A Watershed Moment for Social Policy and Human Rights?: Where Next for the UK Post-COVID 9781447363859

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A Watershed Moment for Social Policy and Human Rights? Where Next For the UK Post-​COVID Amy Clair, Jasmine Fledderjohann, and Bran Knowles

First published in Great Britain in 2021 by Policy Press University of Bristol 1-​9 Old Park Hill Bristol BS2 8BB UK t: +44 (0)117 954 5940 pp-​[email protected] www.policypress.co.uk © Bristol University Press 2021 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 978-​1-​4473-​6384-​2  ePub ISBN 978-​1-​4473-​6385-​9  ePdf The right of Amy Clair, Jasmine Fledderjohann, and Bran Knowles to be identified as authors of this work has been asserted by them in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved:  no part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without the prior permission of Policy Press. The statements and opinions contained within this publication are solely those of the authors and not of the University of Bristol or Policy Press. The University of Bristol and Policy Press disclaim responsibility for any injury to persons or property resulting from any material published in this publication. Policy Press works to counter discrimination on grounds of gender, race, disability, age and sexuality.

Contents

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Introduction: human rights, social policy, and the COVID-​19 pandemic   1 2 The right to medical care  15 3 The right to food  35 4 The right to housing  57 5 The right to necessary social services: digital technology  75 6 Where next for social policy?  97 Notes  107 References  111

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Acknowledgements

Amy

I would like to dedicate this book to my Grandad who passed away while we were working on our book proposal. He ensured that I had plenty of opportunities to practice debating policy and politics from a young age and would be proud that these debates have made it into book format. Amy is funded by the ESRC Research Centre on Micro-​ Social Change (MiSoC) at the University of Essex [ES/​ S012486/​1].

Jasmine

Jasmine is grateful for the encouragement offered by her family and friends through the writing of this book, not least of which came in the form of care packages containing implements for facilitating writerly impulses. She particularly wishes to thank her husband for useful and supportive responses to her endless impassioned monologues about the content of this book during its development and drafting. Jasmine received generous support from a UKRI Future Leaders Fellowship [grant number MR/​T021950/​1], without which this work would not have been possible.

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vi Acknowledgements Bran

Bran would like to thank her family for their love and support, especially during this difficult year. She would like to thank in particular her husband for his resolute calm and humour in the face of turbulence. She would also like to dedicate this book to her children, whose generation has inherited a number of overlapping challenges they must somehow find the strength to resolve.

1 Introduction Human rights, social policy and the COVID-​19 pandemic The COVID-​19 pandemic has caused unprecedented global disruption. In this book we explore what the pandemic has shown us about ideology, social policy, and human rights in Global Minority1 countries. We focus particularly on the UK and US, and on the policy areas of health, food, housing, and technology. The problems we discuss are inherently political ‒ they have political causes and political solutions. For this reason, we focus on the political ideology that has shaped our policy landscape –​neoliberalism –​and countries that have pursued a neoliberal agenda to a great extent. We propose that ideological changes are an essential prerequisite for a well-​planned, equitable, and just system going forward. Without such an explicit consideration of motivations and ideological underpinnings, future policies may fail in their goals, or, perhaps worse, set harmful and unethical goals. COVID-​19 is a timely and salient example of how some states have failed both to plan for a pending disaster and to equitably meet people’s needs up to and throughout the disaster. As Illner (2020) cogently argues, framing disasters COVID-​19 included ‒ as sudden, unpredictable, and often ‘natural’ events which have disrupted an otherwise well-​ functioning system ignores the systematic marginalisation of people whose needs have been long-​ neglected by the state, and further obfuscates how that neglect led directly to disaster. In this view, disasters are not simply the result of external hazards ‒ indeed, the ‘external’ nature of hazards themselves are subject to debate, as human action often directly or indirectly creates conditions for hazards ‒ nor even of social risk factors in isolation; rather, inequitable social structures systematically devalue the lives and contributions of some groups of people, leaving these devalued people 1

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A Watershed Moment

to bear the brunt of hazards with little to no state support, thereby creating disastrous social conditions. As Illner asserts, such structural inequities are only resolvable through large-​ scale systemic change.

Social policy, evidence, and ideology: from human rights to neoliberalism and back again

The 1940s are often considered the beginning of a ‘golden age’ of social policy and human rights. Significant developments such as the Beveridge Report (in the UK), New Deal (in the USA), and Universal Declaration of Human Rights (UDHR) arose during this time. It is often portrayed as a period of consensus around the role of government in meeting human needs, based on the idea of shared citizenship and supported by a population moved by their experience of World War II (WWII, although this framing is not universally accepted). The Beveridge Report, published in 1942, was the foundation for significant developments in the welfare state in the UK. Building on the progress of the interwar period, the Beveridge report sought to revolutionise policy and tackle the ‘5 Giant Evils’: want, disease, ignorance, squalor, and idleness (crudely:  poverty, health, education, housing, and employment), including through the establishment of a ‘national minimum’ (Beveridge, 1942) ‒ a level of support below which no person would fall. Adopted by the UN General Assembly in 1948 and concentrated on similar concerns, the UDHR established an international standard (United Nations, 1948). We focus particularly on Article 25, which states: Everyone has the right to a standard of living adequate for the health and well-​being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood,

Introduction

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old age or other lack of livelihood in circumstances beyond his control. (United Nations, 1948)

Importantly, the Article explicitly specifies that these rights must be realised even when one’s livelihood is threatened by illness or structural forces, and in that respect is similar to the Beveridge Report. The UN Economic and Social Council has subsequently clarified the rights articulated in the UDHR, including through the publication of a series of General Comments from the Committee on Economic, Social, and Cultural Rights (CESCR) detailing the scope of these rights and the obligations placed on states for achieving their realisation. We discuss the relevant Comments in the following chapters. Although the right to food, clothing, housing, medical care, and necessary social services was embedded in the Article 25 of the UDHR, these rights were not officially ratified in the UK until it signed the International Covenant on Economic, Social, and Cultural Rights (ICESCR) in May of 1976,2 by which time the ‘golden age’ of social policy and welfare states was over. This timing helps to explain how human rights have come to be associated with neoliberalism, or market fundamentalism, which became the dominant political ideology in many Global Minority countries in the 1970s. This shift saw the retrenchment of the welfare state, moving it, and the associated human rights framing, from its 1940s ideals. Neoliberalism ‘defines freedom as choice in the market and asserts the creation and sustaining of markets as the primary value of politics’ (McKean, 2020). Neoliberal human rights approaches exclude concerns regarding equality, or social and economic rights, as ‘incompatible’ with a ‘free society’ (Hayek in Whyte, 2017) ‒ a distinct shift from the language of the Beveridge Report or UDHR. This framing of the role of the state has shifted the focus of government support from welfare state to competition state, where ‘social policy is subjugated to the needs of economic competitiveness’ (Horsfall and Hudson, 2017), or, in the words of Foucault (2008), ‘a state under the supervision of the market rather than a market supervised by the state’.

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A Watershed Moment

Neoliberalism emphasises individual responsibility over state responses and causes, identifies those ‘deserving’ and ‘undeserving’ of support, with the ‘deserving’ becoming an ever-​smaller group, and, as far as possible, reimagines the role of the state as facilitator rather than provider. It advocates minimal state spending on social interventions, arguing that the state is not suited to the role, and that the market, left to its own devices, will provide optimal solutions. As a result, neoliberal approaches remove regulations on businesses and cut social expenditure, regardless of costs this will incur elsewhere. Under this model, social assistance3 is restricted to only those most in need, utilising means-​ tested rather than contingent assistance, and applying strict conditions to receipt. In the words of Wacquant (2012), ‘this state practices laissez-​faire at the top, at the level of the circulation of capital and the production of inequality, but it turns interventionist and intrusive when it comes to managing the consequences of inequality at the bottom’. This approach was particularly evident in the UK following the 2008‒2010 global financial crisis (GFC), which saw spending on social assistance shrink dramatically through austerity-​driven reforms. While austerity served the neoliberal purpose of reframing the cause of the recession as excessive public spending rather than reckless banking practices, it is now clear that austerity does not lead to economic growth nor improve living standards (Walby, 2015). Instead, it resulted in a welfare state that provided nowhere near a minimum standard (see for example Jitendra et al, 2018) with financial support for working-​age households, that is, those most likely to lose jobs and income due to the pandemic, particularly hard-​hit (Cooper and Hills, 2021), fundamentally undermining the ability of individuals and the state to respond to any kind of crisis. Instead of state support, neoliberalism encourages community self-​reliance, framing social reproduction as solely the responsibility of individuals, families, and communities (Illner, 2020). Briefly, social reproduction is the continual social process of reconstructing labour power through the reproduction and maintenance of bodies that have the ability to labour, including such processes as childbirth, childrearing, provision of health and elder care, and education

Introduction

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(Bhattacharya, 2017; Federici, 2019). The caring work of disaster response is a form of social reproduction (Illner, 2020). Where communities successfully fend off disaster without state resources, they are patronisingly praised for their ‘resilience’, which frames survival as a moral virtue rather than a necessity driven by a failure of the state. Where communities are less successful in solving large-​scale structural problems without state support, they are critiqued as being fragmented and insufficiently self-​ reliant. Praising community-​ based action and voluntarism has been utilised as a moral safety valve, allowing neoliberal politicians to claim that a compassionate morality underlies their agenda of cutting social assistance (Poppendieck, 1999). As neoliberal icon Ronald Reagan explained in his first term as US President: The truth is we’ve let Government take away many things we once considered were really ours to do voluntarily out of the goodness of our hearts and a sense of community pride and neighborliness. I believe many of you want to do those things again, want to be involved if only someone will ask you or will offer the opportunity. Well, we intend to make that offer. (Quoted in Poppendieck, 1999, p. 92)

This call to action accompanied the establishment of a Presidential Task Force on Private Sector Initiatives and the President’s Volunteer Action Awards, as well as commissioning of a study on strategies to promote voluntarism. Taken together, this paved the way for social assistance cuts in the name of compassion, while also indicating that the work of social reproduction is best undertaken as an uncompensated community task, worthy of praise but not quite valuable enough to be remunerated. This framing offers a guilt-​ free, low-​calorie, neoliberal manifesto for decimating social assistance. As we argue throughout this book, cutting social spending in the name of helping communities to help themselves ‒ to become resilient, in neoliberal parlance ‒ has had disastrous consequences. The perceived association between neoliberalism and human rights, therefore, reflects the way that neoliberals have

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A Watershed Moment

co-​opted the language of human rights to justify reduced social assistance as freedom from state intervention, rather than reflecting any inherently neoliberal characteristics of human rights. As Birchall (2019) argues, ‘the needs of profit are transforming society by gutting the substance, if not the letter, of socio-​economic rights’. To better understand the link between human rights and the role of the state, as well as the flaws in the neoliberal framing of human rights, it is essential to understand that states are obliged under the UDHR to take progressive action to respect, protect, and fulfil human rights. Thus, it is insufficient for states simply to take no action that actively impedes human rights; proactive steps towards progressive realisation of rights are required. Human rights approaches require an active state.

