A previous article discusses the future of health systems operating under neoliberal ideology as it comes a cropper in a world undergoing degrowth.[i] Here I consider how this thrusts public health[ii] into in a “Which side are you on?” dilemma[iii] likely to separate its institutional administration from its frontline professionals –and the public it is meant serve- as part of the larger process of political/economic conflict, cultural and environmental decline, chaos and (possibly) cultural renewal.
The effects of government-imposed austerity[iv], erroneously claimed to restore fiscal responsibility and restart economic growth, are a reflexive (or cybernetic[v]) reaction to protect the economic interests of wealthy elites at the expense of other citizens.[vi] The funding and operation of the public health system and the array of socioeconomic factors that ultimately ensure a nation’s health[vii] are damaged by austerity.
The deep-seated reasons for recent and continuing financial and economic crises (despite mountains of propaganda and self-delusion that a recovery is underway) lie in neoliberalism’s congenital rent seeking,[viii] its class-based dynamic to channel wealth to a tiny economic elite,[ix] and its inability to realize that modern economies are reaching the thermodynamic limits to growth.[x] (This third characteristic is shared by most modernist forms of political thought, from the left to the right.)
It follows that neoliberal leaders of governments and their corporate masters view the ongoing economic contraction as a temporary deviation from the “natural” pattern of wealth accumulation-to-elites-trickle down-to-the-masses economics made possible by constant growth. Therefore, economic elites see an “opportunity” to use austerity as a cover to increase upward wealth transfer.[xi] A bonus is to accomplish the long-standing atavistic goal of rolling back[xii] the gains of the New Deal and Great Society.[xiii] Hence the massive governmental and corporate propaganda assaults on Social Security, Medicare and Medicaid –and other social benefits programs- as “Entitlements” that allegedly weaken the collective moral character, fiscal integrity and work ethic of the nation. The central premise of this attack -which is arrantly false yet widely disseminated without skepticism by mainstream media- is that these entitlements[xiv] for the “Lesser People”[xv] place the United States government at high risk of debt[xvi] default[xvii] or bankruptcy.[xviii]
Sixty years ago Karl Polanyi anticipated the present crisis when he wrote that belief in “free market forces” –a dogma at the core of neoliberalism[xix]– is a direct threat to the “natural environment…[which also] would result in the demolition of society.”[xx] Contemporary society is in the throes of what Polanyi foresaw and I suggest that the science of thermodynamics and the metaphor of the Cat Food Commission are indispensible guides for public health professionals to grasp what is unfolding in this era of ecological overshoot[xxi] and subsequent socioeconomic and cultural upheaval.
Public Health and Austerity
Before turning to thermodynamics and the Cat Food Commission, we must examine austerity’s impact upon public health. Austerity is an ethically decadent and intellectually simple-minded reaction that in the short-term serves economic elites but in the long-term is politically volatile and socioeconomically revanchist. The conclusion from several years of evidence from Europe –Greece, Latvia, Portugal, Spain, Cypress, Great Britain, Italy- is inescapable that social inequality and the collective health of nations are worsened by governmental austerity policies. Add to this the well-known negative health consequences of large and increasing disparities in social inequality and income distribution produced by decades of neoliberal policies[xxii], which have accelerated to warp speed in the United States since 2009.
In political terms, class conflict –not utilitarianism- drives public policy making in nations imposing austerity.
As a government provided service public health must not utter the name class conflict or, it follows, oppose austerity. In policy-speak, this means that the profession’s institutional leaders have no “exit” option, which in turn intimidates them not to use their “voice” option, and therefore renders them loyal to the status quo.[xxiii] They are constrained to play the role of the proverbial Three Monkeys who hear, see, and speak no evil.[xxiv] Put in a larger context, acknowledging the reality of class-based politics behind austerity would undermine the restraining myth of modern democracies that public policy serves the greater public good. Therefore, questions about whose side public health is on are absent from mainstream public health discourse.
