http://ijhpm.com Int J Health Policy Manag 2021, 10(9), 581–584 doi 10.34172/ijhpm.2020.149 Commentary

Welfare , Populist Parties and Health Inequalities Comment on “A Scoping Review of Populist Radical Right Parties’ Influence on Policy and its Implications for Population Health in Europe”

Clare Bambra1* ID , Julia Lynch2 ID

Abstract Article History: In this short commentary, we examine the implications of the welfare chauvinism of the populist radical right (PRR) Received: 2 July 2020 for health inequalities by examining the international evidence about the impact of previous periods of Accepted: 1 August 2020 contraction on population health and health inequalities. We argue that parties from various political traditions have ePublished: 10 August 2020 in fact long engaged in stigmatisation of welfare recipients to justify welfare state retrenchment, a technique that the PRR have now ‘weaponised.’ We conclude by reflecting on implications of the rise of the PRR for the future of welfare states and health inequalities in the context of coronavirus disease 2019 (COVID-19). Keywords: Politics, COVID-19, Social Policy, Public Health Copyright: © 2021 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/ licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Citation: Bambra C, Lynch J. Welfare chauvinism, populist radical right parties and health inequalities: Comment *Correspondence to: on “A scoping review of populist radical right parties’ influence on welfare policy and its implications for population Clare Bambra health in Europe.” Int J Health Policy Manag. 2021;10(9):581–584. doi:10.34172/ijhpm.2020.149 Email: [email protected]

n their scoping review, Rinaldi and Bekker1 examine the UK Independence Party, the and the Sweden the welfare policy consequences of the rise of populist Democrats – are nationalist/nativist, authoritarian and radical right (PRR) parties in Europe and the implications populist (privileging the ‘common sense’ of ‘the people’ over Ifor population health. They conclude that the exclusionary elite knowledge).2 Their approach to the welfare state has welfare chauvinistic positions of PRR parties are likely to have been described as ‘welfare chauvinism’ because it involves negative effects on access to welfare and healthcare provision, increasing or defending welfare provisions (notably social adversely impacting the health of vulnerable population security and healthcare) for the native-insider population groups. Whilst their review is wide-ranging and covers whilst limiting access and eligibility for outsider groups – various PRR policy mechanisms, one of the key factors that most notably immigrants and ethnic, religious, cultural, and Rinaldi and Bekker identify is the PRR division of welfare linguistic minorities (although the wider PRR agenda also recipients into ‘deserving’ and ‘undeserving’ – with knock-on includes reducing the rights of LGBTQ+ [lesbian, gay, bisexual, impacts on the overall size, shape and acceptability of public transgender, queer, and others] minorities and women’s welfare provision for everyone. In this short commentary, we reproductive rights).2 Welfare chauvinism links native birth or examine the implications of this in more detail by examining ethnicity (and sometimes other attributes related to religion, the international evidence about the impact of previous culture, and language) to moral ‘deservingness,’ which entitles periods of welfare state contraction on population health those who possess it – and only those – to state support in time and health inequalities. We argue that parties from various of need.3 So, PRRs in government can lead to an increase in political traditions have in fact long engaged in stigmatisation welfare state generosity.4 However, deservingness criteria can of welfare recipients to justify welfare state retrenchment, a also be used to restrict welfare provision for other individuals technique that the PRR have now ‘weaponised.’ We conclude and groups in the population, too, and are seen for example by reflecting on implications of the rise of the PRR for the in policies that aim to reduce welfare ‘dependency’ amongst future of welfare states and health inequalities in the context those characterized as shiftless, improvident, or otherwise of coronavirus disease 2019 (COVID-19). undeserving of social support.1 PRR parties – including the Rassemblement National The implications of the linkage of nativity with deservingness (French National Front), the Austrian Freedom Party, the for the health of minority groups is as straightforward as it Italian Northern League, the , the is awful. Minority ethnic groups have worse health than the Polish Law and Justice Party, the Dutch , native population – for example, they have higher rates of