The COVID-​19 pandemic in the UK: a challenge to the neoliberal consensus?

The COVID-​ 19 pandemic has presented stark challenges to the neoliberal consensus, acknowledged even by its most fervent followers. Notably, Conservative UK Prime Minister Boris Johnson felt compelled to acknowledge that ‘there really is such a thing as society’ (Johnson, 2020), contradicting the famous statement made decades earlier by Margaret Thatcher, the (Conservative) Prime Minister most associated with the shift to neoliberalism, that, ‘there’s no such thing as society. There are individual men and women and there are families. And no government can do anything except through people, and people must look after themselves first’ (The Guardian, 2013). The nature of COVID-​ 19 ‒ a contagious, airborne, respiratory disease ‒ has served to undermine the key tenets of neoliberalism. Individual choice and responsibility are obviously limited during a pandemic. People who are perceived as low risk may live or be in close contact with high-​risk people; individuals’ ability to avoid risk is highly dependent on the actions of others and of the state. The low levels of social support characteristic of neoliberalism have been implicitly acknowledged as problematic. Universal

Introduction

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Credit (UC), introduced in the Welfare Reform Act of 2012, is the main UK social assistance benefit which incorporates payments, where applicable, for unemployment, housing costs, income support, and child benefit, paid monthly. The (temporary) £20 per month increase to Universal Credit,4 and introduction of an 80 per cent furlough payment at up to £2,500 per month represents government recognition that (particularly unemployment) social assistance levels are too low, and therefore must be supplemented to avoid widespread catastrophe. However, the low levels of sick pay and exclusion of low-​income workers from sick pay have not been addressed and are thought to have contributed to poor adherence with self-​isolating guidelines, as people could not afford to miss work, potentially exacerbating the spread of COVID-​ 19 (Patel et al, 2021b, 2021a). Importantly, many of the people engaging with social assistance during the pandemic will view themselves, and be viewed by others, as ‘deserving’ of support. Whereas pre-​ pandemic discourses around unemployment or low income as individual failings were commonplace, during the pandemic people are facing loss of income and/​or employment because of something that is more obviously beyond their control ‒ a global health crisis.5 Despite changes designed to increase the support available because of the crisis, and the cushioning in place to protect new claimants from some of the harshest aspects of system (such as the benefit cap, which limits the amount of financial support a household can receive (Machin, 2021)), many are still struggling financially and are tackling the hurdles put in place designed to make support as unappealing as possible, undermining arguments that social assistance is overly generous and easily accessed (Summers et al, 2021). Indeed, it is thought that around half a million people eligible for support at the start of the pandemic did not apply, with many citing ‘hassle’ and ‘stigma’ as reasons for their decision (Geiger et al, 2021). The pandemic has highlighted a number of the stark contradictions inherent in neoliberal thinking (Kiely, 2018). Not long after being labelled ‘unskilled workers’ in relation to immigration rules because of their income level, numerous workers, including nurses and carers, have been labelled ‘key

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A Watershed Moment

workers’. These workers that have kept essential services running at a personal cost of increased risk of contracting COVID-​19. This greater risk of contracting COVID-​19 is one of the explanatory factors for the unequal impact of the pandemic. Despite early comments about COVID-​19 being some kind of equaliser, that ‘viruses don’t discriminate’, the impact of the pandemic has been starkly unequal. As with most challenges, it is the lowest paid and most marginalised6 (based on gender, ethnicity, or disability for example) that are hit hardest, and it is no coincidence that the groups targeted by neoliberal policy changes have been hardest hit by COVID-​19. The following chapters describe these unequal impacts in more detail. Another contradiction was willingness of the government to spend large sums of money. In contrast with derisive references to a ‘magic money tree’ in response to requests for increased social spending prior to the pandemic, and even reluctance to continue with the small increase to UC during the pandemic, large sums have been spent on deals with private contractors for services including ‘test and trace’ and for supplies including personal protective equipment (PPE). Many of these deals have raised eyebrows, due to issues including the limited track record of contractors, their links with politicians and advisers, and their poor performance (particularly test and trace). The contrast between the apparent low level of accountability expected of these private contractors and the high level of sanctioning and conditionality (introduced as part of neoliberal reforms) experienced by social assistance recipients is telling (Barr et al, 2016; Czauderna et al, 2021; Dwyer, 2018), reinforcing Wacquant’s (2012) point regarding neoliberalism as ‘laissez-​faire at the top … interventionist and intrusive … at the bottom’.

Our approach

In this book we make the case for abandoning the neoliberal approach to social policy and human rights. We focus primarily on the UK and US, and on the areas of health, food, housing, and technology. This reflects our research expertise

Introduction

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and the impact that neoliberalism has had on these areas as well as the significant role these policy areas have played in the COVID-​19 pandemic. However, these examples are presented as transferrable to other aspects of policy. We are not describing four separate problems, rather we are illustrating four examples of a single problem with a single cause ‒ the dominance of neoliberal ideology in policy making. Space limitations mean that we are not able to discuss many key concepts and topics in the detail they deserve, such as class and other sociodemographic inequalities, employment policy and the role of unions, the details of welfare state reform, or the role of the nation state in a globalised world, but this does not negate their importance. We draw on social reproduction theory (SRT) to contextualise the growing ideological dominance of neoliberalism over the last several decades, and to understand how the associated divestment in social institutions reflects a withdrawal of the state from social reproduction. Recent developments in SRT highlight that the work of reproducing capitalism through reconstituting labour power does not occur exclusively within family systems; it can be led by the state, markets, and/​or civil society, with fluctuation in which domain(s) provide this essential labour varying over time, and with the work itself unevenly distributed across the population (Bhattacharya, 2017; Illner, 2020). A ‘rapid response’ limits our ability to provide a comprehensive coverage of SRT and its value for explaining the rise of neoliberalism. Briefly, rooted in a critical refocusing of the field by feminist scholars and activists in the 1970s, we build from the insight that the labour of social reproduction has historically been falsely framed as naturally occurring in a kinship system external to the ‘productive’ sphere in which commodities are produced and traded, resulting in systematic devaluation of this labour (Bhattacharya, 2017; Federici, 2019; Illner, 2020). Social reproduction is vital for supporting the capitalist hegemony at the heart of our contemporary political economy, but exploitation of both waged and unwaged labour under capitalism erodes the conditions for social reproduction over time.

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A Watershed Moment

As Fraser (2017) summarises, ‘Destroying its own conditions of possibility, capital’s accumulation dynamic effectively eats its own tail’ (p. 24). She contends the ‘crisis of care’ ‒ the modern impossibility of balancing paid employment with myriad social roles outside the workplace ‒ is actually a crisis of social reproduction. Labelling this an ‘expression of the social-​ reproductive contradictions of financialized capitalism’ (p. 22), Fraser explains capitalism has undergone several iterations; this reconfiguration provides a pressure valve on the social contradictions created by the unrelenting, unsustainable accumulation of capital. The new configuration of financialised capitalism in the 1970s was rooted in the shift towards the trade of ‘fictitious capitals’ (McNally, cited in Illner, 2020, p. 45), supported rhetorically and politically by the rise of neoliberalism. Neoliberalism benefits those for whom the system is already working by promoting selective non-​intervention in a system which is purposely structured inequitably in order to generate profits. People who have been marginalised may become caught in a tautological cycle in which structural exclusion is identified as an individual moral failing, and this ‘moral failing’ is then used to justify structural exclusion and public neglect (Gans, 1994). Focusing specifically on poverty, Gans contends that marginalisation of the ‘undeserving’ serves many positive functions for better-​off members of society. For one, where labour needs wax and wane, the undeserving can be designated as ‘unskilled’ or having a ‘poor work ethic’, allowing their marginalisation to be deemed morally acceptable while also relieving pressure to address shortages of liveable work in the labour market, and in some cases allowing marginalised workers to be replaced by more exploitable workers who can be paid even lower wages (such as immigrants). Moreover, by existing as a potential reserve labour force, the undeserving can be used to motivate compliance from employees, as there is always the spectre of being replaced by these ‘hypothetical workers’. Meanwhile, undeservingness narratives assert that the poor are dangerous and/​or badly socialised, and so must be re-​ socialised and/​ or isolated from the rest of society, creating jobs for the deserving, such as social workers, prison guards, police officers, and psychiatrists.