Simultaneously, I sense that there is an untenable collective cognitive dissonance in the rank and file of public health in which, on the one hand, practitioners cringe at the unfolding consequences of fiscal austerity in Europe, and its potential for damage in Canada, the United States and elsewhere. On the other hand, they reduce dissonance by framing austerity as a short-term bitter pill –“shared sacrifice”[xxv] and “hard choices”- that will lead to long-term restoration of prosperity. Once growth resumes, this rationalization goes, urgent and mounting public health threats and risks will receive the funding necessary to mitigate them and the social determinates of health[xxvi] will be revitalized by economic recovery.
This hopeful –and obsequiously loyal[xxvii]– interpretation is proffered in an editorial in the January 2013 edition of the American Journal of Public Health[xxviii], the flagship organ of the American Public Health Association. While I do not know if this editorial is a strategy or symptom of Stockholm Syndrome[xxix], I find it a signal to the Obama administration that institutional public health in the United States wishes to frame the ravages of austerity as “adjustments of transition” so as to avoid assessment of the intellectual and moral turpitude[xxx] of neoliberalism. Indeed, the editorial should be construed as official public health’s grotesque curtsy to neoliberalism.
I have a divergent interpretation, which leaves behind the conventional understanding of left versus right politics, to share with those in public health and related health professions who are beginning to recognize that they are laboring inside a failing public health system. It stems from the contention that as the laws of thermodynamics take charge and class-based public polices proceed- this question will surface among many public health practitioners: “Which side –of the class conflict- are we on?”
I propose that institutional public health, such as professional associations, state health bureaucracies and schools of public health, will continue on in the Three Monkeys orientation to the neoliberal regime of truth.[xxxi] In realpolitik terms these leaders have no choice even as the substantive health threats and risks they are charged to deal with deepen and spread. High-level administrators will not bite the hand that feeds them; if they do they will be replaced with status quo compliant executives. This is not a static situation, however, so we should not fully write off all leadership, especially as the conditions for maintaining the health of the public continue to deteriorate and their exit, voice and loyalty options are altered by volatile and worsening economic and sociopolitical conditions.
In contrast, front line public health professionals will become increasingly despondent, angry and alienated from institutional leaders as their tacit knowledge grows that massive cultural, political and socioeconomic changes are not “structural adjustments” but pose huge threats to the health of the public. These professionals will realize that institutional public health –and the state and federal governments, corporations and foundations that supports it- has no solutions[xxxii] and will tolerate harmful class-based public health policies. Frontline professionals will be open to a new paradigm[xxxiii] –or way of being in the social world[xxxiv]– that offers an intellectual, moral and ethical path forward.
It is vital to remember that on the whole, they do not yet understand why modern societies -right now- are entering a post-growth world, which augers a context where government public policy –if it overcomes neoliberalism,[xxxv] which is not guaranteed- faces the central challenge of justly divvying up a shrinking economic pie. (Remember that almost every public health lecture, article and discussion in the United States ends with some variation of this exhortation: “We’re the wealthiest and greatest nation on earth. We’ve got the technology, know-how and resources to do the job; we just need the determination to commit them…”)
Neoliberal governments are blind to the emerging world of degrowth and continue apace facilitating the 1% to impoverish and cannibalize widening segments of the 99%, in essence producing more and more socioeconomically and politically superfluous people in the process. Neoliberalism can only operate in a social world where as the economy contracts -for thermodynamic reasons- wealth and other economic benefits continue to flow upwards, while the costs and burdens fall upon those outside the tiny elite economic.
Thermodynamics and Public Health
Politically and spiritually, the most important thing to know about the laws of thermodynamics is that their “power” –just like that of gravity- cannot be overcome, especially by political propaganda or bullsh*t[xxxvi]. And thermodynamics never gives out a Mulligan; low-entropy energy is for all practical purposes available to humankind once. These laws express the way the physical world works and, by logical extension, they set parameters for human political/economic activity and social organization. This realization has been hidden from industrial societies in large part because of the enormous endowment of low-entropy fossil fuels –which encouraged the illogical notion that growth on a finite planet is endless- and a companion Enlightenment belief that technology and “progress” solve all social problems, including environmental ones and class conflict.
