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Delan: Hi everyone, welcome to the third series of the race and health podcast. We're partnering with the Lancet voice podcast to discuss issues raised in the series of papers published in the Lancet in 2022. Racism, xenophobia, discrimination, and health. My name is Delan Devakumar and I'm a professor of global child health in university college, London, and the lead on the academic series.
In today's episode, we will focus on the impact of populism and political and structural implications of this. To discuss this with me, I have three guests. There's Alexandra Haas, the Executive Director of Oxfam Mexico. Alexandra headed the Mexican National Council to Prevent Discrimination, and she's conducted research on migration integration policies.
Next, I have Professor Gustavo Andrea de Almeida López Fernández. Who's a professor of public policy at the Fundação Getúlio Vargas ISP, Brazil. His research is focused on race and democracy, showing how populism has led to new ways of prejudice and discrimination, undermining democracy and the delivery of health services.
And finally, Professor Martin McKee who's a professor of European public health and medical director at the London School of Hygiene and Tropical Medicine, and is also president of the British Medical Association. Martin has researched the two way relationship between populism and health, showing how poor health creates a fertile ground for populism, and how populist policies undermine health.
So onto the episode. Today we're going to look upstream, focusing on some of the structural causes of racism. Most people tend to think about how Interpersonal racism affects health individual acts of violence, for example. But a big part of our academic work was to look at what lies underneath. What are the reasons behind the health inequities that we see play out?
And one of the big driving factors underlying racial inequities is populist politics which has happened around the world. Martin, can I come to you first? Can you tell me first what populism is and why it's important for health?
Martin: In a way, the idea of populism is reflected in its name. It is a range of political views that emphasize the idea of the people as the font of knowledge, often contrasting them against the elite or the experts that are within the elite.
Now, why is it important for health? Most obviously, if you're going to be discarding the views of experts, you're rejecting a large part of the elite. scientific development since the Enlightenment, but it is a two way relationship, as you said in your introduction. So we do know that populist leaders tend to pursue policies that are not supported by evidence.
We saw that with Donald Trump and some of the views that he was promoting. We'll also hear, I'm sure, about Jair Bolsonaro, but we've seen that in many other countries. So in a way we can see that people who are pursuing populist policies will damage the health of their populations. But on the other hand, we and others have done research showing that poor health creates fertile ground for populist politics to emerge.
When people feel left behind, when they feel abandoned, when they see people dying young around them, Then it is very easy for someone who is promoting a populist agenda, particularly when they're saying, I'm here to support and defend you against them being some other enemy within in a way, often people who look different in terms of the way they dress or the color of their skin, you can see how easy it is to exploit, create and exploit those divisions and then come to powers as a result of that.
Delan: Thank you. And this is happening around the world, Gustavo, do you want to talk a little bit about what's happened in Brazil?
Gustavo: Oh, yeah, sure. I think one of the point that you just said about this anti establishment view, it's very important to understand why populism is raising. Rising so much on many parts of the world.
For instance, in Brazil we had the impeachment of a president, Dilma some years ago. And it was really a moment when you put everything together. We had a terrible economic downturn. A great recession that was during for years. And at the same time, the rise of a voice that used to tell people the establishment, they don't represent you because I am the true voice of the people.
So very, I think populist story. So and he started, to deliver to the people, all the usual stories that we see in popular. So and then science and establishment and politician and politics anti globalists. And it was very competent using social media.
What's very competent. We never know here if Trump learn with Bolsonaro, Bolsonaro learn with Trump, but probably don't both learn a lot together. And we're very able to use social media to spread this idea that we represent the people. So let me run the country because finally we have, we will have someone of us there.
And then. All the popular stories follow it.
Delan: Thank you. And I remember being in Brazil in Sao Paulo at that election, actually, when Bolsonaro was elected in. And just some of the divisive conversations that were happening amongst friends, usually. Alexandra, anything to add on that?