Full list of authors’ affiliations is available at the end of the article. Bambra and Lynch hypertension, diabetes, asthma, heart, liver, renal disease, in social protections in the United States – beginning in cancer, cardiovascular disease, obesity and smoking.5 And yet, the 1980s and continuing through the post-global financial as Rinaldi and Bekker point out in their review, the influence crisis (GFC) recession – have resulted in increasing health of PRR welfare chauvinism has led to calls for – and in some inequalities and worsening population health, including rising countries such as the UK implementation of – restrictions on ‘deaths of despair’ among white Americans14 (conversely, access to healthcare and welfare state support for immigrant expansions of generosity and eligibility in specific programs communities.1 This has huge public health implications – not had beneficial effects on health15,16). The PRR have merely just for the health of the excluded population groups, but newly ‘weaponised’ what are unfortunately long-standing and also, in the context of endemic infectious disease (notably divisive political and cultural narratives. tuberculosis and COVID-19), for the entire population. The The impact of these substantial reductions in the generosity nativist and authoritarian combination within PRR welfare and universality of welfare state programs on health chauvinism also results in restrictions on welfare state access inequalities has been empirically examined in multiple and social citizenship for lower socio-economic groups countries.17 For example, studies have found that health within the native/insider community themselves. The trope inequalities increased when significant cuts to the welfare of deserving and undeserving recipients is used to further state and public spending were implemented by many retrench the welfare state for everyone – particularly in European countries as a response to the 2008 GFC. For relation to support and pension provision.1 example, in England, studies have found that inequalities The tactic of splitting welfare recipients into deserving in mental health and well-being increased at a higher rate and undeserving is not novel or exclusively one of the PRR.6 between 2009 and 2013, with people living in more deprived Initially based in Protestant charity doctrine, and hence less areas experiencing the largest increases in poor mental health prevalent in Catholic countries,7 there is nevertheless a long and self-harm.18 Similarly, increases in child poverty since history in social policy in Europe and other high income the implementation of austerity in England were associated countries of distinguishing between deserving insiders with increased inequalities in infant mortality rates (IMRs) (eg, hard-working families, widows) and undeserving (deaths aged under 1 year), with every 1 per cent increase in outsiders (eg, scroungers, shirkers, unwed mothers). This child poverty associated with an extra 5.8 infant deaths per is most notable in the liberal Anglosphere,8 but elements of 100 000.19 Inequalities in IMR, life expectancy, and mortality deservingness narratives are also visible in the social policies amenable to healthcare in England also increased from 2010 of the Nordic countries, for example.9 Such narratives have onwards.20,21 Across Europe, reductions in spending levels and been cultivated and put to use for decades - largely by the increased conditionality may have adversely impacted the mainstream political right (eg, Conservative, Republican, mental health of disadvantaged social groups.22 Liberal, and Christian Democrat parties) but also in some These findings about the effects of austerity on health cases by Social Democratic parties – to justify cutting the inequalities are in keeping with previous studies of the effects welfare state for everyone.8,9 Notable examples of this are in of public sector and welfare state contractions in the United the United Kingdom where unemployment, lone parent Kingdom, the United States, and New Zealand in the 1980s and even disability benefits were ‘reformed’ (retrenched) by and 1990s. Krieger et al found that inequalities in premature successive governments