that framing on the part of decisive political pluralities. Central here is the nature of perceptions of economic ‘competence,’ which as many observers have noted is a prerequisite for electoral success (Hay, 2004; Gamble, 2012; Taylor-Gooby, 2013). When neoliberalism becomes accepted as normal or ‘just the way things work,’ the effect is radically to shrink the limits of permissible political discourse. “[T]he higher-order assumptions of the dominant (neoliberal) economic paradigm seem to be accepted by all serious contenders for high office in contemporary Britain” – and, it must be added, in much of the rest of the world – “for this is now taken as a token of their electoral competence and credibility” (Hay, 2004, p. 503). Without credible challenges to the equation of neoliberal policies with economic ‘competence’, egalitarian redistributive policies (as contrasted with the inequality-magnifying policies characteristic of the UK post-2010) are highly unlikely to command sufficient support. This point is explored further in the concluding section of the article.

5. Lessons from Brexit and Trump, or, What if all politics are identity politics?

In the aftermath of the June 2016 UK referendum on European Union membership, the political significance of strong narratives that resonate with the electorate's perceptions of reality, perhaps quite independently and in defiance of evidence-based calculations of gain or loss, cannot be over-emphasized. This point emerges with even greater clarity in light of the 2016 US election, in which Donald Trump won the presidency based on strong regional showings, notably among portions of the electorate who were likely to be most immediately harmed by (for example) his promise to dismantle the Affordable Care Act (Congressional Budget Office, 2017)

Such phenomena arguably call into question the assumption of voter rationality that, at least implicitly, underpins the first two explanations advanced here, and for that matter much of contemporary political science. Ronald Inglehart and Pippa Norris (2016), drawing on decades of cross-national opinion research, posit two explanations for the rise of what they call populism, exemplified by the Brexit and Trump campaigns: the “economic inequality” and “cultural backlash” hypotheses. They ultimately find cultural backlash explanations more persuasive, while emphasizing that “the analytical distinction … may also be somewhat artificial. Interactive processes may possibly link these factors, if structural changes in the workforce and social trends in globalized markets heighten economic insecurity, and if this, in turn, stimulates a negative backlash among traditionalists towards cultural shifts” such that “[it] may not be an either/or question, but one of relative emphasis with interactive effects” (p. 3). A thoughtful post-referendum analysis based on multiple sources of survey data (Swales, 2016) concludes that although some demographic characteristics such as low income, lack of formal qualifications, living in rented social housing and being 65 or older were strong predictors of a leave vote, voters’ individual position on the left-right spectrum had little to do with their referendum vote, and “matters of identity are equally if not more strongly associated with the vote to Leave – particularly feelings of national identity and sense of [negative] change over time” (p. 7). That sense of adverse change, of course, is not unrelated to economic situation.

A stronger variant of this argument is made by Christopher Achen and Larry Bartels (2016), whose Democracy for Realists is closely argued and powerful, even if the authors are too ready to generalize from the US political context with selective use of examples from other jurisdictions. The core proposition (to oversimplify) is that “partisan preferences and voting patterns [are] powerfully shaped by group loyalties and social identities,” such that “most people make their party choices based on who they are rather than on what they think” (p. 264). They go on to argue, in a chapter on “the rationalizing voter,” (pp. 267–296), that voters may be actively indifferent to facts, instead viewing such basic and easily verifiable political claims as those related to the size and trend of fiscal deficits through the lens of their partisanship. In the case of the 2016 US election, and arguably in the case of Brexit as well, favourably disposed electors had a great deal of well financed prompting to believe such “alternative facts,” in the now widely quoted Trump administration formulation. In neither case did or could the prompting create the receptive audience; it merely appealed to existing frustrations – frustrations arising, at least in part, from a changing and uncertain economic context.