Alexandra: Yes. I think what becomes very complicated is when institutions have been built, at least in the place of Mexico, on the basis of unfair distribution of public resources.
We have a health system that is different for people that have formal jobs and people that have informal jobs, and racialized people are overrepresented in the informal job market. And so there's a big criticism to hold on design of public policy and assignment of resources. But the problem, and I'm looping into what Martin and Gustavo have said, is that criticism of institutions shouldn't amount to less institutions, but should go towards more and better institutions.
And the problem with that is that populism is popular, in Mexico at least, because injustice is so deep, deeply felt. And so when institutions are criticized, although they have some good aspects, certainly, It's not so hard to make a bad case for those institutions because we have historically replicated these unjust systems.
So I think that's part of the reason why those discourses are successful, and the danger of those discourses is that they are not. Again, less institutions instead of more better, more universal, more fair institution.
Gustavo: Yeah. Yeah. So just an add something very interesting, Alison, because Bolsonaro, when start government, one of the main policy we could say it's a anti institution policy.
Every part of the government. They try to jeopardize institutions. And it was not just because he choosing the incompetent person that were not able to deliver the job. No, that's not the case. Actually, he was focusing on jeopardize institution as a target of government. So I think this is one of the most interesting part of Bolsonaro government for us that are studying the political side of it.
Is that he was not a side effect, but actually was a target to jeopardize institutions.
Delan: So I, I wonder if we can talk a little bit more about how populism relates to racism and maybe describe in just a bit more detail how this happens both historically and now.
Martin: Often populist politicians are seeking to create and reinforce divisions within society.
When we talk about populism. Being the prioritization of the view of the people, of course, we're not talking about all of the people we're talking about some of the people, typically the majority and when people are facing economic difficulties when they're struggling with precarious lives, it's often very tempting to blame someone else, even though, in fact, all of the people at the bottom of the pile are suffering together.
But you will get politicians who come in to seek to divide the disadvantaged between themselves to create those divisions and exploit them. And so therefore, you do get populist politicians whipping up racism, whipping up racist stereotypes and so on. It's part of the modus operandi of gaining support for a populist program.
So it's this
Delan: divisiveness, right? You've got to create this other group who you can blame. And
Martin: Absolutely. And we have seen that throughout history. The other group can be have many different characteristics and throughout history. It is really whoever is convenient to blame. Obviously, during the 20th century in Europe, we saw the situation with particularly the Jews in Europe, but it has been other groups at other times.
migrants today particularly Yeah,
Alexandra: I think migrants are a huge target the case of mexicans in the u. s But also the case of central americans and haitians in mexico the amazing thing is mexico is a country that has around 32 million mexicans abroad We are the large, the country that has the largest migrant community outside of our country.
And regardless of that, you would think that Mexicans by and large would be, empathetic to, to migrants. What we see in opinion polls is, and we've just conducted a study on this in Adopts from Mexico, is that narratives around migration have a small group, around 7 percent of the population feels.
towards migrants, and then there's like a 10 or 12 percent that feels that they want to reject migrants. And then in the middle, around 80 percent of people don't really care when government policies related to migrants. Don't have a toll on the current or any government's popularity, right? And so people don't really care if the government attends to migrants or they don't.
This is in the case of Mexico, and that makes it easy for the government to become complicit with the United States to put a hold on migration of Central Americans towards the U. S. And in the case of the United States. In some constituencies, it makes the government more popular to have restrictive policies.
And that's something that we've been surprised by in the case of the current U. S. president's migration policies. We expected him to reverse a lot of things that were done under the Trump administration, and he hasn't. And I think it's because it does. Take a lot of political capital that doesn't get renewed if you do positive migration policy.
That's quite shocking to me. And it feels like it makes the migration agenda very hard. And when you come to specific rights like health, it makes it very hard for governments to find public support to fund health services for migrants. And that puts them in a very vulnerable position.