of both the mainstream political right mortality (deaths under age 75) and IMRs by income and and left from the 1980s onwards.10 Benefit values relative to ethnicity increased in the United States between 1980 and wages (replacement rates) in the United Kingdom fell (eg, 2002 – a period when Republican right-wing governments the replacement value of unemployment benefit decreased (starting with Ronald Reagan 1980-1988) cut public welfare from 45% of average wages in 1980 to just 16% in 2000), services (including healthcare insurance coverage) and entitlement restrictions and increased qualifying conditions reduced social assistance benefit levels.23 Similarly, research reduced coverage (the population coverage of unemployment into the health effects of Thatcherism in the United Kingdom benefit in the United Kingdom decreased from 90% in 1980 (1979-1990 – right-wing Conservative government) found to 77% in 2000), duration of benefit receipt were considerably that the welfare state retrenchment pursued in this period was shortened, and most recently, sanctions were introduced accompanied by increased socio-economic inequalities in life for those who fail to meet increasingly strict entitlement expectancy and IMR.24 These findings are mirrored in studies criteria.11 These changes – amounting to a recommodification of welfare state reductions in New Zealand which found of labour – were reflected to a greater or lesser extent in other that while general mortality rates declined, socioeconomic countries.11 For example, in Germany the replacement value inequalities amongst men, women, and children in all-cause of unemployment benefit decreased from 68% of average mortality increased in the 1980s and the 1990s during a wages in 1980 to 37% in 2000, and in Norway from 70% to period in which New Zealand underwent major structural 62%.11 Similarly, in the United States (where deservingness changes (including more targeted social benefits, privatisation is also highly racialised12) reductions in welfare support of public housing, user charges for welfare services).25 Even and increasing work requirements targeted at ‘undeserving’ in the later-liberalizing countries of continental Europe, the minority lone parents (‘welfare queens’) were found to have dominance since the 1990s of a neoliberal master-narrative negative health impacts on mothers and their children.13 More that privileges budgetary restraint and limited state action has broadly, both hostility toward non-natives and reductions hampered efforts to reduce health inequalities.26 Population

582 International Journal of Health Policy and Management, 2021, 10(9), 581–584 Bambra and Lynch health as a whole has suffered, too: Welfare provision is not 2. Falkenbach M, Greer SL. Political parties matter: the impact of the just beneficial for the health of the most disadvantaged and populist radical right on health. Eur J Public Health. 2018;28(suppl 3):15-18. doi:10.1093/eurpub/cky157 marginalised, but also for the whole population, reducing 3. Ennser-Jedenastik L. A welfare state for whom? a group‐based total mortality and increasing life expectancy. 11,17 account of the Austrian Freedom Party’s social policy profile. Swiss This body of work provides the best insights into the Political Sci Rev. 2016;22(3):409-427. doi:10.1111/spsr.12218 potential impact of PRR welfare chauvinism on the health 4. Röth L, Afonso A, Spies DC. The impact of Populist Radical Right Parties on socio-economic policies. Eur Political Sci Rev. 2018; of vulnerable and lower socio-economic groups. It makes 10(3):325-350. doi:10.1017/s1755773917000133 for grim reading: welfare chauvinism is yet another lever 5. Meeks KA, Freitas-Da-Silva D, Adeyemo A, et al. Disparities in type for scaling back the welfare state, resulting in increasing 2 diabetes prevalence among ethnic minority groups resident in Europe: a systematic review and meta-analysis. Intern Emerg Med. health inequalities. The COVID-19 pandemic may well 2016;11(3):327-340. doi:10.1007/s11739-015-1302-9 further enhance the political influence of the PRR. Nativist 6. Piven FF, Cloward RA. Regulating the Poor: The Functions of Public discourses and authoritarian measures (eg, the first post- Welfare. New York: Vintage Books; 1971. war lockdown across Europe including closed borders) have 7. Kahl S. The religious roots of modern poverty policy: Catholic, Lutheran, and Reformed Protestant traditions compared. Arch Eur become increasingly mainstreamed during the pandemic, Sociol. 