Specifically, the laws of thermodynamics are about the science of energy flow and how energy behaves during its transformation from one state to another, in the process producing both heat and work. These laws were formulated during the industrial revolution when early physicists attempted and failed to create a perpetual motion machine. In other words, scientists tried to capture and recycle into work (waste) heat released by the combustion of coal doing work (like running a steam engine). This futile pursuit lingers on in the widespread belief that technology can produce energy. It cannot. We moderns have no choice but to organize society so that it works within the laws of thermodynamics.
C.P. Snow ironically notes the human significance of these laws:
(1) You cannot win or exit the game (you can’t get something for nothing because matter and energy are conserved) (2) You cannot break even (you cannot return to the same energy state because entropy [chaos or randomness] always increases) (3) you cannot get out of the game (because absolute [the temperature of] zero is not attainable).
In summary, thermodynamics explains why we cannot go back to an era when economic growth was taken for granted as the mechanism to integrate or placate social class conflict and deliver material prosperity to all those who honestly worked to achieve it.
There are several excellent academic explanations of how the laws of thermodynamics set the boundaries of human economic activity,[xxxvii] but they can be tough sledding. Readers unsure or downright puzzled by the connections between thermodynamics and economy are pointed to Mark Cunnington’s essay, “Thermodynamics for Economists, Or, “Economics for Scientists,” where he in plain English walks through this process: “energy flow from sunshine –> plants –> food –> humans –> labour –> economy.”[xxxviii]
Cunnington synthesizes a host of predicaments that too often set concerned groups apart or even at odds. I refer to peak oil, climate change, water scarcity, and acidification of the oceans, to name few of these dilemmas. All are connected to the overexploitation and overconsumption of resources and they cannot be addressed individually or serially or, frankly, in ignorance of the laws of physical reality. Further, he has an excellent discussion of money, debt and how our current economic and financial systems are out of sync with the laws of thermodynamics. Finally, Cunnington makes clear why social inequalities should be understood as unequal access to energy, the source of not just wealth but good health and one’s life chances.[xxxix]
In short, conservation of natural resources and reductions of social and technological complexity are in order[xl]; in fact they are occurring now in derivative or disguised forms: unemployment, health systems (blatantly on display in Greece) in decline, public services and businesses disappearing or being cut back, car sales plummeting in Europe,[xli] all manner of financial and fiscal upheaval and so forth.
We should not imagine, however, that human society is merely a reflection of the laws of thermodynamics. Neoliberal ideology is a social construction of reality that is based upon unequal distribution of energy and other natural resources –money = access to energy and resources. In the United States neoliberalism’s desperate responses to degrowth –without its adherents even comprehending degrowth is occurring!- is the Cat Food Commission, to which we now turn.
The Cat Food Commission
The title “Cat Food Commission” is a sardonic moniker –or metaphor- meant to connote that many retirees and the growing list of economically vulnerable groups will be forced into humiliating life-shortening and threatening penury, reminiscent of pre-Social Security times, if proposed cuts to Social Security, Medicare and Medicaid and other Safety Net programs are enacted. The official description of this commission is:
The National Commission on Fiscal Responsibility and Reform (often called Bowles-Simpson/Simpson-Bowles from the names of co-chairs Alan Simpson and Erskine Bowles; or NCFRR) is a Presidential Commission created in 2010 by President Barack Obama to identify “…policies to improve the fiscal situation in the medium term and to achieve fiscal sustainability over the long run.” (For further official details, see the White House site in this footnote:[xlii].
“The Cat Food Commission” epitomizes the class-based nature of the United States government’s organizing principle[xliii] of defending wealth, even at the cost of doing physical, mental and socioeconomic harm to the rest of the citizenry. This is a difficult to blasphemous realization for most Americans, including public health professionals, because it shatters the mythology that the United States is a historically unique society of equality and boundless opportunity for all.