Gustavo: In Brazil it's a very interesting case because as it's no longer a country that receive a lot of immigrants basically the story was an internal story. And Bolsonaro started a strategy, which was incredible and tragic at the same time because he choose an external threat.
So the communists. And it was something absolutely crazy because there is no communist threat anywhere in the world. But he kept telling the people every day that the communist threat was coming. And so all left politics should be erased from the country. For instance, and when you come to the daily lives of people, so policies that were helping blacks to get out of school, so get vaccinated, or policies that were helping indigenous people to be protected from extractive policies from big companies and trying to exploit iron, gold, and so on.
All of this stuff, all these policies were left policies that were part of a big communist threat. So in this indirect way, all the policies that were trying to come back to decrease discrimination, prejudice in Brazil, were more or less abandoned during his government because in the end of the day, the government was very prejudiced with a lot of racists and what in comes to the end.
So I think something that was a tragedy too, is that some part of the government were including Nazis. So we had, for instance secretary of culture that tried to play like some ministers of the Nazi government. And same kind of speech using the same word, same picture, something that was absolutely crazy.
And in his government, all those things over allow it.
Martin: I was going to say that one of the issues to remember is that if a politician dominates or controls the media, they really can have an impact in the way that people think they can create a narrative. We did a paper some years ago where we looked at the shift in the view of the Murdoch owned Sun newspaper in 1997, in the election that brought New Labour to power, when Murdoch decided to support Tony Blair.
And then of course he reversed it in 2010. And we were able to show, by looking, linking the voting data with the, and polling data and so on, We were able to show that there really was a link between the two. He was able to shift the voting, probably not enough on his own to actually shift the election, but he did make a significant contribution.
And we also know from data from the United States from a very nice natural experiment where Fox News was rolled out in cable between 1996 and 2000. So you can see which cities and towns were exposed to it. And then relate that to voting patterns that it did have a significant link to a shift from voting from the Democrats to the Republicans.
And that's why I think in recent elections, discussions about the elections in Hungary and Turkey in particular, people say the elections were free, but were they fair? And the answer is really that they were not because of the control of the media by the incumbent politicians.
Delan: And do you think that power is shifted towards social media now with some of the big tech companies?
Martin: Yeah, I'm not sure anybody really knows what's going on with Twitter at the present, including Elon Musk. He has presided over a collapse in its share price, so quite what his strategy is there, nobody really knows. The difficulty is that social media, of course, allows everybody to be a generator of knowledge, and we do know that certain messages move much quicker.
on social media than others. And in particular, those associated with conspiracy theories will be transmitted much more widely. What we do know is that there are many issues that are underlying that. So why do these populist messages get onto social media and why are they spread? And I think what we do know is that there's a combination of motives.
First of all, there are people who just do have these views. They may be conspiracy theorists, they may be racist, they may be whatever. And they would be doing it anyway. And because they resonate with other people, they get into an echo chamber and it's spread. The other thing is that there are state actors that are promoting some of these messages.
And in fact we know with Russia, for example, in the United States, it has spread often competing messages. It has been spreading messages which have been support Black Lives Matter and also Ku Klux Klan simultaneously, but from different sources. And that is about undermining trust in democratic government.
So it's looking at two constituencies that have reason or may not trust the government to begin with and seeks to encourage them. And then there's another group of people. Who are simply using the speed of the media to earn money. They've monetized it with click bait, with links to monetize pages, or sometimes to distribute malware.
But it is absolutely true that social media has made it much easier to spread some of these very divisive messages.
Delan: Thank you. Gustavo, this is important in the Brazilian elections, right?
Gustavo: Yes, of course. And I can say that by literature, we know that in the past, For running a president and winning an election you must have a very big political base.
And I mean with that, you have to have a lot of local governments, mayors as brokers supporting and making people vote because, Brazil is a country that invests a lot on electoral system. And so elections are considered really fair here. But what we see in the last years is that the system ended, so you no longer need mayors, you no longer need the local governments to make you win an election.