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Another function of the undeserving poor is they can be blamed for social problems, which serves both to displace responsibility for solving social problems on a pragmatic level, and to provide a ‘cathartic object’ towards which social ire can be redirected (Gans, 1994). Importantly, though focusing primarily on the poor to illustrate the functions of marginalisation for more advantaged people, Gans also indicates that other forms of marginalisation perform similar functions, citing, for example, James Baldwin’s observations about how racist stereotypes about Black people also offer catharsis and displacement of responsibility for white Americans. In short, society can selectively discard and/​ or reform the undeserving, which serves to keep our highly inequitable system afloat. Neoliberalism’s utilisation of the (un)deservingness rhetoric also facilitates the marginalisation of already disadvantaged groups by advancing the idea that deserving people ‒ those who are sufficiently productive ‒ will (eventually) reap the benefits of economic growth once the fruits of free markets and fiscal responsibility have ripened. Moreover, it asserts that the deserving have been saddled with the responsibility of caring for the undeserving by funding state-​led social reproduction, and that deregulated markets and state withdrawal from social reproduction will free the deserving from the unfair burden of caring for ‘unproductive’ members of society. Perhaps most insidiously, neoliberal ideology is sufficiently ambiguous to allow people to self-​identify as belonging in the group that will reap the eventual rewards of economic growth, thereby eroding solidarity and community cohesion as any evidence of the violence and inequity of the system can be written off as a failing of personal responsibility. Rather than aimlessly waiting for the hazardous trajectories of amoral, deregulated markets to structure our social systems (the neoliberal approach), we suggest that in order to be equitable, just, and effective, systemic change should be goal oriented. The goal should be to ensure the dignity and welfare of all people, even where external hazards render this obligation a more challenging prospect. This ideological approach prioritises human well-​ being, explicitly asserting

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that social and economic systems must be structured to actively serve the realisation of human rights. In the chapters that follow, we explore several cross-​cutting themes: 1. The pandemic presents a watershed moment for social policy and human rights. COVID-​19 has highlighted and amplified the problems of the existing policy approach. Some social problems have become more widespread, moving them from problems experienced primarily by an ‘undeserving’ minority to problems experienced by large portions of the ‘deserving’ population. This expansion in first-​hand experience of the reality of the current system may make meaningful change more feasible. Similar progressive leaps forward have been made, for example after the Great Depression and WWII, which saw unprecedented improvements in quality of life, highlighting the real, practical value in taking progressive action in such watershed moments. However, this moment is also being used to further the neoliberal agenda, particularly through territorial grabs by global tech companies to further consolidate wealth through artificial intelligence and digital surveillance, making centring this opportunity on human rights all the more important. 2. The supremacy of the economic over the social and political is misplaced and unsustainable. Human rights are not achieved through the free market as neoliberal approaches insist. To paraphrase Raworth (2017), we have economies that need to grow whether or not they make us thrive; we need economies that make us thrive whether or not they grow. Any model which prioritises markets over people will be inadequate to safeguard well-​ being, and any economic system that does not safeguard well-​being raises questions about what the point of living within a society should be. Human rights, including social and economic rights, represent a state obligation to ensure a minimum standard for the population, to be achieved through fair and evidence-​ based social policies. We argue for a reprioritisation of

Introduction

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human dignity and social justice, placing the focus on provisioning for basic needs and moving away from failed market-​based solutions. 3. Technology and third sector action are not solutions to social problems and inequalities. They cannot fill the gaps left by the absence of the welfare state. The neoliberal model is built on a system of privatising gains while socialising risks ‒ a harmful and unsustainable approach. Blaming marginalised populations for their marginalisation, assuming technology will provide miracle solutions, and expecting charities to fill in the gaps is lazy, disingenuous, and ineffective. 4. While neoliberalism is associated with the retreat of government from social interventions, there remain areas where neoliberal governments are happy to intervene. We highlight the areas of action and inaction in policy to demonstrate the contradictions of this ideological approach, as well as demonstrate the priorities of neoliberalism and how they are at odds with a social policy and human rights approach that emphasises dignity and social justice. A key consequence of the neoliberal approach is, despite the ‘safety net’ system of social support that it advocates, neoliberal approaches also seek to reduce spending on those most in need, often through deservingness narratives. By contrast, spending which benefits the wealthy is encouraged. This reflects neoliberal lack of concern with inequality, often under the guise of ‘meritocracy’. 5. We reject the notion that the value of human life hinges on productivity, and in so doing we reject the fundamental tenet of capitalism, along with the current neoliberal ideology that has been developed to support capitalism’s relentless quest for profit above all else. Instead, we begin with the fundamental underlying assertion that human life has value in and of itself, independent of anything it may produce. We advocate for an approach to human rights and social policy rooted in the rights enumerated in the UDHR because this approach also begins with the underlying assumption that human life has value, full stop. That this

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assertion is politicised and controversial is a damning indictment of the prevailing neoliberal ideology, which asserts that economic winners have earned their spoils through their hard work and innovation, while anyone who isn’t prevailing in the current conditions must take responsibility for their failure to be a productive member of society. In the chapters that follow, we explore these themes by examining state failures to realise human rights both before and during the COVID-​19 pandemic, focusing on the rights to medical care, food, housing, and other necessary social services enumerated in Article 25 of the UDHR.

2 The right to medical care

The COVID-​19 pandemic is, first and foremost, a public health emergency. However, while the pandemic’s scale and the associated pace of illness and death merit labelling it an emergency, our use of this term does not imply that a large-​ scale infectious outbreak of this nature was unforeseeable nor impossible to plan for. Although political and popular rhetoric often frames emergencies (or disasters, crises, etc.) as unpredictable disruptions to otherwise well-​ functioning social systems and institutions, SRT challenges this framing (Illner, 2020). Instead, emergencies can best be understood as moments ‘in which natural crises, do not create, but rather expose ongoing social crises’ (Illner, 2020, p. 3). These social crises are the consequence of longstanding neglect and active erosion of structural support for social reproduction, involving processes of marginalisation and social divestment that leave systematically devalued members of the population disproportionately susceptible to natural crises. COVID-​19 is no exception:  Emerging evidence suggests that several governments (including the US and the UK) simulated flu-​ like pandemics and identified catastrophic gaps in the public health response well before the first cases of COVID-​19 were identified, but no action was taken to prepare, and in fact in some cases health systems were subjected to further cuts, leaving systematically devalued people at greatest risk of illness and death (Friedman, 2020; PHE, 2017; Scally et al, 2020). Neoliberal ideology favours private provision of health care and views spare capacity in the system as waste, leaving health systems exposed at times of increased demand. As a result, we are now witnessing severe distortion in the healthcare system of many countries as patients with serious conditions have their treatment slowed by the impacts of the pandemic. 15

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Problematic at any time, by causing a simultaneous health and employment crisis, the trajectory of COVID-​19 in the US has highlighted the flaws of linking health insurance to employment, while the private nature of US healthcare has meant reduced income for health services as capacity for more profitable medical procedures have been limited. Nor has the UK been immune to the damage caused by simultaneous health and employment crises; systematic privatisation of the NHS and neglect to compensate people adequately for lost income in cases where isolation is required has resulted in a catastrophic failure to limit the spread of disease ‒ a situation compounded by increased difficulties accessing food, poor housing conditions, and state investment in ineffective and unreliable methods for tracing the spread of COVID-​ 19. This chapter considers the vital link between the structure of different Global Minority country healthcare systems and will consider the extent to which the right to health is (un)fulfilled in current systems. Particular attention is given to how ideology has shaped the structuring of healthcare systems, and the impact on the people who work within and are served by these systems.

The right to the highest attainable standard of health

Article 25 of the UDHR specifies, among other things, the right to medical care to ensure an adequate standard of living. CESCR General Comment No. 14 (UN Economic and Social Council, 2000), ‘The Right to the Highest Attainable Standard of Health’, expands on this right. It describes health as ‘indispensable for the exercise of other human rights’ and emphasises that this right is ‘not confined to the right to health care’ but relates to all factors and conditions influencing health. Health is also included in the International Convention on the Elimination of All Forms of Racial Discrimination (1965), the Convention on the Elimination of All Forms of Discrimination against Women (1979), and the Convention on the Rights of the Child (1989). This recognition of the role of discrimination in health, both in terms of access to health services and the impact of discrimination generally on

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health, is highly relevant in the context of COVID-​19, which has disproportionately affected racially marginalised groups. Impacts on children have been subject to intense debate, not always with children’s best interests at heart. We use General Comment 14 (UN Economic and Social Council, 2000) as it reflects the ways in which understanding of health has developed since the writing of the UDHR. In particular, social epidemiology has advanced knowledge of the social determinants of health, highlighting that myriad social factors strongly impact our health risks across the lifecourse (Wilkinson and Marmot, 2003). Especially important is how socially structured systems of inequality (for example, race, ethnicity, social class, gender, disability) impact people’s ability to meet their basic health-​ related needs, including accessing medical care, food, housing, and other necessary social services. These social determinants have played a tremendously important role in the pandemic. While the UDHR remains useful for framing and understanding social policy and government responsibilities, Comment 14 reflects the importance of updating our operationalisation of human rights as research, and society more broadly, progress. Comment 14 specifies that the (non-​ exhaustive) essential elements of the right to health are:  availability, accessibility (consisting of non-​ discrimination, physical accessibility, economic accessibility, information accessibility), acceptability, and quality.

Health policy: the UK National Health Service

Health (or, in the language of the ‘5 Giant Evils’, disease) was at the heart of the Beveridge Report which proposed a comprehensive national service. On the 5th of July 1948, the UK1 National Health Service (NHS) was introduced, providing universal, comprehensive, and free health care, funded by taxation (Bloor, 1998). The Minister for Health at the time, Aneurin Bevan, described the introduction of the NHS as ‘the most civilised thing in the world ‒ put[ting] the welfare of the sick in front of every other consideration’ (quoted in Webster, 2002). Replacing a haphazard mix

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of provision (Webster, 2002), action was taken to actively encourage people to use the new NHS. Women and children, who were typically excluded from the prior healthcare service which focused on working-​class men, were disproportionately represented among new service users (Digby, 1998). The introduction of the NHS therefore revealed high levels of unmet need, with the number of prescriptions doubling between the end of the old system and third month of the NHS, with the increase due to the expanded coverage of health care and the ability of patients to pay for prescriptions becoming moot (Digby, 1998). The NHS has changed significantly since introduction, in many cases due to ostensible concerns regarding cost. Prescription, dental, and ophthalmology charges were introduced in the 1950s subject to exemptions (prescription charges were briefly abolished before being reinstated in the 1960s, with some specific exceptions). Scotland (in 2011), Wales (2007), and Northern Ireland (2010) have abolished prescription charges. Exemptions based on age and income are in place in England but leave many with long-​ term conditions to pay for prescriptions. Since their introduction charges have increased, in the case of prescription charges by ‘13-​fold between 1979 and 1997 in cash terms and over five times in real terms’ (Eversley, 2001). Charges for health services are encouraged by neoliberal organisations, such as the World Bank and International Monetary Fund (IMF), who argue they discourage excessive service use among other things. However, critics note that charges lead to unmet need, particularly among those with lower incomes. Moreover, as we discuss in greater detail later, fees for service do not necessarily discourage excessive service use across the board, and may even encourage unnecessary treatment. Charges for health services were often introduced/​increased for reasons well outside of the realm of health policy, not least economic posturing (Eversley, 2001). Concerns about the cost of the NHS are nothing new, having existed for as long as the NHS itself (Digby, 1998). Arguments against the NHS based on its ‘costliness’ are often made by those fundamentally opposed to a nationalised service. One infamous example is the pamphlet produced