There is a critical literature on the commission, including its content, how it is connected to ginned up hysteria about the fiscal cliff, the neoliberal sentiment behind the commission’s formation, and the public relations campaign of the bi-partisan support for reducing Entitlements.[xliv] I recommend interested readers visit the website Naked Capitalism, where there are original essay and aggregations of “Cat food Watch” articles from various sources. (Google: Naked Capitalism+Cat Food Commission”)
I have introduced the science of thermodynamics to explain the unavoidable contraction now occurring in industrial economies and have offered the metaphor of the Cat Food Commission as a metaphor of class conflict. Thermodynamics explains the physical basis of how energy is needed to make things happen –to do work- in the natural world; it describes the physical limits of growth and the loss of low-entropy energy inputs involved in extracting natural resources from the earth and transforming them into goods and services for a human economy. The Cat Food Commission metaphor informs us that the (contingent) way humans have arranged the political/economy of the modern world in the early 21st century is invidious and unsustainable in a world at the end of growth. Henceforth, neoliberalism “works” only if more and more groups –classes of people- are pauperized. In sum, “Cat Food Commission” embodies social inequality.
This is the turbulent context in which public health must first locate itself and then (explicitly) answer the question posed at the outset, Which side are we on? I feel this question will produce a split between, on the one hand, incumbent high-level administrators and “leaders” and, on the other hand, those who are on the front lines engaging a plethora of public health dilemmas and problems. The only way to protect the core functions and essential services of public health[xlv] is by simultaneously understanding thermodynamics and the morality behind the Cat Food Commission and the acting upon this knowledge.
[i] Bednarz, Dan and Allana Beavis. “Neoliberalism, Degrowth and the Fate of Health Systems.” Resilience, September 17, 2012. http://www.resilience.org/stories/2012-09-14/neoliberalism-degrowth-and-fate-health-systems.
[ii] Most Americans are unaware of public health’s indispensible role in preventing disease and protecting and promoting their safety and mental and physical wellbeing. Indeed, in the media “public health” often is confused with single payer health coverage and the “Public Option” to health insurance. Typically, a public health departments address (1) preventing epidemics and the spread of disease, (2)environmental health hazards, (3) preventing injuries, (4) promoting and encouraging healthy behaviors and mental health, and (5) responding to disasters and assisting communities in recovery.
[iv] “Austerity” is the infliction of increasing degrees or socioeconomic hardship on non-elites, the middle, working and lower classes. It is done in the name of rekindling economic growth, the unquestioned –and erroneous- solution to the ongoing economic crisis. Austerity’s consequences are illustrated by several years of increasing poverty and deprivation in Europe.
[v] By cybernetic, referring to communication and control processes in systems, I suggest that austerity is the only systemic (and automatic or reflexive) reaction to economic contraction (actually rooted in the laws of thermodynamics) consistent with neoliberalism. Even though it is counterproductive and socially ruinous in numerous ways, it does continue the transfer of wealth up the hierarchy, from those with less to those with a surfeit –which is never enough given what we know about the psychological state of greediness.
[vi] See Sterling Newberry’s commentary on the suicide of Aaron Swartz in which Newberry argues, “When the West had to start importing oil – the US reached peak oil production in 1972 – this created a problem, very quickly the oil producers formed a cartel, and raised the price of oil…The answer to this, in the west, was the Red Queen’s Race: fight the concentration of wealth in the resource regions, by allowing concentration of wealth here. Thus wealth inequality became a goal of political economy…” Source: “Aaron Swartz’ Blood for Oil,” The Sorcerer’s Apprentice, January 15, 2013. http://symbalitics.blogspot.ca/2013/01/aaron-swartz-blood-for-oil.html.
[vii] Frieden, Thomas. “A Framework for Public Health Action: The Health Impact Pyramid.” American Journal of Public Health, April 2010, Vol 100, No. 4. http://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.2009.185652.
[viii] “A simple definition of rent seeking is spending resources in order to gain by increasing one’s share of existing wealth, instead of trying to create wealth. The net effect of rent-seeking is to reduce total social wealth, because resources are spent and no new wealth is created.” See: “Rent Seeking,” Wikipedia, http://en.wikipedia.org/wiki/Rent-seeking.