You need social media. And I think, Bolsonaro was the the point where everything changed. Because he didn't have enough time on television, for instance. He didn't have, he didn't have enough, any support, electoral support. He didn't have mayors to, all around the country, to tell people to vote on him.
He won the election and basically he was I think the first time that the president in Brazil won election mostly based on social media. And so I think this is a term that would change forever the way elections are are won.
Alexandra: I would say that From our point of view here in Mexico, I think the anti establishment discourse this current government is supposed to be a left wing populist government, but it has a lot of right wing policies, anti establishment and, the shortening of budgets for public services, that type of thing.
But I would say there's a couple of things that happen. One is this This idea for people, and it's very much related to cash transfers, which are not bad in and of themselves. They have become a substitute for public services, and that's very problematic, because on the one hand, you can't live and have all of your services through cash transfers because you don't get enough cash.
And secondly, it really erodes the relationship between the citizens and the government, where citizens are not used to holding the government accountable for the service. And so the expectation is, just make the deposit and I'll figure out how I get my services, which is really bad, the human rights.
But on the other hand, is the misinformation around COVID, for example, and COVID vaccination. And again, that falls on top of experiences, of, Mexican Indigenous communities having been unduly and involuntarily sterilized in You know the 80s and 90s and so what we've we saw Right now with the covid vaccination is that because the communication wasn't great and the rollout was quite quick actually, but not accompanied by good communication A lot of people from indigenous rural communities didn't approach the covid vaccine rollout because they were, they received information through social media that they would be sterilized.
And because they had been sterilized in the 1980s and 90s, that, that's where the misinformation falls on top of previous experience. So I just feel it. It's a sort of a it's a loophole where it's not that people believe misinformation It's that people have had negative experiences and when they have That misinformation makes sense to them.
Delan: Can we talk a little bit more about how populism? Relates to health outcomes. What are the ways in which this happens?
Martin: Most obviously, populist politicians, because of their anti elite stance, and therefore their rejection of scientific expertise, will make decisions that are unlikely to be consistent with what we know about what has to be done to promote public health.
We saw that very clearly with Donald Trump, where he was talking about using ultraviolet light or bleach, his promotion of chloroquine, which had all sorts of consequences, ivermectin and so on. So that's the very obvious way in which you see this. You also see populist politicians using the divisions they've created in society to undermine support for collective action, to promote public health, social welfare and so on.
So therefore you're undermining the social determinants of health.
Delan: Thank you. And I suppose my feeling is a populist Politicians didn't do very well in the COVID pandemic. Is that right?
Martin: I think that's generally true, but there are a few exceptions. I think you could say that Erdogan in Turkey actually did reasonably well.
Hungary did reasonably well during the first wave, but not subsequently. So it doesn't correlate directly, but there were certainly a number of politicians like Jair Bolsonaro, Donald Trump, Boris Johnson, who did very poorly, at least in the initial waves.
Delan: And I suppose that goes a little bit back to the lack of institutions or the belittling of institutions.
Martin: The institutions may even be strong as they were in the United Kingdom, but they're just ignored. As we're recording this episode, there is a debate going on about the decision that was made by the finance minister, the chancellor of the exchequer at the time, where he promoted a policy which encouraged people to go to restaurants.
And we know that was strongly linked to a rise in cases that was done. By ignoring the scientific advice that was there that he could have drawn upon.
Alexandra: In the case of Mexico, it was exactly the same case of policies that weren't taking into account recommendations, worldwide recommendations. For example, the president refused to wear a face mask, which was.
Really bad for the population and for, as an example. But but on the other hand, also, I would like to say that we need to look at economic policy because, health wise the pandemic had a, had an impact, but also economically wise. So one of the things that did happen in Mexico, and I guess it was hard to prevent it because of the way the.
economy works. A lot of people live off of what they make during the day. And if there was total lockdown, then they would just have, they wouldn't have any income for everyday survival. And so I just want to bring in to the mix a real problem, which is austerity measures. In the case of Mexico, at least This particular government believes that the macroeconomic balance is much more important than whatever happens at the micro level.