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by a number of Conservative MPs, including former Health Secretary Jeremy Hunt, which argues (Carswell and Direct Democracy, 2005): ‘Our ambition should be to break down the barriers between private and public provision, in effect denationalising the provision of health care in Britain’ (see also ‘The Plan:  Twelve Months to Renew Britain’ which describes the NHS as ‘the national sickness service’). They also, in typical neoliberal fashion, argue in favour of the benefits of a market-​oriented system:  ‘Competition would drive up standards. It would produce better outcomes.’ These beliefs are reflected in the years of policy changes designed to open the NHS to for-​profit providers (briefly summarised in Hall et al, 2020, see also Exworthy and Mannion, 2016), but particularly in changes to the NHS (in England) since the election of the Conservative-​led coalition government in 2010 (Exworthy and Mannion, 2016). There is not space to cover the changes in detail here, but notably they required more and more NHS services to open to competitive tender, privatisation of procurement services, and removing limits on income from private patients in NHS hospitals, among other changes (Hall et al, 2020; Peedell, 2011). Issues relating to privatisation of the NHS were made clear during the COVID-​ 19 pandemic. One example was the deadly shortage of PPE, which is supplied through the privatised NHS Supply Chain, a complicated network of private providers. Particularly during the early stages of the pandemic, PPE levels failed to keep up with need, despite manufacturers (who were not part of the supply chain) contacting the government offering to help, and leading to the needless deaths of NHS staff (Hall et al, 2020). Lack of central management, the complexity of the system, and the failure of private contractors to meet their responsibilities all combined to worsen the effects of the pandemic ‒ a situation brought about through the commitment to an ideology which reveres privatisation. A further issue highlighted by the pandemic is the effect of ‘efficiency’ drives and reductions in capacity, which affect service provision at all times, but particularly during times of heightened pressure on the system. Reductions in capacity of care in the UK have seen the number of hospital beds per

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10,000 people decrease from 40.8 in 2000 to 24.6 in 2019 (WHO, n.d.). Attempts were made to expand capacity during the pandemic (for example Nightingale hospitals), but these efforts were hampered by staff shortages (Wise, 2021). The result of this lack of capacity has been a massive distortion in health care. Access to health care and treatments have been severely restricted because of lack of capacity during the pandemic, with NHS England waiting lists at ‘record highs’ (Triggle, 2021), the consequences of which will likely last for years for both individuals and the NHS itself. This undermines the ability of the NHS to meet the requirement for ‘timely access’ included in General Comment 14. One of the most damning consequences of lack of capacity during the pandemic was the discharging of older people from hospital into care homes without COVID-​19 testing, in order to free up hospital spaces (Daly, 2020; Devi et al, 2020). This callous act is a blatant example of how ‘unproductive’ people are devalued and discarded in our system of financialised capitalism. Likewise, the neglect of social care in England, which is not part of the NHS, is reflected in the severe effects the pandemic has had on social care settings, a likely explanatory factor in the appalling and disproportionate effect COVID-​ 19 has had on disabled people. Disabled people accounted for nearly 60 per cent of those who died of COVID-​19 in England between January and November 2020 (Ayoubkhani and Bosworth, 2021), with living in a care or communal setting being one explanatory factor in this higher risk of death (Heslop et al, 2020). Despite the challenges and criticisms the NHS has faced, it remains one of the most popular institutions in the UK.2 However this popularity, and the political promises to prioritise the NHS this inspires from politicians, has not protected the NHS from being ‘mismanaged, neglected, and starved of resources’ (Webster, 2002). Frequent denials regarding the privatisation of the NHS don’t always reflect the reality of policy changes (for example Peedell, 2011), especially given some politician’s overt support for private and for-​ profit systems. The next section explores some of the risks of such systems using the US as an example.

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The perils of private systems: examples from the US

Privatisation of the NHS and the associated shift to a fee-​ for-​service model represents a threat to the right to medical care in future for a multitude of reasons. Perhaps the most obvious threat is that fee-​for-​service healthcare is regressive; those with greater economic resources will have better access to care than those with fewer resources, meaning these services fail to ensure equal access to health care. Such social gradients represent a fundamental failure of states to fulfil the right to medical care enshrined in the UDHR and General Comment 14, but arguably indicate a successful profit-​driven system. Oncologist Otis Webb Brawley (Webb Brawley, and Goldberg, 2012) rejects the common assertion that disparities in healthcare access and health outcomes reflect a failure of the American healthcare system. Instead, he says, by providing healthcare only for those who can afford it, and not providing care for those who cannot afford it, the US healthcare system is doing precisely what it was designed to do:  extracting profits. This is reflected by the phenomenon of ‘Cadillac care’, in which those with greater economic resources are able to purchase more expensive healthcare and health insurance. These people are also typically healthier, resulting in people who are more profitable having access to premium care. In more general terms, market-​oriented systems such as that in the US accelerate the ‘inverse care law’, where availability of care is inversely related with need (Hart, 1971). The Affordable Care Act (ACA, also often called Obamacare), passed into law in 2010, aimed in principle to address some of the most glaring problems with the US healthcare system by improving the affordability of health insurance, expanding Medicaid (which provides publicly funded, means-​tested health coverage), and supporting the development of new models of care to facilitate cost-​saving (US Department of Health and Human Services, n.d.). Rather than all people enrolled through the ACA having access to plans that will equitably meet their needs, however, the idea that healthcare is a consumer product is still firmly embedded in this pseudo-​ public, half-​ measure option.3 Individual healthcare consumers can enter personal details (state of

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residence, age, etc.) and see a range of healthcare plans with associated costs and different levels of coverage. Not only does such a system of differential costs and coverage based on sociodemographics and economic means embed a social gradient in health directly into the ACA, but it also ignores the population health dynamics that shape healthcare costs for all people in the healthcare system. Ultimately, the notion that the ACA will be able to fully achieve its cost-​saving goals while significant numbers of Americans remain uninsured or underinsured is preposterous. This is because prevention is more cost-​effective but difficult to pursue due to gaps in coverage and, relatedly, because the high costs of delayed treatment, especially through the emergency care system, are paid for in part through inflated costs throughout the system (Webb Brawley and Goldberg, 2012). This situation vividly highlights the health risks and inefficiencies involved in a piecemeal, for-​profit healthcare system ‒ the US has by far the most expensive, yet one of the poorest performing, health systems in the OECD (OECD, 2019). A related but somewhat more subtle threat to the right to medical care imposed by a fee-​for-​service model is that, perversely, illness itself can be profitable. On the surface, this may seem overly cynical, or even paranoid; however, a brief look at a few examples evidences the veracity of this statement. For instance, in the US, free events in public spaces such as mini-​malls offer men complimentary prostate cancer screening under the narrative that early identification and, if needed, treatment, are vital for survival (Webb Brawley and Goldberg, 2012). Men who take up these free screenings have a follow-​ up consultation, where results of a prostate-​specific antigen (PSA) test are reviewed. Based on these tests, men may be advised to undergo surgery which, unlike the screening, is not complimentary. Webb Brawley contends that PSA tests are often badly misused to support recommendations of potentially unnecessary surgery, which carries with it common side effects of impotence and incontinence. In reality, early prostate cancer very often grows slowly and carries a low risk of spread, meaning regular check-​ups and an approach of regular monitoring without intervention is often best in terms of health outcomes. He links this unnecessary and

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harmful medical intervention to the disturbing revelation that the funders of these free screening programmes are Kimberly-​ Clark, the makers of Depend incontinence pads. In short, unnecessary and often harmful prostate surgery generates revenue. The profitability of illness under a privatised system is not limited to frontline medical care. For example, in 2015, former hedge fund manager Martin Shkreli gained notoriety by raising the cost of a life-​ saving drug (Daraprim) from USD$13.50 to $750 per tablet overnight (Pollack, 2015). This price hike was driven not by a sudden change in the manufacturing process, shortage of a key ingredient, or other supply issues, but rather reflected a broader trend in the pharmaceutical industry of generating profit by buying up older drugs and repricing them as ‘specialty drugs’. While Shkreli was ultimately imprisoned, his guilty verdict was based not on his role in this unconscionable price hike, but rather on his actions defrauding investors (Clifford and Moynihan, 2017). After all, generating revenue is the purpose of a for-​ profit company ‒ that Shkreli’s legal trouble was rooted not in making life-​ saving drugs financially inaccessible to the (marginalised) people who needed them, but rather in (potentially) costing investors money epitomises the problem with for-​profit medicine. Nationalised systems such as the NHS are less vulnerable to such risks regarding drug prices, as their scale improves their ability to negotiate prices with drug providers (subject to trade deals), and individual patients are better protected from the costs of pharmaceuticals (Sarnak et al, 2017). The opioid addiction crisis in the US offers a similar but even more deadly example of how the quest for profits causes harm and threatens human rights. As of December 2020, the death toll of the opioid crisis neared half a million people (Walters, 2020). Addiction itself is not a new phenomenon, nor one limited to the realm of prescription drugs. Part of what makes the opioid crisis a compelling example of how market-​ based medicine makes illness profitable, however, is the way that the well-​established addictive properties of opioids were downplayed through deceptive marketing (Keefe, 2017). Developed in 1995 by Purdue Pharma,

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OxyContin was actively marketed to doctors as a miracle pain relief drug through a campaign to dispel doctors’ concerns about the dangers involved in prescribing such potentially addictive drugs. This campaign included funding of research and direct payment to doctors to support false claims that addiction concerns were overstated and that the drug was, in fact, safe to prescribe. Although not all opioid prescriptions are OxyContin, and not all opioid addiction is directly linked to OxyContin, Purdue Pharma’s extensive efforts to mislead doctors and shift the narrative about addiction risks to promote prescriptions of OxyContin also opened the door to prescription of other opioids. This deception was a critical turning point in the opioid epidemic. The evidence suggests that Purdue Pharma, and the Sackler family which owns it, knew that their product was addictive, but went out of their way to portray otherwise in order to generate profit. And generate profit OxyContin did, to the tune of $35 billion in revenue for Purdue Pharma. Since their malfeasance has come to light, settlement of civil and criminal penalties is ongoing, but the Sacklers currently appear set to pay only a fraction of their wealth, leaving them with a net worth of around $9 billion (Spector, 2021). Although Purdue Pharma has declared bankruptcy, the Sacklers, who gained much of their wealth from the company (Keefe, 2017), appear to be financial winners from their role in the injury and deaths of hundreds of thousands of Americans, highlighting how potential penalties are worth the reward in a market-​oriented system ‒ particularly where a company front can offer some indemnity. In contrast to the profit potential for providers, health costs are a source of considerable financial hardship for people in need of health care, and can lead to bankruptcy (Himmelstein et al, 2019). The earlier examples of unnecessary and harmful practices also relate to a broader trend towards medicalisation ‒ the process through which human behaviours or conditions come to be defined and treated as medical problems ‒ which is arguably encouraged by the potential for profit inherent in privatised systems. Indeed, Conrad (2007) identifies the commodification of medical care and its subjection to market forces, including consumer demand, as one of the key drivers

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of medicalisation. The development of biotechnology, a second driver Conrad identifies, is also highly relevant, as pharmaceutical companies play an active role in identifying which human conditions are ‘treatable’ and, as we’ve seen with OxyContin, actively promoting the use of medical ‘solutions’. Our point is not that all medicalisation is inherently harmful, nor problematic. There are countless examples of medical progress and innovations in treatments and care that have improved health, saved lives, and reduced suffering. However, as unnecessary treatments highlight, medicalisation can also cause harm and erode health, particularly where the development and recommendation of treatments is undertaken to advance a profit motive. This is particularly important in terms of the expansion of technological health ‘solutions’.

