In January 2020, Susan Sell and myself edited and published a Special Issue of the Review of International Political Economy (or RIPE), on the global political economies of health. Our introduction to the collection had the pretty pompous title – ‘Health under Capitalism: a global political economy of structural pathogenesis’. Basically, the argument that carries it is that capitalism is harmful to health on a structural and human level, a process of interaction dating back at least to the Industrial Revolution, with new dimensions and drivers of this toxic relationship emerging under neoliberal capitalism and globalisation. We picked up on a piece I co-authored in 2009 in which the interaction of capitalism with health is explained by a series of systemic vectors, these spreading, intensifying and scaling-up of adverse health outcomes globally. The vectors of capitalism were poverty and inequality; poor conditions of work; the financialization and commodification of health; mass markets, production and consumption; and neoliberal policy templates, especially those related to market fundamentalism and austerity measures.  Capitalism engenders vulnerabilities by these vectors and spread disease by living and working conditions and social reproduction of poverty via structures of accumulation. All very Marxist.

What seemed a pretentious and grand title to a journal article in fact finds some real purchase when explaining some of the fundamentals of the COVID crisis. The interaction of neoliberal capitalism with COVID is proving fatal and aggressive at the systemic and population levels. In a future piece with Matt Sparke, we are treating the relationship as being ‘co-pathogenic’; this being a medical term for the infection of the host by two (or more) pathogens, involving their interaction to produce a more adverse and complex health outcome than would otherwise be the case if they acted alone. Neoliberal capitalism has this co-pathogenic relationship with COVID and it is plain to see, Marxist or not.

The historical legacy of neoliberalism has been to create societal and global conditions in which the health effects of the virus are being felt disproportionately by those marginalised and poor. It is important to state that poverty is not accidental but created, it is product of history, structures and power in the political economy. Poverty is produced by what has been termed the inequality machine. The moment where COVID arrives in history is after decades of austerity and privatisation and the most recent long-cyclical crisis of capitalism following the GFC. Austerity and neoliberal policy templates have eroded public health systems and wider mechanisms of social resilience and welfare, and despite band aids such philanthrocapitalism and reconfigured mechanisms of delivering aid and welfare goods.

All of the vectors described above are presently interacting with each other in various combinations to shape health outcomes for COVID patients and further spread the disease. But poverty and inequality are proving one of the most successful in delivering the virus to the host. It is clear now, for example, that where people work and the conditions in which they live are determining different exposures to the virus.  The conditions of the homeless, the migrant workers, refugees, the urban poor and slum dwellers, women and young girls, meat packers and essential workers, the incarcerated, the ethnically and racially disadvantaged, have all been produced by four decades of systematic policies of precarity and inequality, and collided with a pandemic.

The interactions of the different neoliberal vectors are myriad in this pandemic crisis, and we have ready evidence that COVID and neoliberal capitalism are devastatingly co-pathogenic. One example of the dynamic of brutal interactions can be witnesses in poverty and inequality having led the poor to be integral to the mass global markets for harmful products (such as energy dense ultra-processed foods and tobacco), with complex dependencies meaning socially marginalised populations are suffering from higher obesity, diabetes and respiratory disorders. This has made the less well off more vulnerable to the virus and more prone to mortality once it is contracted. The ubiquitous ‘pre-existing conditions’ that make COVID so often fatal are produced by poverty, inequality and mass markets, and there are substantial literatures on both the social and commercial determinants of health which map health status onto social gradients, poverty and consumption. While markets have spread many of the pre-existing conditions to the poor by diets or infections, they are doubly damned in their greater exposure to COVID.

Those worse off in society and on lower incomes are becoming COVID infected because of where and how they have to work, in order to care for us, feed us, or clean our cities. Their socially produced status allows wider social reproduction to continue without complete collapse. Many cannot lock down and continue to have to work and interact in a pandemic.   

Yet other interactions between the vectors can be seen in chronic under investment in health systems and years austerity combining with no access to health insurance and sick pay. Many people cannot access privately provided health when they are infected, and continue to transmit when infected, especially if they have to keep working or do not know their status. In the background to this the neoliberal state and atomistic society have served to limit the ability of governments and people to construct effective responses to the virus, producing vulnerabilities across multiple sites and peoples. It is a perfect mess.

The post today is on the most powerful vectors of the virus, poverty and inequality. Some of the material used incorporates bits and pieces from my diary over the last months, so apologies. I will try here today to give focus what the primary health effects of the co-pathogenesis of neoliberalism and COVID on those who are marginalised and poor in two OECD countries, the US and UK. I want to then write about the poverty vector and COVID in LMICs in coming days, before turning to secondary effects of COVID, namely how it is already producing new poverty and entrenching existing inequalities.

In global terms, there has been a great deal of debate about how globalisation and capitalism have acted to lift many millions out of poverty, in China, South East Asia, Africa and Latin America. While this has certainly been the case in net terms in many of these regions, the globalisation of neoliberal capitalism has also massively expanded income and other inequalities within many LMICs, and has done the same within OECD countries. Many of the poor have got poorer in relative and absolute terms, and the socially marginalised have also become more marginal and precarious, while wealth has concentrated in the hands of the super-wealthy and asset holders. Social and employment insurance and welfare systems have been eroded, and bars for welfare or social assistance in areas such as disability and education have been raised, or they have been closed off completely. Poverty has become generational once more in many of the OECD countries that escaped that trap with the boomer generation.