And so they have kept the austerity measures in place ever since the pandemic start. And that had, that meant a lot more deaths, a lot more poverty, a lot more people in extreme poverty because of the austerity measures.
Gustavo: So I think the Brazilian case is a very interesting one because we have this anti science view.
Which is, of course led to an idea that those scientists, they are trying to help to stop the pandemics and actually are the enemies and probably the COVID is it's a threat, they, something that they work You're responsible for. And I think this led to something that I think that we must understand better.
It's a kind of medicine populism. A very large group of doctor physicians that tried to actually be unscience too. So they were using Instagram and social media. They kept doing that. Telling people actually what you have to do is this. It's simple. So we are part of this voice of the people.
So this is a very interesting thing that happened here in Brazil. So I think the kind of populous in medicine a second thing that's important to the Brazilian case is that well. Here usually there is a large literature that shows that the president is real, it's really accountable for the economy.
And usually local governments, state governments, and mayors and governments they are in charge of the health service. So Bolsonaro played a kind of blame avoidance strategy. He divided people saying that You have to choose health or economy. And if we don't choose economy, in the end, we'll be worse because a strong economy can help us go after COVID.
So he also divided all the people playing this strategy and it worked very well. And I think the third and final consequence is Brazil is that when you have a populist. President that that wants to jeopardize institutions and the federal government here in the system, it's the responsible for coordination, the coordination of all health policies.
So coordination wasn't done. And so this damaged a lot. Vaccination a lot. The local governments that need to receive money from the federal government to supply medicine to help people. And so I think the way the populace work it here in Brazil was very prejudicial for what happened in the pandemic.
That's the reason why we had so many losses of lives here.
Delan: Thank you. And that goes back to your earlier comment, Martin, about this link between health and The economy and how it's the opposite is true.
Martin: That's right. When we know that health is a major driver of economic growth, it acts through a number of ways.
First, a healthier population is more productive. Second, healthier workers are more likely to remain in the labour force, either working more hours per week or not retiring early. Third, the healthier people, particularly young people, are more likely to invest in their own education. And therefore progressive become more productive and fourth, healthier people are more likely to invest their savings because they're looking forward to a retirement and the savings that they invest then contributes to growth, particularly a small and medium enterprises.
Now, that argument is well, accepted by, for example, the European Union, it had a health is wealth strategy in the 2000s and by many others, and it has been also developed by the European Regional Office of WHO and the European Observatory into a strategy which is based on the idea of mutually reinforcing investment in health systems and in economic growth.
All of them acting in a bidirectional way. Better health contributes to economic growth. Economic growth can contribute to better opportunities to be healthy and so on. So we're trying to create a virtuous cycle.
Delan: Thank
Martin: you.
Delan: Thank you.
Gustavo: I just want to add something on the lines that Martin said. All those true scientific findings, they were all block by faking news.
There's something that I think we are missing here, and I don't have to say about social media. Because in Brazil we had lots of faking news saying the opposite. So we knew that some, that health labor, it's better. But the act, fake news spread the idea that the opposite was the true everybody every day received lots and lots of meshes.
Delan: So on to my final question, and it's a question about what we should do, how can we reduce the impact of populism on health? How can we help to move forward? Alexandra?
Alexandra: I think for the first thing is we really need to make sure that we revise our communication strategy. We need to recognize, at least in the human rights defender area, that we have to Not done a great job of arguing for human rights as a way of establishing a relationship between constituencies and the government.
And so we really need to think of how people are living their health situations and what they're asking the government to do. And if that comes up as a delivery of universal. Sensitive to differences, quality services that are there for all I think we, we would have a great game. The other thing I think that is important is to talk about taxation problems, at least in Mexico and in Latin America with public services is that taxation is hugely unpopular.