The commodification of care, COVID-​19, and technological ‘solutions’

Artificial Intelligence (AI) was already making inroads into the health sector prior to the pandemic, if slowed somewhat by concerns relating to secure handling of sensitive health data (Korinek and Stiglitz, 2021). Invariably, the need for AI in health was justified on the basis of ‘an overburdened health system’ (a phrase so ubiquitous that we could cite any number of scholarly and news articles). This is a techno-​fix to a crisis created by austerity policies. Deep cuts to spending on public health infrastructure have left these systems unable to cope with demand, and in recognising this shortfall, governments have chosen not to repair these infrastructures with spending for additional doctors, nurses, technicians, and administrators; instead, they have opted to ‘optimise’ these infrastructures with AI that purports to speed up diagnosis and reduce patient waiting times. With the added strain of the pandemic, these patched infrastructures arrived at their inevitable breaking point. While this might have spurred large-​ scale reinvestment in the welfare state, for example through a series of public works programmes such as a new ‘Community Health Corps’ that simultaneously improved

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A Watershed Moment

delivery of health care while bolstering a struggling middle class through job creation in the public sphere (Klein, 2020a), the crisis was instead leveraged to justify a massive expenditure of supposedly scarce public funds on Health AI research and development, revealing an appetite for swift government action when beneficial to industry. In addition to being the means by which governments are able to continue limiting spend on jobs in the health sector, AI is poised to eliminate the jobs that currently exist for healthcare professionals, thus consolidating wealth for the select few who own technology and further increasing inequality (Korinek and Stiglitz, 2021). The inequalities arising from the introduction of AI into healthcare are not limited to income and wealth. AI is known for its tendency to carry and broadly spread human bias while appearing, and being proclaimed to be, objective. These biases can be enormously consequential in the myriad ways they solidify the influence of socioeconomic factors on outcomes for different individuals, increasing inequality between groups that have enjoyed historical advantage and those who have been actively disadvantaged. In the health space, bias can have deadly consequences for marginalised populations. As an example, AI is better at detecting melanoma on light skin than it is on dark skin ‒ a function of having been trained on a majority light-​skinned image dataset, the result being later detection of skin cancer and therefore higher mortality for darker-​skinned individuals (Noor, 2020). Many of the biases in AI systems originate in representation issues in the dataset, which themselves point to bigger picture socioeconomic inequalities ‒ for example, racialised and marginalised populations are more likely to face difficulties in accessing healthcare, and health tracking smartphone data excludes those with limited access to digital technology (Leslie et al, 2021). This is particularly problematic when, for instance, the under-​sampled group is disproportionately vulnerable to the disease in question (as for racially marginalised groups with respect to COVID-​19), as it would result in lower than necessary sensitivity for these groups (Leslie et al, 2021). Biases can enter at various stages in the AI development pipeline, beginning with privileging particular problems for resolutions (with those choices determined by people in

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dominant groups), and including issues related to problem definition, such as which quantifiable proxies are selected. All this is before getting to problems in data collection and algorithm training4 (Leslie et al, 2021). In a particularly instructive example, Obermeyer et al (2019) found that a widely used AI system for allocation of care resources on the basis of predicted risk was found to significantly under-​allocate these resources to Black patients: when comparing individuals receiving the same risk score, ‘Blacks have significantly more illness burden than Whites’. The reason the system ‘learned’ to allocate fewer resources to Black patients is because they already receive less spending on their medical care:  The AI relied on health care costs as a proxy for illness, and thus optimised for cost reduction in ways that are both revealing of underlying neoliberal logics and greatly disadvantaging to Black individuals. AIs have been developed at unprecedented speed to improve management of the COVID-​ 19 pandemic. That the rush is understandable does not render it unproblematic. There has already been evidence of bias in AI systems developed to identify at-​risk individuals, diagnose COVID-​19, and predict mortality from this disease. A recent systematic review rated all such models as having ‘high or unclear risk of bias’ (Wynants et al, 2020), with unclear risks stemming from lax adherence to existing AI reporting guidelines in the health sector. It is worth noting the immaturity of the field when it comes to explaining how machine learning (a subset of AI) systems arrive at their decisions, raising serious concerns about the applications of these technologies in safety critical or high-​risk domains; but these concerns have been pushed aside by the prospect of gaining some small advantage against COVID. There are reasons to be concerned that AI technologies being used to combat COVID-​19 are biased, further harming the very groups that are already bearing the brunt of this virus. ‘Every time a prediction model which has been tailored to the members of a dominant group is applied in a “one-​size-​fits-​ all” manner to a disadvantaged group, the model might yield suboptimal results and be harmful for disadvantaged people,’ say Leslie et al (2021)5. The longer-​term problem is that this pandemic is being used as a vast experiment in AI-​based

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healthcare, which if it takes root, entrenches an approach that threatens to widen inequality in ways that can be deadly to disadvantaged groups. The treatment of AI accountability as an unaffordable luxury when faced with a pressure to save lives is deeply worrying, as that threat is ever-​present in the health context and could be used broadly to deflect compliance with ethical standards. These standards were developed to protect individuals from discrimination, misuse of data, and intrusions on privacy. While these concerns may seem like a luxury to comparatively advantaged individuals, marginalised people have significantly more to lose from the erosion of these protections. We further discuss issues of racism in health care systems, and the unequal impact of the COVID-​ 19 pandemic, in what follows.

Health and social reproduction

Keeping the population of (current, future, potential) workers healthy to maximise productivity is a core function of social reproduction under capitalism (Bhattacharya, 2017). Much of the caring work that contributes to health and well-​ being is undertaken for free within homes and communities, disproportionately carried out by women whose social-​ reproductive labour is systematically devalued. Where formalised, remunerated health work takes place, inequalities in the broader political economy are mirrored in hospitals, care homes, and in-​home care, with women in general and racially marginalised and immigrant women in particular taking up some of the most underpaid, physically taxing, and dangerous frontline health work. Meanwhile, the structural inequities of racism and sexism in the broader social system shape working conditions, including not only daily stressors, but also restricting opportunities for career advancement out of the most difficult and dangerous work. This situation pre-​ dated COVID-​19 (Allan et al, 2004; Connor and Miller, 2014; Culley, 2008), but grim statistics about the mortality risks of healthcare workers during the pandemic have demonstrated just how high risk and inequitably distributed this work can be. The British Medical Association reports (BMA, 2021)

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that while 21 per cent of nursing staff in the UK are from racially marginalised groups, 64 per cent of nurses who died during the pandemic (to date) were from racially marginalised groups. Among medical staff, 44 per cent are from racially marginalised groups, compared to 95 per cent of the doctors who have died. The BMA identified inequalities in access to PPE, disproportionate employment in patient-​facing roles, and fewer workplace adjustments to mitigate COVID-​ 19 risks as potential contributing factors, but evidence on the full range of risk factors driving these trends is still forthcoming as the pandemic unfolds. In another illustrative example, while only 4 per cent of nursing staff in the US are Filipino, 31.5 per cent of nurses who have died during the pandemic were Filipino (Hunte and Berbey, 2021). One particularly salient factor which may be driving this hugely disproportionate risk of mortality among Filipino nurses is their concentration in critical care nursing. In the 1970s, social and economic conditions in the Philippines under dictator Ferdinand Marcos were extremely poor, and many people emigrated to seek opportunities abroad during this period (Choy, 2003). Recruiters actively sought emigrants to work in nursing in the US to fill gaps in the healthcare system left by upward occupational mobility of American women, for whom feminist activism had opened new professional opportunities. The migration route from the Philippines to the US was rooted in large part in the US’s self-​proclaimed process of ‘benevolent assimilation’, which framed US colonialism in the Philippines as a ‘friendship’ between the two countries. This also led to the establishment of American style nursing schools in the Philippines, providing a pool of English-​ speaking women—​ men were explicitly discouraged from pursuing this training—​who were trained to be able to work in American hospitals. Paired with skills-​ based immigration rules under the 1965 Immigration Act, this confluence of US foreign policy facilitated recruitment of nurses from the Philippines in the 1970s to fill the void in nursing left by American women, pushing many Filipino women into critical care nursing fields which are now considered the frontline in the COVID-​19 pandemic (Choy, 2003; Hunte and Berbey, 2021). This structural inequity

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may help to explain their increased risk of death during the pandemic. While much of the dialogue on the right to medical care focuses on patient access and outcomes, to not also apply the logic of non-​ discrimination embedded in the UDHR and subsequent human rights documents to the medical staff who provide this care is antithetical to the broader aim of fulfilling the highest attainable standard of health for all. The examples mentioned highlight how the inequities of social reproduction are embedded in the healthcare system, and how the consequences of these structured inequities can be deadly. These examples also vividly illustrate a crucial point in contemporary feminist SRT:  Marginalisation and the exploitation which it facilitates—​phenomena which are vital for accumulation and profit under capitalism—​structure inequalities not only within countries, but also between them, perpetuating well-​worn patterns of colonial exploitation in new guises (Bhattacharya, 2017; Fraser, 2017; Mohandesi and Teitelman, 2017). Fraser (2017) explains that since gender emancipation allied with marketisation under the new regime of financialised capitalism in the 1970s, a ‘care gap’ has resulted from more privileged women stepping back from the caring work of social reproduction. This work is often transferred to less privileged women: Typically, it is racialized and/​or rural women from poor regions who take on reproductive and caring labor previously performed by more privileged women. But to do this, the migrants must transfer their own familial and community responsibilities to other, still poorer caregivers, who must in turn do the same thing ‒ and on and on, in ever longer ‘global care chains’. (p. 34)

Framing the increased risk of mortality among racially marginalised people during the pandemic as a ‘crisis’ obfuscates the longstanding processes of marginalisation that have directly caused these inequities by implying that inequities are short term and unique to the current situation. As the examples mentioned demonstrate, the erosion of the

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conditions for social reproduction in many Global Majority countries is accelerated through the exploitative practices of Global Minority countries. This increases the likelihood that migration to Global Minority countries will be appealing to migrants, simultaneously causing harm in Global Majority countries while providing a labour reserve for Global Minority countries. The value of applying an international human rights framework is twofold in this context:  first, protections embedded in these covenants explicitly apply not only to citizens, but to all under a state’s jurisdiction, meaning migrant labourers have the same right to safe, healthy, and non-​ discriminatory working environments (in the healthcare system and beyond) as any state citizen. Second, an international framework is structurally better suited to address the transnational processes of exploitation that underpin some of the most egregious inequities and acts of structural violence embedded in our current system. In the current moment, this also speaks to the need to think internationally and collaboratively about ensuring access to medical supplies and vaccines, particularly given, for example, the severity of the COVID-​19 pandemic in India at the time of writing (Roy, 2021).

