The COVID-19 Pandemic as a Tipping Point: What Future for the Right to Health?

Vol 25/2, 2023, pp. 111-123  PDF

Ted Schrecker


“Building back better” post-pandemic, as advocated by the Organisation for Economic Co-operation and Development, could advance the realization of health as a human right. However, the COVID-19 pandemic is more likely to represent a tipping point into a new and even more unequal normal, nationally and internationally, that represents a hostile environment for building back better. This paper begins with a brief explanation of the tipping point concept. It goes on to describe the mechanisms by which the pandemic and many responses to it have increased inequality, and then identifies three political dynamics that are inimical to realizing health as a human right even in formal democracies, two of them material (related to the unequal distribution of resources within societies and in the global economy) and one ideational (the continued hegemony of neoliberal ideas about the proper limits of public policy). Observations about the unequal future and what it means for health conclude the paper.


In June 2020, the Organisation for Economic Co-operation and Development, a group of the world’s high-income countries and some middle-income ones, called for “building back better” post-pandemic, in terms of a decarbonized and more sustainable economy.[1] The rhetoric was subsequently embraced by the US president.[2] It is certainly possible, in the sense of not being precluded by such constraints as the laws of thermodynamics, that such efforts to build back better could also reduce inequalities in access to preconditions for realizing the right to health: the social determinants of health.[3] The authoritative interpretation of the right to health emphasizes that it “embraces a wide range of socioeconomic factors that promote conditions in which people can lead a healthy life, and extends to the underlying determinants of health, such as food and nutrition, housing, access to safe and potable water and adequate sanitation, safe and healthy working conditions, and a healthy environment.”[4] Despite officially expressed interest in building back better, the COVID-19 pandemic and its knock-on effects will be understood in retrospect as a tipping point into a new and more unequal normal that is even less hospitable to realizing the right to health than the pre-pandemic world. This prediction is grounded in three political dynamics, two of them material (related to the unequal distribution of resources within societies and in the global economy) and one ideational (the continued hegemony of neoliberal ideas about the proper limits of public policy, and the associated limits to political agendas).[5]

The tipping point concept has been widely invoked, sometimes imprecisely and at other times with considerable rigor. It is most familiar from discussions of global environmental change. Leading climate change researcher Timothy Lenton explains that tipping points “occur when there is strongly self-amplifying (mathematically positive) feedback within a system such that a small perturbation can trigger a large response from the system, sending it into a qualitatively different future state.”[6] Stated more colloquially, “sometimes little things can make a big difference,” or at least a disproportionate difference, “to the state and/or fate of a system.”[7] Researchers now anticipate that continued atmospheric warming is likely to lead to a number of such tipping points, instantiated by the potential effects of continued loss of tropical rain forests.[8] Such forests generate a substantial proportion of their own rain: in other words, much of the water that falls as rain in a rain forest is the product of evapotranspiration within the forest itself.[9] “Self-amplified forest loss” as a consequence both of human activity (forest clearance) and reduced oceanic moisture inflows may lead to a tipping point followed by accelerated forest dieback and the transformation of the rain forest into savannah or steppe.[10] This will, among other consequences, accelerate climate change as the forest no longer provides a carbon sink. Such oversimplification would make professional climate researchers blanch, but it suffices to suggest the relevance of the tipping point concept to understanding the post-pandemic world.

When the tipping point concept is used to understand social change rather than change in natural systems, tipping points must also be understood as occurring when new path dependencies arise, as the consequences of past policy choices cross a threshold beyond which certain future directions become prohibitively difficult or impossible to pursue. This can happen either as the magnification or acceleration of existing trends qualitatively changes distributions of resources or when the basic structure of institutions changes. (Adoption of formulae for amending constitutions is an example of the latter category.) In some situations, “tectonic policies” may be designed to create path dependencies, as with British Prime Minister Thatcher’s privatization of council housing, in the hope of creating a new cohort of Conservative-leaning homeowners.[11] The tipping point envisioned here operates through political processes by way of various channels associated with increased economic inequality. As in the case of climate tipping points, we cannot anticipate many of the details of the new normal, but we can anticipate some of its key characteristics.

The landscape of inequality: Before and during the pandemic

The COVID-19 pandemic occurred against a background of rising economic inequality associated with (roughly) post-1980 globalization, during which global gross domestic product more than tripled. Although substantial reductions in absolute poverty occurred, primarily in China, between 1980 and 2016 the top 1% of the global income distribution captured 27% of the entire value of global growth, while the global bottom half of the income distribution captured just 12%. More recent income inequality data are available, but the earlier data have been used in order to avoid the effects of temporary wage supports during the early stages of the pandemic. (The top 1% of the global distribution is defined by a household before-tax income for two adults and two children of more than US$300,000 in 2008, so approximately US$422,000 in 2023 dollars.)[12] Many countries also saw drastic increases in within-country income inequality.[13]

The pandemic and many responses to it magnified existing trends of increasing inequalities in the underlying social determinants of health and thereby compromised possibilities for realizing the right to health in several ways.[14] Populations such as poorly paid frontline service workers who were unable to work from home were and are more likely to be infected; they also often relied on public transport, associated with another set of exposures because of the proximity of other passengers. Many workers whose jobs were not considered essential by the jurisdiction in question were disproportionately vulnerable to the economic effects of lockdown-related job loss, and often to economic losses associated with illness given dramatic variation across the high-income world in entitlement to sickness pay.[15] “[I]mmune systems weakened by long-term exposures to adverse living and environmental conditions” made people both more susceptible to infection and vulnerable to severe illness.[16] Preexisting conditions and comorbidities such as diabetes and obesity, which themselves exhibit a socioeconomic gradient, likewise made people more vulnerable to severe illness once infected. Finally, increased transmission was associated with such socially patterned variables as crowded or multigenerational housing, which rendered social distancing impossible while often magnifying work-related exposures and vulnerabilities. The actuarially convenient cull of elderly care home residents, especially during the first year of the pandemic, must also be noted as reflecting the tacitly accepted disposability of that population in many countries.[17]Although the cited source warns against direct comparisons among countries, because of differences in how data were collected, the individual national figures are powerful indictments in themselves.