The riches don't pay as much taxes as they should. The whole public discourse undermines the government delivery of services. And so people don't find a relationship between, paying taxes and paying fair taxes and the delivery of quality services. Mexico is the worst country in Latin America for collection of taxes, and that is going to become worse in terms of people's health. And it always leaves the more racialized communities and migrant communities. having worse services than the rest. So I think if I would have to choose two, two policies, I would say communication of a rights based approach in the relationship between the government and citizens and putting into the mix the taxation agenda that is key.
Delan: Fantastic. Thank you. So communication and we'll focus on taxation. Martin.
Martin: I absolutely agree with what Alexandra has said about taxes. We do know that progressive taxation is a major correlated driver of achieving universal health coverage and thus the sustainable development goals. I'm minded at a time like this to recall the quotation from Oliver Wendell Holmes, a US Supreme Court justice, when he said that taxes are the price that we pay for civilization.
I think from the public health community, we need to be determined to call out populism, to highlight the damage that it does to the health of everyone, and particularly to speak to those groups that the populist politicians are also speaking to, to make, to help them to understand that in fact it is often the people who are backing the populists who have created the disadvantage that they experience, because many of these populist politicians are being funded by.
neoliberal billionaires and are working through the populist politicians to undermine the left wing parties that would challenge their interests. So often we find ourselves in a situation that in public health, we are told that we should not be political, but we allow other people to define what political means.
And I, my hero, Rudolf Virchow, The pathologist who worked in the 19th century was very clear when he was asked to investigate an outbreak of typhus in Silesia that it was the power of the aristocracy propped up by the church that was actually creating the conditions. He was not afraid to speak truth to power and I think we should be as well.
I think we also need to look at our mainstream political parties, and I'm going to compare two countries where the mainstream right wing parties have moved in different ways. Whenever the Conservative Party in the United Kingdom was threatened from the right by the Brexit Party, the party that wanted to leave the European Union, It shifted to the right to try to occupy that territory.
It fired, it dismissed a number of Members of Parliament who were in the centre. However, we're seeing now there's a rising support for the alternative for Deutschland, an extreme right wing nationalist party, now gaining up to about 17 percent in some of the most recent polls, far more than it ever had before.
But there, the Christian Democrats, the centre right party, are appalled by this and have made it very clear that they will not move in that direction in any way. And of course, in Germany, they have a historical example to look to. So I think it's very important that centre right parties resist any temptation to move.
to the right to occupy that territory because that is where problems lie.
Gustavo: The main tool we have is more democracy. And we've, when I, and I mean that we need more accountability. So for instance, populists are, they are on general blame avoiders. They are blaming all the old, all the other people. They are creating divides in the society.
And so They can't do that because the clear, the accountability is not clear. We don't know who is responsible for everything. We don't know who hold accountable to hold accountable. So I think we need to have more institutions that make clear who is responsible for everything. We need more stable rules about funding, so who is going to have supply the service must have money enough to do that.
At the same time, what the role played by the central federal government must be clear too. And I think I I think the second thing I agree totally with Martin, I think we that work on the health on the health work, we should also do some kind of politics, explain the importance of a system, the national system, how public policies are important, how they are important for the private sector.
To people, to make people be healthy, to live their lives. And so we must tell the message too. So if we don't do something else, we'll bring a different message and probably not a very good one. And I think my final thought about that comes to education. People are not educated to deal with so much information so fast.
And I think, so we have to think about information, maybe. I think some kind of health policy should be done when people are in school, for instance. In the end of the day, we need more more invest on education too, to make people more able to deal with this complete praise
Delan: war. Brilliant. Thank you very much.
And thank you to all of you. To Alexandra Gustavo Martin, interrogating populism is essential to understanding racial inequities that we see today. And this is something that we really need to focus on. Health is political. So thank you to all of you.