COVID has again ruthlessly betrayed these fault lines and the harmful legacies of recent decades. In both the UK and US, COVID has disproportionately impacted the racially marginalised and poor. The LA Times carried an article on May 11^th centred around a news briefing given by the LA County Director of Public Health. She is angry at the racial and economic disparities playing out in the COVID-related mortality figures in the city:

‘Officials reported a rate of 89 deaths per 100,000 people among native Hawaiian and Pacific Islanders and 18 per 100,000 among black people. The rate was 15.5 for Latinos, 12 for Asians and nine for white people. “These rates are significantly higher than the mortality rate for other races and ethnicities, and although some of the numbers are small, they are still very concerning,” Los Angeles County Public Health Director Barbara Ferrer said Friday at a news briefing. People who live in areas with high poverty rates have nearly four times as many deaths from COVID-19 — 29 deaths per 100,000 people, compared with eight per 100,000 people in communities with low poverty rates, she said.’

Initially in LA the virus struck both the white and BAME populations, but the figures for infections in the former group quickly stabilised, while case trajectories rose higher in communities of colour, and in economically disadvantaged areas such as South Los Angeles.

In Chicago half the deaths from COVID have been in the African American community despite that population being on 30% of that city’s population. A similar picture is apparent in Detroit, and 80% of all COVID hospitalisations in Georgia are black Americans. Apart from the still highly racialized nature of the US and high levels of BAME inequality and poverty, COVID is interacting with significant and higher disease burdens of hypertension, diabetes, cardiovascular and respiratory disorders than compared to the white population. Lack of access to preventative care plays a role in shaping these disease burdens, as does consumption and use of harmful products often by virtue of income or the consumptagenic environments that surround us all.

Other ethnic groups are also suffering disproportionately in the US. Native Americans, or First Nations people, have seen catastrophic impacts of the virus on reservations in the north and south of that country. Despite repeated warning of the need for intervention by the Federal government and pleas for medical and financial assistance, COVID has torn through indigenous communities. Nationally, 80% of the First Nations population lives below the poverty line and life expectancy for men is a shocking 55 years of age as compared to the US average of 78 years. Conditions on many reserves are often appalling, with poor and cramped accommodation, and in the worst cases, homes without running water and electricity. In Arizona, one report cites that despite being just 5% of the population the Navajo mortality from COVID accounted for 16% of that state’s fatalities at one point. One community leader in New Mexico estimated a 2000% increase in cases in a just a few short weeks. Marginalisation and a national history of neglect, racism and exclusion are now framed by infection and deaths.

At work, the poor in the US and UK are also being routinely more exposed to infection, with little choice to but continue to work for many citizens. The absence of sick pay and precarity from low income, coupled with the fear of losing already vanishing jobs, make isolation at home an impossible luxury for so many. Some weeks ago I wrote about the outbreak of COVID in a meat processing plant in South Dakota. The staff were invariably undocumented or refugees and reliant on incomes, and COVID had ripped through the workforce. Trump has now ordered that meat packing facilities remain open under the Defence Production Act, and there were scenes this week of open-up supporters protesting at a soon to be closed COVID-riddled meat packing plant. One sign read we need our meat. A recent mapping project in the US has traced outbreaks at 200 hundred packing plants across the US, and some 14,600 workers have tested positive for COVID to date, all involved in food processing. People are dying for meat.

In the UK, the picture is equally bleak in terms of poverty and marginalisation interacting with the virus. According to Office for National Statistics (ONS) COVID deaths in England and Wales (ages 20-64 years) are highest among a number of quintessentially working class and low-paid professions. Deaths have been way above the UK average of 9.9 deaths per 100,000 (9.9/100,000) for those working and being exposed to contact repeatedly. For security guards and related jobs it is 45/100,000; taxi drivers, chefs and bus drivers all somewhere in the 30s/100,000; and sales and retail clerks all in the 20s/100,000. These are figures double to four times the national average fatality rate from COVID.

The Guardian carries a series of reports this week which dwell on the ONS data. Mortality rates in the most deprived areas of the UK are double those of the least deprived, this grim comparison playing out in some London Boroughs on literally a street by street basis. The lowest income London Boroughs, such as Hackney, are amongst the worst affected council areas of the UK. In Wales, where there have been some of the highest mortality rates in the UK and especially where poverty is rampant in post-industrial South. The most deprived areas where I grew up have seen rates of 44.6/100,000 from 1 March to 17 April, as compared to an already high 23.2/100,00 in the least deprived of Wales. Overall in the UK, 25% of all the hundreds of thousand COVID cases have been in the most deprived areas, and if you are black in the UK then you have been four times as likely to die from COVID as compared to a white person.

This disease has proven no great leveller. As Michael Marmott has argued since 1978, cites Polly Toynbee in The Guardian 5^th May, disease can be mapped on to the social gradient and COVID is no different to chronic illnesses in this effect. And since the financial crisis, poverty and inequality have got far worse in the UK under the most recent phase of neoliberalism:

‘Marmot’s report in February [2020] measured the steep deterioration in health inequality in England since 2010: the rise in child poverty, insecure work, food banks, worsened living conditions “with insufficient money to lead a healthy life”, and the loss of children’s centres. “Austerity,” he warned, “will cast a long shadow over the lives of the children born and growing up under its effects.”’

So far I have detailed the impact of COVID in the poor and marginalised in just two developed countries. In the second post on this I will look to the same dynamics in some low and middle income countries, before turning to a final post on the emerging effects of the virus on poverty and marginalisation that seem certain to outlast the pandemic and imprint poverty on future generations, all unless something in the global political radically changes after the crisis.