Part way through the pandemic, the trajectory anticipated in this paper would have seemed improbable in some country contexts. Stimulus and furlough programs transferred resources to people deprived of livelihoods by lockdowns and cushioned the collapse of many economic sectors; in the highly unequal United States, the effect was to reduce poverty as officially defined to a degree that would never have been attained under less extreme circumstances.[18] The US Federal Reserve’s annual survey of households in 2021 found the highest levels of several indicators of financial well-being since the survey began in 2013, although this was before the cost-of-living crisis started to bite in 2022.[19] However, these measures and outcomes were temporary, as emphasized by the headline of a May 2023 New York Times story—“The U.S. Built a European-Style Welfare State. It’s Largely Over”—indicating that at least in that country, such policies merely created a short-term interruption of a longer-term trend of increasing income inequality.[20] On the other hand, in the UK the prevalence of destitution soared by more than 60% between 2019 and 2022.[21]

Outside the high-income world, a grim prognosis manifested earlier. Stimulus programs were confined to relatively affluent polities with the fiscal capacity and autonomy to undertake them. International Monetary Fund (IMF) figures published in October 2021 illustrated the scale of this issue, with advanced economies (as classified by the IMF) having deployed far more extensive spending and investment and forgone far more revenue than so-called emerging market countries and, in particular, low-income countries.[22] Many low-income countries were facing impending debt crises even before the pandemic.[23] Sixty-four low- and middle-income countries spent more on servicing their public debt than on public health care in the last pre-pandemic year of 2019, and 25 countries spent more than 20% of total government revenues on debt servicing in 2022.[24] Citing the 2019 figure, in January 2023 the American Public Health Association called on the IMF, World Bank, and G20 “to eliminate debt for the poorest countries and expand fiscal space for public financing of health services and public health programs.”[25]

Although comparative national data on wealth are less reliable than income data, it is generally accepted that wealth inequalities are not only greater than income inequalities but were likewise growing pre-pandemic, notably because of labor’s declining share of national income as a consequence of globalization.[26] Worldwide, the indispensable World Inequality Report 2022 observed that “between 2021 and 2019, the wealth of the top 0.001% grew by 14%, while average global wealth is estimated to have risen by just 1%. At the top of the top, global billionaire wealth increased by more than 50% between 2019 and 2021.”[27] A broader pattern of increasing wealth among the already wealthy was driven by asset purchase programs (otherwise known as quantitative easing) by central banks that were massively expanded in response to the pandemic.[28] According to the Global Wealth Reports, the number of US dollar millionaires worldwide rose from 46.8 million in mid-2019, the last pre-pandemic year, to 62.5 million in 2021, and the number of ultra-high-net-worth individuals (those with a net worth of more than US$50 million) rose by 21% in 2021 alone.[29] Share prices have since become more volatile, but the temporary nature of pandemic-era social supports makes it clear that even when these are effective, the greatest damage will be suffered at the lower levels of the economic distribution.

As the effects of expansionary fiscal policies that were intended to counteract the destructive consequences of lockdowns combined with ultra-low interest rates, many countries saw a rapid increase in housing prices (both purchase prices and rents).[30] A widespread housing affordability crisis already existed pre-pandemic, consequent to the financialization of housing and leading in many places to the “double precarity” of housing and employment, with both direct and indirect effects on health.[31] The crisis was proximally driven by price increases that were extraordinary in historical perspective, but distally by the entry of major corporate investors into housing markets.[32] Across the European Union, house prices rose 10% between the fourth quarter of 2020 and the fourth quarter of 2021, with considerably higher increases in some countries.[33] In the UK, average sale prices increased by 18.5% between the end of 2019 and the end of 2021, along with rising private sector rents—leading one researcher to warn in 2021 that “the UK [was] sleepwalking into a potential evictions crisis” that has now materialized.[34] In Canada, as households sought more space in the suburbs, between 2019 and 2021 house prices increased by an average of just under 20% to over 45%, depending on distance from downtown, in the country’s 15 major census metropolitan areas.[35] City center housing did not become more affordable; rather, stratospheric downtown prices spread to suburbs, further worsening access to employment and transport for households with limited resources.