Safeguarding future health

The UK and US have significantly different health systems, but both have been among the poorest performers during the pandemic, suffering high infection and death rates. Neoliberal approaches to health undermine the ability of countries to meet the health needs of their populations at the best of times, evidenced by the link between austerity spending cuts and declining life expectancy in England and Wales (Hiam et al, 2018). During the pandemic its emphasis on the economic over the political and social has had devastating consequences. Resistance to life-​saving lockdowns have come from neoliberal voices, who have co-​ opted the language of social determinants of health to justify opening up the economy before it is safe. There are undoubtably significant consequences of lockdowns, potentially including increased

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risk of mental distress and intimate partner violence (Piquero et al, 2021); however, these risks, driven in part by pre-​ COVID-​ 19 cuts to social spending, merit direct, additive attention (Rose et al, 2020). Framing resolution of such risks as an either/​or to weigh against risks of continued spread and mutation(s) of COVID-​19 is a false dichotomy. Moreover, governmental insistence on sending children in England back to school during an ongoing pandemic, sometimes for a single day before again closing schools, runs counter to the inclusion of health in the Convention on the Rights of the Child. While children are thought to be less at risk from COVID-​19, low risk is not equivalent to no risk. There is evidence of significant complications among some children such as severe inflammatory syndromes and ‘Long COVID’ (Chew-​ Graham, Lokugamage, and Simpson, 2021). Children’s health shouldn’t be gambled in order to ‘help’ parents back to work for the government’s benefit. Effects on children are important in their own right, but may also have increased exposure amongst other household members, including those who are at high risk and shielding. There have, however, been some positives during the pandemic which can be built on going forward. Access to abortion in England improved, with consultations becoming available via telemedicine, and the success of this policy may be extended beyond the pandemic (Aiken et al, 2021). Arguments against charges for healthcare (for example Eversley, 2001) were implicitly recognised by neoliberal governments, notably the US, in not charging for the COVID-​19 vaccine. The idea that a profit motive is necessary for the development of medicines is proved false by Professor Jonas Salk (who famously refused to patent the Polio vaccine) and Professor Nicola Curtin (who donated royalties from her ovarian cancer treatment to a non-​profit), among others. Conversely, the ability of the Sacklers to profit from human suffering highlights the dangers of a profit motive. A further stark example of how profit distorts development and distribution of medications is provided by Goldman Sachs analysts asking ‘Is curing patients a sustainable business model?’ (Kim, 2018).

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The right to health applies to health (and social) care workers too, and economically motivated neoliberal cuts to social spending, as well as outsourcing, have eroded their working conditions. NHS England staff salaries have significantly decreased (by up to 32 per cent) in real terms since 2010 (London Economics, 2021), and many facilities have been chronically short-​staffed. The COVID-​19 pandemic has had a devastating impact, causing significant mental distress (Alexander, 2021) and threatening their physical health. Medical and social care staff must be fairly renumerated for their work, and their health and safety must be reprioritised. This is both the morally correct thing to do, and the practical thing to do in light of pre-​existing staff shortages. The pandemic has highlighted the importance of a well-​ funded, well-​supported health system. We aim for a return to a health system that Bevan described as ‘civilised’ ‒ that cares about ensuring the health and well-​being of people. If, as the famous statement by Virchow argues ‘Medicine is a social science, and politics nothing but medicine at a larger scale’, then we must conclude that neoliberal politics is bad medicine.

3 The right to food

The right to food is a key right enshrined in Article 25 of the UDHR. Unarguably, food is a basic need for human health and survival. However, the significance of food extends well beyond this; it is essential for ensuring that people can live with dignity, and is intimately linked to the fulfilment of other important human rights. This reality is well-​captured in CESCR General Comment 12, which clarifies: the right to adequate food is indivisibly linked to the inherent dignity of the human person and is indispensable for the fulfilment of other human rights enshrined in the International Bill of Human Rights. It is also inseparable from social justice, requiring the adoption of appropriate economic, environmental and social policies, at both the national and international levels, oriented to the eradication of poverty and the fulfilment of all human rights for all. (UN Economic and Social Council, 1999 p. 2)

The Comment emphasises the right to food is not simply a matter of meeting minimum caloric needs; food must be healthy, safe, diverse, and culturally acceptable. Meeting these requirements must be sustained over time; sporadic access to food does not adequately fulfil this right. Accessibility includes not only physical but also economic access to food. ICESCR signatory states ‒ the UK included ‒ have signalled their commitment to these principles. As with other human rights, states have a legal obligation to respect, protect, and fulfil the right to food, including through implementation of social programmes which directly and/​or indirectly facilitate access. While realisation of the right to food is expected to 35

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be progressive, Comment 12 recognises that pragmatic constraints may impede progress. One might argue, then, that the social and economic barriers to accessing food in the UK since food systems and livelihoods were disrupted by COVID-​19 do not represent a failure of the state to meet the right to food. However, the recognition of pragmatic challenges articulated in Comment 12 does not negate states’ obligations, ‘even in times of natural or other disasters’ (UN Economic and Social Council, 1999 p. 3). This continued obligation in the face of crisis is essential in part because the need for food does not cease simply because there is a crisis ‒ indeed, the need for assistance to access an adequate supply of food often increases during a crisis, as demonstrated by the meteoric rise in food parcel distribution through food banks in the UK during COVID-​19 (IFAN, 2020; The Trussell Trust, 2021a). Even more fundamentally, to suspend states’ obligations during periods of crisis would in effect excuse state failures leading up to the crisis. It is preposterous to suggest that states should be released from their obligation to meet needs at a critical juncture because they have failed to do so in the period leading up to the juncture. Comment 12 specifies that not only physical barriers, but also social and economic barriers to the realisation of the right to food must be addressed by the state. This emphasis on reviewing and, where needed, revising social and economic systems to serve human welfare is consistent with Illner’s (2020) call for systemic change, implying by extension that a human rights framework may decrease the frequency and magnitude of disasters because of its ability to redress marginalisation and restructure social systems to better serve human well-​ being. By contrast, the prevailing neoliberal ideology frames crises as resulting from fiscal irresponsibility of the state, and encourages retrenchment of the welfare state under the disingenuous assumption that deregulation of markets will stimulate economic growth (Walby, 2015). In turn, economic growth is seen as the panacea for poverty and its sequelae, and those who are left behind are seen as lazy, needy ‘scroungers’ who aren’t deserving of support because their hardship is deemed to be rooted in their personal

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inability to reap the benefits of economic growth (Garthwaite, 2016; Purdam, Garratt, and Esmail, 2016). Although the UK has ratified the ICESCR, committing to upholding the right to food, this commitment is irreconcilable with neoliberal ideology, which prioritises profits and passes moral judgement on those who produce but do not benefit from those profits. Food insecurity is a direct and growing challenge to the realisation of the right to food. As a phenomenon, it offers a useful lens for understanding how the state has failed to fulfil the right to food to date, and how individualising risk ensures that the right to food will remain unrealised in future.

Food insecurity in the UK

The term food insecurity1 refers to a complex, multidimensional phenomenon in which people are not able to consistently get enough safe and nutritious food to sustain a healthy life (FAO et al, 2020). This could include, for example, not having food available to purchase locally; facing economic barriers to affording available food; being unable to find appropriate food; and having sporadic access to food. Operating on a continuum, mild food insecurity involving worries or anxieties about accessing food, while moderate to severe forms involve eating less diverse or poor-​quality food, skipping meals, or even going without altogether for a period of time. It is associated with a range of far-​reaching negative outcomes, including malnutrition, difficulties managing chronic diseases, stigmatisation and feelings of shame, fatigue, mental distress, diminished cognition and poorer learning outcomes for school-​aged children, and social exclusion (Burke et al, 2016; Garthwaite, 2016; Lambie-​Mumford, 2017; Loopstra, 2018; Martinez et al, 2018; Purdam, Garratt, and Esmail, 2016; Seligman and Schillinger, 2010). The deleterious impacts of food insecurity highlight the central importance of food for health and well-​being broadly defined. Food insecurity is not a new phenomenon. Rather, it reflects longstanding state inaction towards fulfilment of the right to food. Research on Global Minority countries has documented the disproportionate risk of food insecurity faced by

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marginalised populations, including pensioners, low-​income households, people with nonstandard employment, racially marginalised people, and people with disabilities (Brucker and Coleman-​ Jensen, 2017; Garratt, 2019; Garthwaite, 2016; Lambie-​ Mumford, 2017; Loopstra, Reeves, and Tarasuk, 2019b). Prior to COVID-​19, estimates for England, Wales, and Northern Ireland suggested around 20 per cent of adults experienced food insecurity (Loopstra, 2020). Some food insecure people ‒ around 10 per cent of adults ‒ reported more severe forms, such as skipping meals, with roughly 4 per cent of adults going without food altogether for a time. COVID-​19 has certainly aggravated the situation, with the number of food insecure adults quadrupling during the initial weeks of the first national lockdown. However, though it has received substantial attention2 as a pressing concern during the COVID-​ 19 pandemic, these pre-​ pandemic statistics highlight that a large minority of the population was unable to realise their right to food well before COVID-​19. A key challenge for monitoring food insecurity in the UK has been the lack of food insecurity measures in large-​scale population data. While Comment 12 requires that states actively monitor their progress towards fulfilment of the right to food (UN Economic and Social Council, 1999), the Food and You survey for England, Wales, and Northern Ireland only began including a food insecurity module in its data collection in 2016 (ENUF, 2019). More recently, the UK Government Department for Work and Pensions (DWP) included a food insecurity module in their Family Resources Survey (FRS) beginning in 2019, providing large-​scale population data for all four UK nations for the first time. Though there are few data points so far due to the recency of the data collection, the direct measurement of food insecurity in large-​scale data is a useful step for monitoring progress towards fulfilment of the right to food. Prior to these welcome developments, much of the work on food insecurity in the UK utilised data on food bank use as a very rough proxy. As researchers working with these data repeatedly warned, however, food bank usage is not a suitable measure of food insecurity. Food bank data tend to underestimate food insecurity, in large part because many food insecure people are prevented from accessing food