2005;46(1):91-126. and are likely to worsen as the economic ramifications of 8. Deeming C, Johnston R. Coming together in a rightward direction: the pandemic, including mass unemployment expected post-1980s changing attitudes to the British welfare state. Qual across Europe and other high-income countries, take hold. A Quant. 2018;52(1):395-413. doi:10.1007/s11135-017-0473-z 9. van Oorschot W. Making the difference in social Europe: deservingness widespread economic depression is likely to increase health perceptions among citizens of European welfare states. J Eur Soc inequalities, especially if further welfare state retrenchment Policy. 2006;16(1):23-42. doi:10.1177/0958928706059829 is enacted as a result.27 The PRR may well contribute to – 10. Bambra C, Smith KE. No longer deserving? sickness benefit reform and benefit from - economic volatility by further promoting and the politics of (ill) health. Crit Public Health. 2010;20(1):71-83. doi:10.1080/09581590902763265 welfare chauvinism and protectionist trade policies. This 11. Schrecker T, Bambra C. How Politics Makes Us Sick: Neoliberal will test the legal and constitutional barriers (eg, in the Epidemics. London: Palgrave Macmillan; 2015. European Union where the European Court of Justice is a 12. Gilens M. Why Americans Hate Welfare: Race, Media, and the Politics strong defender of cross-border welfare rights) that currently of Antipoverty Policy. Chicago: University of Chicago Press; 1999. 13. Gibson M, Thomson H, Banas K, et al. Welfare-to-work interventions offer some protection against welfare chauvinist policies and their effects on the mental and physical health of lone parents and from being fully enacted. Beyond welfare chauvinism, other their children. Cochrane Database Syst Rev. 2018;2(2):CD009820. notable areas of public health policy that have been beneficial doi:10.1002/14651858.CD009820.pub3 for reducing health inequalities are under threat from PRR 14. Knapp EA, Bilal U, Dean LT, Lazo M, Celentano DD. Economic insecurity and deaths of despair in US counties. Am J Epidemiol. parties, include tobacco control (eg, the Austrian coalition 2019;188(12):2131-2139. doi:10.1093/aje/kwz103 government incorporating the PRR Austrian Freedom Party 15. Beckfield J, Bambra C. Shorter lives in stingier states: social policy cancelled the planned public smoking ban) and reproductive shortcomings help explain the US mortality disadvantage. Soc Sci health rights (eg, in the United States, Trump is championing Med. 2016;171:30-38. doi:10.1016/j.socscimed.2016.10.017 16. Popham F, Dibben C, Bambra C. Are health inequalities really 28,29 the restriction of access to abortions and birth control). not the smallest in the Nordic welfare states? a comparison of As the Rinaldi and Bekker review shows, it is increasingly mortality inequality in 37 countries. J Epidemiol Community Health. pressing for public health and health policy researchers and 2013;67(5):412-418. doi:10.1136/jech-2012-201525 17. Bambra C. Health Divides: Where You Live Can Kill You. Bristol: policy makers to understand the potential threats posed Policy Press; 2016. by the PRR and welfare chauvinism for increasing health 18. Barr B, Kinderman P, Whitehead M. Trends in mental health inequalities.1 inequalities in England during a period of recession, austerity and welfare reform 2004 to 2013. Soc Sci Med. 2015;147:324-331. Ethical issues doi:10.1016/j.socscimed.2015.11.009 Not applicable. 19. Taylor-Robinson D, Lai ETC, Wickham S, et al. Assessing the impact of rising child poverty on the unprecedented rise in infant Competing interests mortality in England, 2000-2017: time trend analysis. BMJ Open. Author declares that he has no competing interests. 2019;9(10):e029424. doi:10.1136/bmjopen-2019-029424 20. Barr B, Bambra C, Whitehead M. The impact of NHS resource Authors’ contributions allocation policy on health inequalities in England 2001-11: longitudinal CB led on conception and design, analysis and interpretation, drafting of the ecological study. BMJ. 2014;348:g3231. doi:10.1136/bmj.g3231 manuscript and critical revision of the manuscript. JL contributed to analysis and 21. Robinson T, Brown H, Norman PD, Fraser LK, Barr B, Bambra C. interpretation, drafting of the manuscript and critical revision of the manuscript. The impact of New Labour’s English health inequalities strategy on geographical inequalities in infant mortality: a time-trend analysis. 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