As in many other contexts, “crisis talk” must be qualified by recognition that all invocations of crisis—indeed, whether particular features of the post-pandemic world manifest as crisis or opportunity—depend on aspects of social situation such as class, gender, racialized status, and place. Housing is a case in point because of how housing wealth contributes to inequality. Before the pandemic, one team of researchers had concluded that “sustained inflation of property values … has fundamentally shifted the social class structure, from a logic that was structured around employment towards one that is organized around participation in asset ownership and appreciation.”[36] In the United States, the flip side of housing unaffordability was an increase of US$6 trillion in housing wealth, which disproportionately benefited the already well-off.[37] There as elsewhere, there will be knock-on effects on inequality as this wealth is transferred intergenerationally.[38] In another dimension of financialization, income-seeking investors accounted for 24% of US single-family home sales in 2021, driving up rents as a consequence, and for 30% of all Canadian residential purchases in the first three months of 2023.[39]

The political economy of post-pandemic possibilities

Changing distributions of income and wealth are central to political analysis of prospects for realizing health as a human right. Two explicitly equity-oriented blueprints for building back better actually predate the pandemic but can inform understandings of the post-pandemic context. In 2019, the United Nations Conference on Trade and Development (UNCTAD) called for a global Green New Deal that included raising labor’s share of incomes, raising additional revenue to support fiscal stimuli, and expanding public investment in clean transport and energy systems and sustainable food production.[40] Doing so, UNCTAD argued, would require a range of innovative policy instruments, notably including public banking, to which it devoted an entire chapter of that year’s Trade and Development Report. Also in 2019, British researchers published a prize-winning UK-focused proposal for “incentivizing an ethical economics” featuring such directions as raising additional tax revenue to invest in sustainable growth and offering universal care provision in old age—a “new social contract” and “new intergenerational contract.”[41] Importantly in view of the argument made here, both analyses emphasized the need to improve the progressivity of taxation in order to fund the initiatives they proposed.

Realizing the right to health requires first of all access to a variety of material prerequisites, on a basis that does not depend on individuals’ or households’ economic situation. Indeed, the idea of health as a human right, and of economic and social rights more generally, draws its power from its challenge to the norms of the marketplace, in which claims to the requisites for health must be asserted based on the claimant’s purchasing power, even as that marketplace has penetrated multiple new areas of human existence and interaction.[42] Background research for the World Health Organization’s Commission on Social Determinants of Health identified the “three Rs”—rights, redistribution, and regulation—as essential to reducing the inequality of health outcomes that was the commission’s focus.[43] Necessary policy instruments are available, as shown in the preceding paragraph; it is the politics of redistribution that are problematic. Whether redistribution is direct, as through progressive taxation and social protection spending, or indirect, as when regulations limit the power of commercial actors, it has both winners and (often powerful and well-resourced) losers. The essence of the tipping point represented by the pandemic is that in many jurisdictions, increased inequality in the distribution of resources necessary to shape political outcomes is creating barriers to realizing the right to health that may well be insurmountable.

Even in the shrinking number of functioning formal democracies, at least three relevant dynamics are at play. The discussion that follows is necessarily what economists describe as stylized. The dynamics in question will be mediated by the structure of national and subnational political institutions, by such variables as the extent of trade union representation, and, in the case of many low- and middle-income countries, by the country’s relations with its external creditors. My choice of examples is necessarily selective, since the universe of relevant datasets and research is impossible to canvass in a paper of this length. Comparative country-specific inquiry will be very useful.

The first dynamic is the growing influence of super-rich individuals and corporations on policy choices, as a consequence of both their deployment of financial resources to influence electoral outcomes and their global mobility: the ability to shift residence and investment to jurisdictions with more favorable policy environments.[44] As early as 2001, the former director of the IMF’s Fiscal Affairs Department identified “fiscal termites” that chew away at the foundations of national governments’ abilities to raise revenues in order to meet their domestic policy objectives, by way of interjurisdictional tax competition.[45] A sociologist who trained as a financial planner for the ultra-wealthy concluded based on extensive interviews that “many countries are already more receptive and accessible to wealth managers, who are acting on behalf of the world’s richest people, than they are to elected representatives from their own governments … [T]he high-net-worth individuals of the world are largely ungoverned, and ungovernable.” In a provocative analogy, she continued, “What this is doing to the Westphalian host system is similar in some respects to what e-commerce has done to bricks-and-mortar business, destroying it in a race to the bottom.”[46] Transnational corporations are recording a growing share of their profits in tax havens; this is especially true of intellectual property–intensive growth industries such as technology and pharmaceuticals, in which opportunities for tax avoidance are abundant.[47]

The second is the domestic influence of a broader stratum of the affluent, whether we think in terms of the archetypal 1% or a larger cohort that includes (for example) millions of homeowners enriched by pandemic-era increases in property prices, who often constitute a decisive political plurality except in tenant-majority urban settings. A policy analyst later to serve in the US Clinton administration described a “secession of the successful” in which the affluent have less and less need for services provided in the public realm and become increasingly committed to resisting the taxes necessary to finance them.[48] Sometimes, the impulse to secede takes more concrete form: in 2023, Georgia’s legislature rejected the attempt by Atlanta’s affluent Buckhead neighborhood to form a separate municipality, taking with it 40% of the city’s property tax revenues.[49] Pre-pandemic political science research from multiple, mostly high-income democracies found

remarkably strong and consistent evidence of substantial disparities in responsiveness to the preferences of affluent and poor people. Insofar as policy-makers respond to public preferences, they seem to respond primarily or even entirely to the preferences of affluent people. Indeed … the influence attributed to poor citizens is not just less than that attributed to affluent citizens, but consistently negative.[50]

This finding is especially instructive as a counterweight to the claim that political leaders will respond to electorates’ “demands” for particular policies.

