On 12 January, one of the grimmest findings of the Covid-19 pandemic was published: “excess deaths” in England and Wales were reported to have risen to their highest level since the Second World War. In 2020, 608,002 deaths were registered, the largest number since the 1918 Spanish flu and 75,925 more deaths than occurred on average over the preceding five years (the technical definition of excess deaths).
But few noticed another disquieting trend on the viral graphs: even before the pandemic, excess deaths were rising – by 2,911 in 2012, 11,314 in 2013, 6,408 in 2014, 32,624 in 2015, 20,735 in 2016, 20,803 in 2017, 22,355 in 2018 and 4,647 in 2019. By contrast, over the preceding 20 years, excess deaths fell in all but two years (1993 and 1995).
The pandemic and the UK’s Covid death toll of 126,284 – one of the highest in the world – have raised the salience of mortality. Rarely have the political choices that influence who lives and who dies been clearer. The UK’s prodigious death toll was not inevitable or an act of God. But this thought prompts another: why were more people dying in the years before the pandemic, and how many lives could have been saved?
Graph by Michael Goodier
In May 2010, the Conservative-Liberal Democrat coalition government embarked on a radical experiment that still reverberates today: austerity. Over the New Labour years spending on public services had risen, but it would now be cut in an attempt to reduce the budget deficit and to reshape the state.
After David Cameron assumed office, more than £20bn of welfare cuts were imposed, departmental budgets were reduced by an average of more than 20 per cent and local government funding was cut by 49 per cent (with baleful consequences for social care).
When George Osborne delivered his first austerity budget in 2010, he declared: “When we say that we are all in this together, we mean it.” But the reality was otherwise.
In February 2020, before Covid-19 monopolised attention, the landmark Marmot Review found that, for the first time in more than 100 years, life expectancy in England had stalled and even declined for women in the poorest 10 per cent of areas. “England has lost a decade,” lamented Michael Marmot, the University College London professor who led the review. “If you ask me if [austerity] is the reason for the worsening health picture, I’d say it is highly likely.”
Marmot was not alone in concluding that the UK government had presided over avoidable deaths or, more radically, what Friedrich Engels called “social murder”. In his book The Condition of the Working-Class in England (1845), Engels wrote of how “the class which at present holds social and political control” places “hundreds of proletarians in such a position that they inevitably meet a too early and an unnatural death, one which is quite as much a death by violence as that by the sword or bullet”.
In 2019, an IPPR report suggested that 130,000 deaths in the UK since 2012 could have been prevented had improvements in public health policy not been halted by austerity. From 2015 to 2019, as my colleagues Anoosh Chakelian and Michael Goodier have reported, real-terms reserves for public health spending fell by 30 per cent.
One of those who was early to note the rise in excess deaths during the 2010s was Danny Dorling, the Halford Mackinder Professor of Geography at Oxford University. Though a Public Health England report – Excess Winter Mortality 2012-2013 – suggested that “influenza has contributed significantly” to the excess death count that winter (which appears modest compared to the spikes that followed), Dorling was sceptical.
As he wrote in the New Statesman in 2014, “Cold weather is no excuse for more deaths. We know that countries with frequently low winter temperatures, such as Finland and Germany, where most housing has adequate insulation and heating, have very low rates of excess winter mortality… There are many factors that matter, but the timing suggests it is the cuts, austerity and not all being in it together that matter most this time.”
Today, after confirmation that the rise in excess deaths was a trend, not a blip, Dorling again cites austerity as the decisive factor. “We first saw evidence in 2012/13 of a fall in the life expectancy of women over the age of 65, of just two weeks – tiny, but still a bit surprising,” he recalled when we recently spoke.
“I wrote a long piece in the NS about all the possible explanations: the halving of adult social workers, that’s the biggest one. People would go round and spend time with elderly people, perhaps only 15 minutes, make a cup of tea and go away again. It sounds silly that they should have been useful but if that was the only person you met each week for 15 minutes it made a difference. At the extreme, these adult social care workers could find elderly people who’d fallen down the stairs but they also could contact GPs and say ‘something’s going wrong here’.”
He added: “The interesting thing is that one of the arguments at the time was ‘these are just old people, they’re going to die anyway’” – a claim that has been echoed all too often during the pandemic.
Though NHS spending was formally “protected” after 2010, the health service still endured the longest period of austerity in its history. Since 1950, health expenditure has grown at an average annual rate of 4 per cent, but over the 2010-15 parliament, despite increased demand, it rose by an average of just 0.5 per cent.
Before the pandemic, NHS winter crises had become a grim feature of the political calendar. “The overwhelming of the health service, twice, and the cancellation of all elective surgery,” Dorling noted, also contributed to the rise in excess deaths.
What does he say to those who riposte that while higher mortality correlated with austerity, there is no proof that it was caused by it? “You can’t directly prove it,” Dorling said. “There are experiments where you give old people a pot plant and they live longer, but you can’t do a randomised control trial where you do austerity on half of England and not on the other half.”
However, he added: “The circumstantial evidence is so enormous… The claim that it was flu doesn’t work for a number of reasons. ONS data shows that flu was very low, the UK has had no significant cold winter since 2010, we’ve got global warming. If it was influenza it was a very British influenza and it didn’t manage to get into other European countries.”
During the Covid-19 pandemic, the UK has suffered one of the highest excess death rates in Europe. But at the close of our conversation, Dorling explained why the picture is even grimmer than it appears: “All these excess death calculations that are being made, we’re comparing ourselves in 2020 with five truly awful years, whereas other countries are comparing themselves with the best years they’ve ever had.”
The social ills that Covid-19 has newly exposed – entrenched poverty, loneliness, dilapidated housing and inadequate welfare support – preceded the pandemic and will likely outlast it. As Richard Horton, the editor of the Lancet medical journal, has argued, the UK is enduring a “syndemic” – a synthesis of epidemics. Coronavirus interacted with pre-existing inequalities to lethal effect.
If there is a lesson from the plague year, it is surely that no government should ever again be cavalier about death – or the policies that cause it.