At least an indirect connection with health and place is suggested by finding that, at a county level, a composite index of health indicators predicts a larger proportion of the electoral shift to the Republicans between 2012 and 2016 than the percentage of whites without a college/university degree (Illness as indicator, 2016), even after controlling for other factors (which as noted understates the magnitude of the demographic effect), with the largest swings concentrated in the US Midwest. Many of the counties in question are territories where people increasingly find themselves living as refugees in their own land as a consequence of deindustrialization and the migration of economic opportunities, places where, to quote Bruce Springsteen (1980): “You wake up and you’re dying/you don’t even know what from.”8 As voters recognize this, their appetite for any kind of respite from downward mobility and desperation may understandably be both ravenous and – especially in the absence of coherently and credibly presented alternative policy directions - undiscriminating. This is far from the only explanation of Trump's appeal to voters, and as noted in the next section of the article it may not be the most persuasive, but it would not be wise to ignore it.

6. Conclusion: Critical tasks; future uncertain and volatile

Each stylized response to the question of whether Mackenbach was right has important implications for political prospects for reducing health inequalities, and to restate a point, the explanations and what they imply are not mutually exclusive. Historian Simon Szreter (1999) argues that “a cross-class political alliance” made viable by rapid expansion of the franchise was responsible for advances in public health in England in the nineteenth century. The first and second explanations explored here suggest the need for similar alliances today, yet In the UK, current electoral allegiances now appear to reflect an implicit coalition between plutocrats and an electorally decisive plurality of the so-called middle class, including the “squeezed but basically safe.”

A provocative analogy may help in understanding the scale of the difficulty. Historian Steve Stern begins his trilogy The Memory Box of Pinochet's Chile by pointing out: “After eight years of democratic rule that included credible revelations of human rights violations … a substantial minority of Chileans – about two of five – continued to remember the military overthrow of the elected government of Salvador Allende in 1973 as a rescue mission” (Stern, 2006, p. 7). The 2009 Chilean elections, in which the presidency was won by a billionaire beneficiary of the Pinochet regime against an uninspiring candidate of the centre-left, suggest the longevity of such allegiances; even in 2013, when the centre-left returned to power, the right's candidates won between 36 and 38 percent of the vote in parliamentary elections and the presidential runoff election. The coalitions in question are not invincible, as the Chilean experience shows, but the consistency across decades of the “about two of five” proportion suggests their durability.

The second line of argument suggests that creating compelling narratives that challenge the neoliberal equation of austerity with economic competence on its own terms, as well as from a social justice perspective (which may have limited appeal to tactically important elements of the electorate) is a necessary (although not sufficient) condition for expanding support for policies that will reduce health inequalities (cf. Lynch, 2017). Until the dogma that neoliberal policies are the only ones that ‘work’ (cf. Fourcade-Gourinchas and Babb, 2002) can be challenged ‘on the ground,’ as it were, destructive consequences for health will continue to be accepted (especially by those not directly and immediately exposed) as collateral damage, inevitable as the price of avoiding economic peril. Certainly the “social movement to advance the cause of health equity through action on the social determinants of health” that Sir Michael Marmot envisioned following on from the Commission on Social Determinants of Health that he chaired (Marmot et al., 2010) has seldom materialized. This may be due in part to the difficulty of constructing necessary cross-class alliances, and in part to incomplete recognition of their necessity.

Much is yet to be understood about developments like the result of the EU referendum and the election of Donald Trump, which are central to any assessment of the prospects for constructing cross-class alliances, so one must be more tentative here. At the level of individual US voter preferences, race and attitudes towards race appear to be much stronger predictors of political allegiance than economic situation (Wood, 2017; McElwee and McDaniel, 2017). This finding may or may not be relevant outside the US, but apparent mismatch between economic interests and political commitments underscores the importance of credibility, and the complexity of articulating in an electorally effective way the connections among the core propositions of neoliberalism, the policies that embody them, and their selectively destructive consequences for health outcomes. This enterprise might be described as a populism that speaks to those left behind by current economic trends and policies in a way that is progressive rather than retrograde; examples can be found in the UK media, although the discourse remains for the moment outside the political mainstream (Schrecker, 2017). In somewhat different ways the three explanatory perspectives outlined here all direct our attention as engaged researchers and advocates to the complex, untidy and often unpalatable enterprise of political communication.