To illustrate the value of this analysis, consider the disappearance of wealth taxation from political agendas. Early in the COVID-19 pandemic, even before the full extent of its effects on wealth concentration became evident, UNCTAD argued that “[in] light of the further increase in inequality resulting from this crisis the case for a wealth tax seems irrefutable.”[51] Even the editors of the Financial Times conceded that wealth taxes would “have to be in the [policy] mix.”[52] More recently, silence on this point has been deafening, including on the part of parties on the electoral left, although economists such as the 2023 winner of the American Economic Association’s John Bates Clark Medal have convincingly refuted claims about the difficulty of implementing wealth taxation.[53] In Canada, where one 2021 poll indicated that 79% of respondents favored a wealth tax, the Liberal finance minister has been categorical in rejecting even more modest measures such as changing the preferred tax treatment of capital gains, which overwhelmingly accrue to the affluent.[54] In the UK, a probable future Labour finance minister unequivocally rejected wealth taxes and higher top marginal income tax rates.[55]

Post-pandemic increases in the ratio of high-income countries’ debt to their gross domestic product, combined with rising interest rates that increase the cost of borrowing, augur expanded conflicts between obligations related to the right to health and resistance to raising the necessary revenue. The debt crisis issue outside of the high-income world has already been identified, and leading researchers warn of a “coming austerity shock” in many low- and middle-income countries in the absence of extensive debt cancellation.[56] The effect will be to replicate and deepen the well-documented destructive effects of pre-pandemic austerity on economic and social rights, and of past structural adjustment conditionalities attached to debt restructuring loans by the World Bank and IMF.[57] (In 2022, Ghana’s finance minister said, “We have forgotten how difficult and tenacious that master from Washington was.” The following year, Ghana entered its 17th IMF debt restructuring program.[58]) The austerity shock will probably increase both within-country economic inequality, by way of further cuts in social protection and health care, and inequality among countries, should it lead to slower growth in those economies that are most in need of it. It is possible to envision a range of alternative approaches, as articulated by the United Nations Independent Expert on the effects of foreign debt.[59] However, these would probably create losses for both foreign private lenders and domestic debtor-country elites who benefit from the use of foreign loans to socialize the cost of their own accumulation of fortunes.[60] Leading authorities on capital flight from Africa note that the value of capital flight from 30 countries over the period 1970–2015 is several times the value of their external debt in 2015 and that “some of these debts fueled the accumulation of capital flight abroad through the ‘revolving door’ and various mechanisms of embezzlement of public funds by politicians.”[61] Further, an initiative to address debt crises in a way that does not invite future repetitions might need to include net direct transfers from wealthy countries to poorer ones, against a background in which, between 2000 and 2017, the overall pattern of annual financial flows was consistently from “developing and transition” economies to developed ones, occasionally approaching US$1 trillion, even before accounting for an estimate of illicit financial flows.[62]

The third dynamic is ideational: the continuing hegemony of neoliberal or market fundamentalist perspectives domestically and internationally. In 1995, a multidisciplinary panel of social scientists described neoliberalism after the election of the Thatcher, Reagan, and Kohl governments as “the central ideological force in the Western world.”[63] Much more recently, the introduction to a study of politics in 50 countries, many with data going back half a century, noted “the transformation of global ideology toward the liberalization of the economy, the sacralization of private property, the decline of progressive taxation, and more generally the abandonment of any perspective supporting the transformation of the economic system and the supersession of capitalism.”[64] This hegemony is not unrelated to material interests. According to one leading historian, “A transatlantic network of sympathetic businessmen and fundraisers, journalists and politicians, policy experts and academics grew and spread neoliberal ideas between the 1940s and the 1970s”; more recent support has, if anything, intensified.[65] Innovation scholar Mariana Mazzucato argues compellingly that this “dominant economic paradigm” is especially inadequate and inappropriate to address the challenges of building back better post-pandemic while addressing climate change.[66] In a newly unequal age, barriers to the migration of these insights into the policy mainstream are formidable, buttressing persistent hostility toward equity-oriented policy innovation that one think-tank has called “zombie neoliberalism.”[67] Simply put, the ideational end point of the material dynamics explicated here is that policies necessary to build back better can become unthinkable. When this process was much less advanced, historian of science Donna Haraway referred to it as “losing effective social imaginaries.”[68]

Readers may regard the preceding discussion as too pessimistic, pointing to such trends as headline wage settlements for unionized workers and social policy initiatives like Scotland’s £25/week payment for each child in a family on benefits.[69] As welcome as such developments are, it could be pointed out (for example) that unionized workers are a minority in many jurisdictions, while the ranks of workers in the “gig economy” are swelling; that Scotland is still unlikely to meet its own child poverty reduction targets; and that these examples are of limited relevance to the differential accumulation of wealth and the concentration of resources and influence at the top of the economic distribution.[70] More generally, the tipping point argument does not imply a linear and undifferentiated trajectory of increased inequality and deprivation but rather a longer-term trend: the difference between weather and climate, as it were.

Two further observations and a conclusion

First, Beveridge-style, tax-financed health systems have historically been major contributors to reducing health inequalities related to economic situation and realizing a rights-based approach to health care access. They will probably be among the early casualties of the tipping point, gradually deteriorating into residual services for users unable to afford private provision or insurance. Those users may be quite numerous, but they lack political resources. As Robert Evans, the magnificently acerbic dean of Canadian health economists, observed, “[A] well-functioning modern health system requires the transfer, through taxation, of a very significant amount of money from the healthy and wealthy to the care of the unhealthy and unwealthy.”[71] Britain’s National Health Service (NHS) and Canada’s provincial and territorial systems of public health insurance are two of the most conspicuous examples of Beveridge systems, with Canadian national policy nominally committed to avoiding the emergence of a parallel private tier that has always existed in Britain. Arguments that these systems are unsustainable are code for saying that the richest members of those societies do not want to pay for the care of those others perceived as undeserving, and they are increasingly able to translate that preference into policy outcomes. Predictably, publicly financed health care in both countries is in potentially terminal crisis as this is written, because of failure both to supply needed funding in the short term and to plan for future workforce needs and finance the necessary training. (In June 2023, NHS England finally released a 15-year workforce plan.[72] Analysis by the Institute for Fiscal Studies pointed out the formidable revenue requirements it implied, underscoring its political implausibility, especially if needed revenues were to be raised in ways that preserved the redistributive effect identified by Evans.[73])