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banks due to social barriers, such as stigma and shame, and structural barriers, such as limited opening hours, geographic inaccessibility, and requirements that users receive a voucher from a referring agency to access services (Garthwaite, 2016; Lambie-​Mumford, 2017; Loopstra, Lambie-​Mumford, and Fledderjohann, 2019a). That food bank data tend to underestimate food insecurity, however, made research on the staggering increase in food parcel distribution over the past decade all the more worrying. The UK’s largest food bank network, the Trussell Trust (2014), reported an increase in food parcel distribution from 61,468 parcels in the 2010‒2011 fiscal year to 913,138 in 2013‒2014. This increase in distribution was coupled with an operational expansion from covering 29 local authorities in 2009‒2010 to covering 251 local authorities by 2013‒2014 (Loopstra et al, 2015). While some commentators dismissed rising rates of food bank use as stemming from their increasing availability rather than from an increase in food insecurity, a wealth of qualitative and quantitative research provided robust counterevidence that rising food bank use was being driven by increased need (Garthwaite, 2016; Lambie-​ Mumford, 2017; Loopstra et al, 2015, 2018). Recently available large-​scale survey data have also confirmed the rise in food insecurity in the UK, particularly since 2010, coinciding with rising food bank use (Loopstra, Reeves, and Tarasuk, 2019b). Taken together, the available data show that food insecurity was a pressing social problem in the UK prior to COVID-​19, and that COVID-​19 has compounded an already worrying situation. Not only is food insecurity an important concern in its own right, but it also threatens to raise costs and decrease efficiency of state-​run systems. For example, where healthcare provision is state-​ operated, the increased health costs for management of complications (for example, treatment of malnutrition) attributable to food insecurity (Berkowitz et al, 2018; Tarasuk et al, 2015) are problematic, but preventable through realisation of the right to food. The neoliberal approach claims that cost-​ cutting on social spending and deregulation of markets will lead to economic growth and a better standard of living for all ‒ or at least for all who are

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sufficiently productive. Increased healthcare costs due to erosion of living conditions, however, challenge the notion of savings through spending cuts. Neoliberalism offers an easy fix for this conundrum ‒ while preventable illness is an inefficient drain on state-​run systems, it is an opportunity for profit in private systems. Cuts to social assistance necessary for fulfilling human rights are thus justified in the name of economic growth. Despite the CESCR’s explicit assertion that, in order to progressively fulfil the right to food, equitable economic, environmental, and social policies should be implemented, the UK government’s programme of austerity following the GFC has instead retrenched such policies en masse. Scholars have sounded the alarm about how food insecurity and rising food bank use are closely tied to inadequate social protection and regressive reforms, including problems caused by administrative delays, introduction of conditionalities, and abrogation of extant provisioning (Garthwaite, 2016; Lambie-​Mumford, 2017; Loopstra et al, 2015, 2018). These cuts have impacted marginalised populations particularly strongly (Garratt, 2019; Garthwaite, 2016; Lambie-​ Mumford, 2017; Loopstra et al, 2018, 2019b). Recently released statistics from the national FRS corroborate many of these inequities identified in the literature. The FRS data likely underestimate food insecurity because they focus on a 30-​day (rather than 12-​month) reporting window (ENUF, 2019). Nonetheless, these are a novel and important source of population-​level statistics on food insecurity. Collected for the first time for financial year 2019‒2020 (pre-​COVID-​19 only; data collection was suspended from March 2020), FRS data show that 6 per cent of households experienced mild food insecurity, and an additional 8 per cent of reported changes to their diets such as reduced quality or quantity of food due to lack of resources (DWP, 2021). Focusing on moderate to severe food insecurity hereafter, disaggregating these statistics by household type provides stark evidence of inequalities. Prevalence was highest among households with one adult and three or more children, with 41 per cent reporting moderate or severe food insecurity. Fewer than half (45 per cent) reported being food secure. These

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families are particularly vulnerable because of the removal of child benefit after the second child and the disproportionate effect of the benefit cap on single-​parent households. In fact, lone-​ adult households with children reported the highest levels of food insecurity across the board, with 28 per cent of households with two children and 26 per cent of those with one child reporting food insecurity. Households with one or more unemployed working-​age adults had the next highest levels, with one-​quarter reporting insecurity. Among households with one or more disabled working-​age adults, nearly one in five (19 per cent) reported food insecurity. The data also show stark inequalities by ethnicity: food insecurity was substantially lower in households with a Pakistani (5 per cent), white (7 per cent), Indian (8 per cent), or other Asian background head (8 per cent) compared to households with a Black/​African/​Caribbean/​Black British (19 per cent) or other ethnic group (14 per cent) head. The survey also collected data on state support households received. It is not possible to assess causality from the descriptive statistics provided from DWP. Nonetheless, the figures are suggestive of the inadequacy of paltry income-​ related programmes for helping households meet their basic needs:  Among households on income-​related programmes, one-​ quarter were food insecure. Particularly egregious is that 43 per cent of households receiving UC reported food insecurity. Households receiving Jobseeker’s Allowance and Income Support also reported very high prevalence, at 37 per cent and 36 per cent respectively. While limited in their explanatory power, the initial descriptive statistics from DWP are consistent with extant evidence that income-​ related support programmes are inadequate (Garthwaite, 2016; Lambie-​ Mumford, 2017; Loopstra et al, 2018). Clearly, food insecurity was a pressing social problem before the pandemic. Unfortunately, emerging evidence suggests that increased income precarity and weaknesses in the food system throughout the pandemic moved the UK even further from realising the right to food.

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Meeting needs and making trade-​offs

The phrase ‘food system’ refers to the wide range of elements and actors involved in producing and consuming food, including not only macro-​level elements such as ecological, trade, processing, and distribution systems, but also micro-​ level elements such as food preferences and household resources (Nguyen, 2018). Examining food systems in detail is beyond the scope of this book. However, a key point is the full set of elements and actors involved in food systems are closely, reciprocally interconnected; changes in one area of the food system can have sometimes large-​scale impacts on other areas. This is vividly illustrated by the climate crisis, which has negatively impacted crop yields, river levels, drought, coastal erosion, and other agricultural predictors of food supplies, increasing the risk of food insecurity globally (FAO et al, 2020). As the supply of fresh, nutritious foods diminishes, diets shift towards highly processed and animal source foods, leading to an increase in greenhouse gas emissions and a compounding of the climate crisis. Responsible and proactive state policies which facilitate not only sustainable agricultural practices, but also greener practices in other interconnected arenas, such as energy and transportation, are urgently needed to realise the right to food. Social assistance policies are a vital buffer against rising food prices, unemployment, and other threats to the right to food (Reeves, Loopstra, and Stuckler, 2017), but will be ineffective unless paired with a broader, holistic focus on stemming the tide of the climate crisis and developing sustainable food systems (The Lancet Planetary Health, 2019). This is not only because of the impacts of climate change on our ability to produce food from an agricultural standpoint, but also because, as COVID-​19 has demonstrated, food systems are at risk when the people who produce and transport our food face public health emergencies. COVID-​19 is only one of many health threats traced to the unrelenting environmental violence that is a hallmark of our global food system; human disruption of ecosystems through our land use and subjugation of animals have left humanity highly susceptible to zoonotic pathogen spillover (Plowright et al, 2021). The public health

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threats arising from anthropogenic land use offers a salient example of how ‘natural’ crises are caused by the additive harms inflicted by our social systems over time. COVID-​19 has demonstrated how crises can compound food system weaknesses and increase food insecurity. Potential and actual problems in the food system were identified early on in the pandemic, including rising food prices, stockpiling, food shortages, disruptions in grocery delivery service, closures at food processing plants, long queues in supermarkets, and sparsely stocked shelves (Power et al, 2020; Swanson, 2020). While many food items remained reasonably available, changing consumption patterns, such as increased home baking, did result in some item-​specific shortages (FAO, 2020; Power et al, 2020; Swanson, 2020), highlighting the reciprocal links between macro-​ level and micro-​level processes in the food system. As infection rates soared and national lockdowns and migration restrictions were instituted in many countries in spring 2020, the extent to which agriculture as an industry is reliant on both migrant labour and the free movement of goods became another emerging threat to supply chains with links to food insecurity (Carroll et al, 2020). Food bank use has skyrocketed since the start of the pandemic. The most recent figures from the Trussell Trust show a rise to 1.2 million food parcels distributed in April‒ September 2020 alone, up from 843,655 in the comparable six-​month period in 2019 and nearly double the 658,048 distributed in the comparable period for 2018 (The Trussell Trust, 2021b). Similarly, the Independent Food Aid Network (IFAN) reported a rise from 168,560 parcels distributed between February‒November 2019 to 354,613 parcels between February‒November 2020 (IFAN, 2020). At the same time, social distancing, staffing shortages, and a reduction in donations left food banks struggling with the logistics of providing for rapidly increasing demand, with many unable to fully keep pace with need (Power et al, 2020). The rise in food bank use corresponds with a rise in the prevalence of food insecurity:  Early estimates suggest food insecurity quadrupled during the first UK lockdown (Loopstra, 2020). These figures could be read as supporting early concerns