Second, territorial distinctions between core and periphery, or developed and developing countries, increasingly fail to reflect the disparate living conditions of people sharing national borders but little else. Development scholar William Robinson has argued that globalization necessitates a shift to “social” rather than “territorial cartography” in which, for example, “a global division of labour suggests differential participation in global production according to social standing and not necessarily geographic location.”[74] A striking illustration of the importance of social cartography for understanding new dimensions of inequality related to the right to health involves the fact that more than a million people in the United States, many in affluent cities, now lack connections to running water.[75] The authors of a recent ethnographic study of three US cities hard hit by the pandemic note that in the case of Detroit, which saw a drastic increase in water shutoffs after the city’s bankruptcy led to raised prices for service, “the water situation erodes perceived notions about the U.S. as a high-income, or ‘developed’ context, bringing traditionally ‘global’ health concerns to the heart of an iconic American city.”[76] Similar situations are likely to multiply in future.

The normative urgency of a human rights perspective on health as a challenge to the marketplace thus increases, even as its political viability declines. In an apparent concession to this maldistribution of political influence, the UK’s opposition Labour Party has tried to lower expectations of change, its leader using the language of unaffordability, wooing private equity magnates and “constantly calculating which of the people desperately awaiting his government he can afford to ignore because they have no powerful advocates,” as Guardian columnist Nesrine Malik has put it.[77] For a darker glimpse of the probable pattern of allegiances in a world of deepening inequality, consider a pre-pandemic study of São Paulo, notoriously one of the world’s most unequal cities and the site of an iconic and widely reproduced 2004 aerial image showing the juxtaposition of ostentatious wealth and extreme poverty.[78] Urban anthropologist Teresa Caldeira began her book City of Walls with excerpts from an interview with a former teacher who was married to a real estate agent: an archetypal middle-class couple. The teacher lamented the decline of her neighborhood and said of her husband, “When he sees a cortiço, a favela, he says that a bottle of kerosene and a match would solve everything within a minute.”[79] In the more unequal post-pandemic world, such perspectives are likely to become increasingly mainstream, and the economically precarious more likely to be criminalized than recognized as holders of rights. Multiple manifestations, notably including the criminalization of homelessness, are already conspicuous in the United States.[80] Again, comparative inquiry and documentation will be valuable. The last word of Albert Camus’s famous essay on suicide is “hope,” but it is difficult to sustain in these times.


Parts of this argument were presented in March 2023 at the Annual Meeting of the International Studies Association in Montreal and (virtually) at the Exploring the Contours of Wellness and Health conference at Sorbonne Université, Paris. The comments of two anonymous reviewers and the section’s guest editors substantially improved the argument and presentation.

Ted Schrecker is a Canadian political scientist, emeritus professor of Global Health Policy at Newcastle University, and fellow of the Global Policy Institute, Durham University, UK.

Please address correspondence to the author. Email:

Competing interests: None declared.

Copyright © 2023 Schrecker. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited. 


[1]. Organisation for Economic Co-operation and Development, Building Back Better: A Sustainable, Resilient Recovery after COVID-19 (Paris: Organisation for Economic Co-operation and Development, 2020).

[2]. “President Biden Announces the Build Back Better Framework,” White House (October 28, 2021),

[3]. B. G. Link and J. Phelan, “Social Conditions as Fundamental Causes of Disease,” Journal of Health and Social Behavior 35 (1995); F. Diderichsen, T. Evans, and M. Whitehead, “The Social Basis of Disparities in Health,” in M. Whitehead, T. Evans, F. Diderichsen, et al. (eds), Challenging Inequities in Health: From Ethics to Action (New York: Oxford University Press, 2001); Commission on Social Determinants of Health, Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health (Geneva: World Health Organization, 2008).

[4]. Committee on Economic, Social and Cultural Rights, General Comment No. 14, UN Doc. E/C.12/2000/4 (2000), para. 4.

[5]. For a classic plain-language description of the importance of these processes, see E. E. Schattschneider, The Semisovereign People: A Realist’s View of Democracy in America (Hinsdale: Dryden Press, 1960), chs. 2, 4.

[6]. T. Lenton, “Tipping Positive Change,” Philosophical Transactions of the Royal Society B: Biological Sciences 375 (2020), p. 20190123.

[7]. T. Lenton, “Environmental Tipping Points,” Annual Review of Environment and Resources 38 (2013), p. 2.

[8]. T. Lenton, J. Rockström, O. Gaffney, et al., “Climate Tipping Points: Too Risky to Bet Against,” Nature 575 (2019).

[9]. C. Smith, J. Baker, and D. Spracklen, “Tropical Deforestation Causes Large Reductions in Observed Precipitation,” Nature 615 (2023).

[10]. Lenton et al. (see note 8); D. Zemp, C. Schleussner, H. Barbosa, et al., “Self-Amplified Amazon Forest Loss Due to Vegetation-Atmosphere Feedbacks,” Nature Communications 8/1 (2017).

[11]. R. Young, “Tectonic Policies and Political Competition,” in A. Breton, B. Galeotti, P. Salmon, et al. (eds), The Competitive State (Dordrecht: Kluwer, 1991).

[12]. B. Milanovic, “The greatest reshuffle of individual incomes since the Industrial Revolution,” VOX: CEPR Policy Portal (July 1, 2016), Data on global distribution of the gains from growth are from F. Alvaredo, L. Chancel, T. Piketty, et al., World Inequality Report 2018 (Paris: World Inequality Lab, 2017), p. 51.

[13]. United Nations Development Programme, Human Development Report 2019: Beyond Income, Beyond Averages, Beyond Today; Inequalities in Human Development in the 21st Century (New York: United Nations Development Programme, 2019), ch. 3.

[14]. C. Bambra, J. Lynch, and K. Smith, The Unequal Pandemic: COVID-19 and Health Inequalities (Bristol: Policy Press, 2021); World Health Organization, COVID-19 and the Social Determinants of Health and Health Equity: Evidence Brief (Geneva: World Health Organization, 2021).

[15]. Organisation for Economic Co-operation and Development, Paid Sick Leave to Protect Income, Health and Jobs through the COVID-19 Crisis (Paris: Organisation for Economic Co-operation and Development, July 2020), p. 9.

[16]. Bambra et al. (see note 14), p. 8.

[17].  A. Comas-Herrera, J. Zalakaín, E. Lemmon, D. Henderson et al., Mortality Associated with COVID-19 in Care Homes: International Evidence (London: International Long Term Care Policy Network, 2021).

[18]. “Reducing Poverty: When Policy Works,” Economist (September 18, 2021).

[19]. Federal Reserve Board, Economic Well-Being of U.S. Households in 2021 (Washington, DC: US Federal Reserve, 2022).

[20]. C. Miller and A. Parlapiano, “The U.S. Built a European-Style Welfare State. It’s Largely Over,” New York Times (April 6, 2023),

[21]. S. Fitzpatrick, G. Bramley, M. Treanor, et al., Destitution in the UK 2023 (York: Joseph Rowntree Foundation, 2023).

[22]. International Monetary Fund Fiscal Affairs Department, “Fiscal Monitor Database of Country Fiscal Measures in Response to the COVID-19 Pandemic,” (last updated October 2021).

[23]. “Debt and Disease,” Economist (April 11, 2020); “Debt and Denial,” Economist (April 30, 2022).

[24]. Debt Justice, “Sixty-Four Countries Spend More on Debt Payments Than Health,” (April 12, 2020),; S. Ecker, G. Molina, L. Jensen, and E. Ortiz-Juarez, The Human Cost of Inaction: Poverty, Social Protection and Debt Servicing, 2020–2023 (New York: United Nations Development Programme, 2023).

[25]. American Public Health Association, “A Call to Expand International Debt Relief for All Developing Countries to Increase Access to Public Resources for Health Care” (January 18, 2023),

[26]. G. Zucman, “Global Wealth Inequality,” Annual Review of Economics 11 (2019); L. Chancel, T. Piketty, E. Saez, and G. Zucman, World Inequality Report 2022 (Paris: World Inequality Lab, 2021); United Nations Conference on Trade and Development, Trade and Development Report 2017: Beyond Austerity; Towards a Global New Deal (New York: United Nations, 2017).

[27]. Chancel et al. (see note 26), p. 46.

[28]. United Nations Department of Economic and Social Affairs, World Economic Situation and Prospects 2022 (New York: United Nations, 2022), pp. 72–75.

[29]. A. Shorrocks, J. Davies, and R. Lluberas, Global Wealth Report 2019 (London: Credit Suisse Research Institute, 2019); Global Wealth Report 2022 (Zurich: Credit Suisse Research Institute, 2022).

[30]. See, e.g., IMF Blog, “Housing Prices Continue to Soar in Many Countries Around the World” (October 18, 2021),; L. Flynn, “The Pandemic Worsens Europe’s Housing Problems,” Current History 121/833 (2022).

[31]. S. Wetzstein, “The Global Urban Housing Affordability Crisis,” Urban Studies 54/14 (2017); R. Rolnik, “Housing under the Empire of Finance,” in J. Knox-Hayes and D. Wójcik (eds), The Routledge Handbook of Financial Geography (London: Routledge, 2020); G. Blakeley, “Financialization, Real Estate and COVID-19 in the UK,” Community Development Journal 56/1 (2021); R. Bentley, E. Baker, and Z. Aitken, “The ‘Double Precarity’ of Employment Insecurity and Unaffordable Housing and Its Impact on Mental Health,” Social Science and Medicine 225 (2019).

[32]. “Prime Cuts,” Economist (March 9, 2019); European Commission, “Housing Price Statistics: House Price Index,”; Rolnik (see note 31).

[33]. European Commission (see note 32).

[34]. Office for National Statistics, “UK House Price Index: December 2021” (2022),; Blakeley (see note 31), p. 79; S. Goodley, “’It Makes Me Want to Cry’: Inside Crumbling Courts as Judges Wrestle with Rise in Rent Eviction Cases,” Guardian (March 3, 2023).

[35]. L. Morel, “Analyzing the House Price Boom in the Suburbs of Canada’s Major Cities during the Pandemic,” Bank of Canada (2022),

[36]. L. Adkins, M. Cooper, and M. Konings, “The Asset Economy: Conceptualizing New Logics of Inequality,” Distinktion: Journal of Social Theory 23/1 (2022), p. 17.

[37]. E. Badger and Q. Bui, “Pandemic Home Market Creates Vast Riches, and More Inequality,” New York Times (May 2, 2022).