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about supply chain issues. Among households reporting food insecurity during the first lockdown, however, only 40 per cent identified a lack of food available for purchase in shops as the only reason for their food insecurity (Loopstra, 2020). Around 16 per cent identified solely economic reasons, 16 per cent identified isolation only, and the remaining households identified a combination of these or some other factors as pushing them into food insecurity. Taken together, these data highlight that supply chain issues have had an impact, but other social and economic factors are also important drivers of food insecurity. Beyond supply chain issues, mass layoffs and loss of income for many households during the pandemic raised questions about how households would afford food (FAO, 2020). Early polling data found that three-​fi fths of UK households reported financial hardship associated with lockdown, and one-​in-​five faced a choice between purchasing food or paying the rent and other bills (Gayle, 2020). Meanwhile, sudden and extended school closures left households which usually rely on school meal programmes to provide healthy and nutritious meals for children under a sudden strain, often while also facing an income shock (FAO, 2020). Early in the pandemic, some schools delivered food parcels to pupils in Free School meal programmes, alongside provision by the Department of Education of vouchers for £15 per week per child to qualifying families. Unfortunately, efficacy was limited due to delivery delays in the first several weeks of such programmes, restrictions on vouchers to specific supermarket chains, and lack of central coordination, as individual schools were left to meet students’ needs (Power et al, 2020; The Food Foundation, 2020). Moreover, the government’s emergency food parcel distribution to school children and individuals who were shielding was contracted out to commercial enterprises, with low-​quality parcels at a high cost offering a vivid example of how neoliberal market-​based solutions can generate profit from human suffering (Batchelor, 2021; Butler, Lawrence, and Proctor, 2020). Rather than disrupting a well-​ functioning system, COVID-​19 has added another stressor to an already failing, inequitable system. As Illner (2020) asserts, disasters highlight

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how the existing systems of inequity have created longstanding everyday crises for marginalised people. Marginalised people struggling to access fresh, nutritious food due to geospatial inequities in the food system ‒ inequities that shape the food environments in which people live and work ‒ have been well-​documented long before the pandemic (Burgoine and Monsivais, 2013; Vonthron, Perrin, and Soulard, 2020). School holiday hunger, in which children experience food insecurity during school holidays because they are unable to access school meals, is also a longstanding problem (Graham et al, 2018). Layoffs and other household financial shocks are long-​understood as a driver of food insecurity, and are often reported by food bank users as a key reason for visiting a food bank (Garthwaite, 2016; Lambie-​Mumford, 2017). These examples demonstrate that our food system is not independent of our political economy; even if food could be made physically available to all people at all times through a perfectly functioning supply chain, the access dimension of food insecurity will always be problematic where some people are systematically devalued and their access to basic necessities, including food, is restricted. The clarification in Comment 12 that equitable economic, environmental, and social policies must be implemented to realise the right to food is therefore vital. As evidence on the reasons for food bank use during the pandemic suggest, existing socioeconomic and sociodemographic inequalities, spurred on by austerity and justified through neoliberal ideology, have long restricted access to society’s basic resources for marginalised people. Poverty is a particularly strong driver of food insecurity. Low income directly limits people’s ability to afford not only enough safe and nutritious food, but also a variety of necessary social services. As a result, many impoverished households and individuals face difficult decisions about how to prioritise resources to meet their basic needs. As food budgets are often the most flexible components of household budgets, cutting food spending is sometimes the most feasible of a series of bad options for households trying to survive (Poppendieck, 1999). Put differently, several fundamental human rights, including the right to food, are placed in competition with one another through the neoliberal state’s failure to fulfil the human

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rights of individuals in its jurisdiction. This is epitomised by the heat-​or-​eat phenomenon, in which households struggle to afford energy costs, particularly during cold spells, and must decide whether to live in a sometimes dangerously cold home or to make dietary sacrifices to afford heating (Beatty, Blow, and Crossley, 2014; Garthwaite, 2016). Many households also compromise on the quality of housing itself due to issues with affordability (Clair et al, 2019a). This situation can compound food insecurity, as lack of adequate cooking facilities makes the preparation of nutritious meals more challenging, leading some food banks to offer kettle parcels that prioritise processed foods that can be prepared with limited cooking facilities (Garthwaite, 2016). Another example of the trade-​offs households may face is the treat-​ or-​ eat dilemma, in which competing demands for limited household resources may prompt postponement of medical care and/​ or limited adherence to prescribed regimens to free up resources for purchasing food (Berkowitz et al, 2018; Seligman and Schillinger, 2010). The availability of public healthcare through the NHS would seem to render trade-​offs between medical care and other basic necessities a moot point in the UK. The reality, however, is more complex. Take medically necessary surgery as one example. As adequate nutrition is an important part of recovery, NHS doctors may provide nutritional advice or refer patients to a dietician. For a food insecure person, that nutritional advice may be entirely out of reach (Garthwaite, Collins, and Bambra, 2015). Moreover, with the recent rise of zero-​hour/​casual employment contracts, tenuous employment is a key driver of food insecurity and food bank use (Garthwaite, 2016). For people struggling to budget with unsteady income and worried about consequences of absence in a precarious and often punitive employment situation, taking time off for recovery may simply be infeasible. As Farmer (2004) argues, patients cannot follow medical recommendations without the basic means to do so. He asserts that medical professionals must resist the urge to attribute non-​adherence to regimens as a personal failing of the patient; instead, non-​adherence should be understood and addressed in terms of structural barriers.

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Providing for one basic need while ignoring others promises limited success at best. The salience of trade-​offs between medical care and other basic needs in the context of inadequate social assistance in the UK is devastatingly illustrated by David Clapson’s infamous and entirely preventable death in 2014. Clapson was a diabetic whose jobseeker’s allowance ‒ a meagre £71.70 per week ‒ had been withdrawn after he missed a single jobcentre meeting (Ryan, 2014). Found in a home with bare cupboards, Clapson had no food in his stomach and, without sufficient funds to keep his electricity running, had no way to keep his insulin refrigerated as required. Clapson’s cause of death was diabetic ketoacidosis (severe lack of insulin). The availability of medical care through the NHS was insufficient to meet Clapson’s healthcare needs because he was forced into making impossible trade-​offs between his basic needs; his right to food and to adequate housing went unfilled, leaving him unable to adhere to a medical regimen, with fatal consequences. That people still face such trade-​offs despite the availability of universal healthcare highlights just how ultimately untenable state systems which neglect to meet the full range of basic needs are; failing to fulfil human rights in one domain can have knock-​on effects for other rights.

Can’t charities fill the gap?

In the absence of adequate social assistance at the state level, many communities have responded to hunger through charities. Charitable food aid includes a range of civil-​society-​ led provisioning in the short term, such as food banks,3 which distribute food for people to take away, very often supplying only a few days’ worth of food; soup kitchens and soup-​runs, which provide a free or steeply discounted prepared meal; and food rescue/​redistribution programmes, which locate food that would otherwise go to waste and redistribute the food to people in need. The operation of food charities as national, large-​scale institutions is a recent development in the UK: the largest foodbank network, The Trussell Trust Foodbank Network, was established as a national franchise operation in 2004, while IFAN was founded in 2016. FareShare, the

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main food redistribution charity, was also established as an independent charity in 2014. Food charity is often rhetorically upheld as a laudable example of communities working to meet their own needs (Garthwaite, 2016; Poppendieck, 1999), and on the surface communities assessing and then meeting local needs sounds like the often-​ praised phenomenon of ‘resilience’. However, charitable provisioning is incompatible with the aim of achieving the right to food for two key reasons: first, charitable responses are unable to meet need and fully address food insecurity in the long term. Second, charitable food aid ‒ and indeed ‘resilience’ more broadly ‒ provides a pressure valve on a state system which is failing to provide for human rights, leaving systemically marginalised communities to resolve systemic problems that they did not create while simultaneously reducing the pressure for much-​ needed systemic change. The inability of charities to address food insecurity in the long term has been well-​documented by sociologist Janet Poppendieck (1999). Tracing the growth, structure, and on-​the-​ground functioning of food banks in the US, Poppendieck identified ‘7 deadly “ins”’ of charitable food aid:  insufficiency, nutritional inadequacy, instability, inaccessibility, inefficiency, inappropriateness, and indignity. Insufficiency refers to the fact that providers struggle to consistently provide ‘enough’ food for people who access their services. In part, this is because it is difficult to accurately estimate how many people may be in need in a given day, and in part because social factors such as stigma and operational barriers to access may limit uptake of services among those in need. Even if it were easy to anticipate need, however, adequately planning for supplies is difficult when stock is determined by external donations. Nor do charities operating with volunteer staff on shoestring budgets typically have the resources to assess individual needs to determine what constitutes ‘enough’ food, meaning the food available is typically a fairly standardised package. What may be sufficient for some individuals and households may fall far short for others. Additionally, food banks typically provide a parcel of food to cover only a very short period of time (for example, Trussell Trust parcels aim for three days’ worth of food), and

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often also include limits on the number of parcels a household can claim in a given time period. Even a parcel that provided ‘enough’ food for three days does not resolve food insecurity in the longer term; those who have visited a food bank have not suddenly transitioned from being food insecure to being food secure. This links to the next deadly ‘in’:  nutritional inadequacy (Poppendieck, 1999). Food donations are typically driven by the supply of donated food, not by the nutritional needs of the people receiving that food. While food banks may request donation of specific food items, there is no guarantee they will receive these items. That a large share of what gets donated is highly processed food of limited nutritional value reflects some combination of donors’ beliefs about the needs and preferences of food bank users and the kinds of food available for purchase in the food system more broadly (Garthwaite, 2016; Poppendieck, 1999). Dependence on donations also contributes to the ‘in’ of instability, along with reliance on volunteer labour (Poppendieck, 1999). Donors tend to give when they are able, and not to give when they feel unable to do so (Poppendieck, 1999). As a result, food donations often decrease precisely when they are most needed. Where food is donated by food suppliers because it has been overproduced or deemed unsellable, the very act of donating alerts suppliers to problems with their systems and prompts them to correct errors, leading to a reduction in donations in future. Even if a steady supply of donations could be procured, however, reliance on volunteer labour also contributes to instability because volunteers are ultimately free to donate their time or not as they wish; where there is a shortfall in volunteer labour, programmes may need to cut back their operational hours or even close programmes for extended periods. This problem was particularly well-​ illustrated by the donation shortfalls and staffing shortages during COVID-​19, which showed how instability can increase precisely when food aid is most needed. Reductions in services in turn contribute to the ‘in’ of inaccessibility (Poppendieck, 1999). Although there may be high need, reliance on donations and volunteers means that

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food charities will operate where there are both the means and the will to open and maintain the charity. Pre-​COVID-​19 research in the UK showed that only 21 per cent of food banks in the Trussell Trust Foodbank Network were open on weekends and only 13 per cent were open in the evenings, with the majority (64 per cent) of food banks being open for