[38]. On the US context, see T. J. Smith, “Baby Boomers Leaving Behind Riches, Still Mostly for the Rich,” New York Times (May 15, 2023).

[39]. T. Henderson, “Investors Bought a Quarter of Homes Sold Last Year, Driving Up Rents,” Pew Stateline (July 7, 2022),; R. Younglai, “Investors Account for 30 Percent of Home Buying in Canada, Data Show,” Globe and Mail (September 9, 2023).

[40]. United Nations Conference on Trade and Development. Trade and Development Report 2019: Financing a Global Green New Deal (New York: United Nations, 2019).

[41]. S. Szreter, H. Cooper, and B. Szreter, Incentivising an Ethical Economics: A Radical Plan to Force a Step Change in the Quality and Quantity of the UK’s Economic Growth (London: Institute for Public Policy Research, 2019).

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[43]. R. Labonté and T. Schrecker, “Rights, Redistribution, and Regulation,” in R. Labonté, T. Schrecker, C. Packer, and V. Runnels (eds), Globalization and Health: Pathways, Evidence and Policy (New York: Routledge, 2009).

[44]. J. Mayer, Dark Money: The Hidden History of the Billionaires behind the Rise of the Radical Right (New York: Doubleday, 2016); P. Geoghegan, Democracy for Sale: Dark Money and Dirty Politics (London: Head of Zeus, 2020); J. Hacker and P. Pierson, Let Them Eat Tweets: How the Right Rules in an Age of Extreme Inequality (New York: Liveright/W.W. Norton, 2020); B. Harrington, Capital Without Borders: Wealth Managers and the One Percent (Cambridge, MA: Harvard University Press, 2016).

[45]. V. Tanzi, “Globalization and the Work of Fiscal Termites,” Finance and Development 38/1 (2001).

[46]. Harrington (see note 44), pp. 296–297.

[47]. R. Toplensky, “Multinationals Pay Lower Taxes Than a Decade Ago,” Financial Times (March 11, 2018); T. Tørsløv, L. Wier, and G. Zucman, “The Missing Profits of Nations: 2016 Figures,” Missingprofits (2019),

[48]. R. Reich, “Secession of the Successful,” New York Times Magazine (January 20, 1991).

[49]. B. Mock, “How Buckhead’s Secession from Atlanta Would Destabilize the Entire State,” Bloomberg CityLab (March 2, 2023),

[50]. L. Bartels, “Political Inequality in Affluent Democracies: The Social Welfare Deficit,” CSDI Working Paper 5-2017 (2017),, p. 47, emphasis in original.

[51]. United Nations Conference on Trade and Development, Trade and Development Report 2020: From Global Pandemic to Prosperity for All: Avoiding Another Lost Decade (Geneva: United Nations, 2020), p. x.

[52]. “Virus Lays Bare the Frailty of the Social Contract,” Financial Times (April 4, 2020).

[53]. E. Saez and G. Zucman, “A Wealth Tax on Corporations’ Stock,” Economic Policy 37/110; G. Zucman, “Globalization, Taxation, and Inequality,” Fiscal Studies 44/3 (2023).

[54]. M. Bubbers, “The Federal Budget’s New Tax on Luxury Cars Is Just a Smokescreen,” Globe and Mail (April 22, 2021); T. Cole, “Minister of Everything: Chrystia Freeland Has Taken on Some of the Liberal Government’s Toughest Portfolios,” Globe and Mail Report on Business Magazine (March 2022).

[55]. P. Crerar, “Rachel Reeves Rules Out Wealth Tax If Labour Wins Next Election,” Guardian (August 27, 2023).

[56]. A. Kentikelenis and T. Stubbs, “Austerity Redux: The Post-pandemic Wave of Budget Cuts and the Future of Global Public Health,” Global Policy 13/1 (2022); I. Ortiz and M. Cummins, End Austerity: A Global Report on Budget Cuts and Harmful Social Reforms in 2022–25 (New York: Initiative for Policy Dialogue, 2022).

[57]. Notable recent analyses of austerity impacts include Office of the United Nations High Commissioner for Human Rights, Information Received concerning the Negative Impacts of Budget Cuts, Structural Adjustment and Austerity Measures Implemented since 2014, on Several Human Rights, UN Doc. AL BRA 7/2016 (2018); Human Rights Council, Report of the Special Rapporteur on Extreme Poverty and Human Rights on His Mission to the United States of America, UN Doc. A/HRC/38/33/Add.1 (2018); Human Rights Council, Guiding Principles on Human Rights Impact Assessments of Economic Reforms, UN Doc. A/HRC/40/57 (2018); Human Rights Council, Visit to the United Kingdom of Great Britain and Northern Ireland: Report of the Special Rapporteur on Extreme Poverty and Human Rights, UN Doc. A/HRC/41/39/Add.1 (2019). On structural adjustment, see A. Kentikelenis, “Structural Adjustment and Health: A Conceptual Framework and Evidence on Pathways,” Social Science and Medicine 187 (2017).

[58]. “Africa’s Debts: Seeing Red Again,” Economist (May 20, 2003).

[59]. United Nations General Assembly, Effects of Foreign Debt and Other Related International Financial Obligations of States on the Full Enjoyment of All Human Rights, Particularly Economic, Social and Cultural Rights, UN Doc. A/78/179 (2023).

[60]. Ortiz and Cummins (see note 56).

[61]. L. Ndikumana and J. Boyce, Capital Flight from Africa: Updated Methodology and New Estimates (Amherst, MA: Political Economy Research Institute, University of Massachusetts-Amherst, 2018), p. 8.

[62]. United Nations Conference on Trade and Development, Topsy-Turvy World: Net Transfer of Resources from Poor to Rich Countries, Policy Brief No. 78 (Geneva: United Nations Conference on Trade and Development, 2020).

[63]. A. Przeworski, P. Bardhan, C. Bresser Pereira, et al., Sustainable Democracy (Cambridge: Cambridge University Press, 1995), p. 5.

[64]. A. Gethin, C. Martínez-Toledano, and T. Piketty, “Introduction,” in A. Gethin, C. Martínez-Toledano, and T. Piketty (eds), Political Cleavages and Social Inequalities: A Study of Fifty Democracies, 1948–2020 (Cambridge, MA: Harvard University Press, 2021), p. 39.

[65]. D. Stedman Jones, Masters of the Universe: Hayek, Friedman, and the Birth of Neoliberal Politics (Princeton: Princeton University Press, 2012), p. 134. See generally ibid., pp. 85–179; P. Dardot and C. Laval, The New Way of the World: On Neoliberal Society (London: Verso, 2013), pp. 49–73, 101–254; N. MacLean, Democracy in Chains: The Deep History of the Radical Right’s Stealth Plan for America (New York: Viking, 2017); Mayer (see note 44); Geoghegan (see note 44); Hacker and Pierson (see note 44).

[66]. M. Mazzucato, “Financing the Green New Deal,” Nature Sustainability 5 (2022). For a longer critique of “the dominant economic paradigm of the past five decades,” see M. Mazzucato, Inclusive and Sustainable British Columbia: A Mission-Oriented Approach to a Renewed Economy (London: Institute for Innovation and Public Purpose, University College London), p. 11.

[67]. F. Wong, “Zombie Neoliberalism Strikes Again,” Roosevelt Institute (October 22, 2021),

[68]. D. Harvey, D. Haraway, A. Kobayashi, et al., “Nature, Politics, and Possibilities: A Debate and Discussion with David Harvey and Donna Haraway,” Environment and Planning D: Society and Space 13/5 (1995), p. 519.

[69]. L. Mnyanda and A. Borrett, “How a £25 Payment Is Turning Scotland into a European Pioneer in Reducing Child Deprivation,” Financial Times (October 23, 2023).

[70]. On poverty in Scotland, see C. Birt, C. Cebula, J. Evans, et al., Poverty in Scotland 2023 (York: Joseph Rowntree Foundation, 2023).

[71]. R. Evans, “A Casualty in the Class War: Canada’s Medicare,” Healthcare Policy 7/3 (2012), pp. 17–18.

[72]. NHS England, NHS Long Term Workforce Plan (London: NHS England, 2023).

[73]. M. Warner and B. Zaranko, Implications of the NHS Workforce Plan, IFS Green Budget 2023 (London: Institute for Fiscal Studies, 2023).

[74]. W. Robinson, “Remapping Development in Light of Globalisation: From a Territorial to a Social Cartography,” Third World Quarterly 23/6 (2002), p. 1067.

[75]. K. Meehan, J. Jurjevich, N. Chun, and J. Sherrill, “Geographies of Insecure Water Access and the Housing-Water Nexus in US Cities,” Proceedings of the National Academy of Sciences 117 (2020).

[76]. R. Whitacre, A. Oni-Orisan, N. Gaber, et al., “COVID-19 and the Political Geography of Racialisation: Ethnographic Cases in San Francisco, Los Angeles and Detroit,” Global Public Health 16/8–9 (2021), pp. 1404–1405.

[77]. W. Louch and J. Pickard, “Keir Starmer and Rachel Reeves Meet Private Equity Bosses as Labour Confirms Industry Tax Plan,” Financial Times (April 25, 2023); N. Malik, “Labour Dreams of a Slightly Better Britain. But a Truly Great Country Is within Reach – I’ve Lived There,” Guardian (February 27, 2023).

[78]. See T. Vieira, “Inequality … in a Photograph,” Guardian (November 29, 2017).

[79]. T. Caldeira, City of Walls: Crime, Segregation and Citizenship in São Paulo (Berkeley: University of California Press), p. 24.

[80]. See, among many other sources, K. Gustafson, “The Criminalization of Poverty,” Journal of Criminal Law and Criminology 99/3 (2009); A. Cammett, “Shadow Citizens: Felony Disenfranchisement and the Criminalization of Debt,” Penn State Law Review 117 (2012); “The New Debtors’ Prisons,” Economist (November 16, 2013); American Civil Liberties Union, A Pound of Flesh: The Criminalization of Private Debt (New York: American Civil Liberties Union, 2018); A. Aykanian and S. Fogel, “The Criminalization of Homelessness,” in H. Larkin, A. Aykanian, and C. Streeter (eds), Homelessness Prevention and Intervention in Social Work: Policies, Programs, and Practices (Cham: Springer International Publishing, 2019); L. Foster, “The Price of Justice: Fines, Fees and the Criminalization of Poverty in the United States,” University of Miami Race and Social Justice Law Review 11 (2020); C. Herring, Cruel Streets: Criminalizing Homelessness in San Francisco, PhD thesis (University of California, Berkeley, 2020); S. Rankin, “Civilly Criminalizing Homelessness,” Harvard Civil Rights-Civil Liberties Law Review 56 (2021); E. Zwiebel, K. Dolder, V. Dowden, et al., Boundaries and Barriers: Denver’s Policy Choices to Force Visible Poverty from Public View (Denver: Homeless Advocacy Policy Project, University of Denver Sturm College of Law, 2023).