[ix] McCarthy, Ryan. “A handy guide to Davos-speak.” January 25, 2013. Davos Notebook, Reuters Blogs. http://blogs.reuters.com/davos/2013/01/25/a-handy-guide-to-davos-speak/.
[x] Meadows, Donella, Jorgen Randers, Dennis Meadows. The Limits to Growth: The 30 Year Update. White River Junction, VT: Chelsea Green. 2004.
[xi] Indeed, neoliberals typically argue that income inequality is necessary to “incentivize” the “job creators” to spur growth and allow a “rising tide to raise all boats.”
[xii] President Obama in a January 14, 2013 press conference said: “I’m Open to Making Modest Adjustments to Programs Like Medicare.” Meanwhile, the jobs problem has evaporated from the government’s purview.
[xiii] Hudson, Michael. “The Ideological Crisis Underlying Today’s Tax and Financial Policy.” Counterpunch, January 4-6, 2013. http://www.counterpunch.org/2013/01/04/the-ideological-crisis-underlying-todays-tax-and-financial-policy/.
[xiv] Revealingly, Googling “Reagan social security deficit” turns up a clip of Ronal Reagan explaining why Social Security does not contribute to the federal government deficit. To be fair to those who say it does, here is the argument: To cover paying back its debt to the Social Security Trust Fund the government must borrow money. Therefore Social Security is contributing to the deficit.
[xv] Christopher, Tommy. “GOP Leader Alan Simpson’s ‘Lesser People’ Gaffe Overlooked By News Media.” Media-ite. June 23, 2010. http://www.mediaite.com/online/republican-deficit-commission-chair-alan-simpsons-lesser-people-gaffe-flies-under-the-radar/.
[xvi] Kervick, Dan. “The Coin Abides.” New Economic Perspectives, January 13, 2013. http://neweconomicperspectives.org/2013/01/the-coin-abides.html#more-4484.
[xvii] Strether, Lambert. “Going Platinum.” Naked Capitalism, January 16, 2013. http://www.nakedcapitalism.com/2013/01/going-platinum.html.
[xviii] In fact, there are many areas of the Federal budget that could be reduced if the old saw of “waste, fraud and abuse” were taken seriously. For instance, 1) the recently passed fiscal cliff compromise legislation of December 31, 2012 contains tax breaks for NASCAR, Goldman Sachs and other corporations; 2) the Pentagon’s budget is so convoluted it is impossible for auditors to know where the $600 billion (official figure) it receives each year is going; the oil depletion allowance and other fossil fuel and agriculture tax breaks are antediluvian. And on and on this list goes for those truly concerned about reducing government spending.
[xix] Gray, John, False Dawn: The Delusions of Global Capitalism. NYC: The New Press. 1998.
[xx] Polanyi, Karl. The Great Transformation: The Political and Economic Origins of Our Time. Boston: Beacon Press. 1957, P. 73.
[xxi] Catton, William R, Jr. Overshoot: The Ecological Basis of Revolutionary Change. Urbana: University of Illinois Press. 1982.
Social, Political, Economic and Environmental Issues That Affect Us All. August 22, 2010. http://www.globalissues.org/article/39/a-primer-on-neoliberalism.
[xxiii] Hirschman, Albert O. Exit, Voice and Loyalty: Responses to Decline in Organization and States. Cambridge, MA: Harvard University Press.
[xxiv] Wikipedia. “Three wise monkeys.” In the Western world both the proverb and the image are often used to refer to a lack of moral responsibility on the part of people who refuse to acknowledge impropriety, looking the other way or feigning ignorance. http://en.wikipedia.org/wiki/Three_wise_monkeys.
[xxv] Millions of Americans have lost their jobs and homes, seen their purchasing power shrink and their health status decline or be placed at heightened risk; meanwhile the top 1% of earners are “Striking it Richer: The Evolution of Top Incomes in the United States” by Emmanuel Saez, Scribd.com January 23, 2013. http://elsa.berkeley.edu/~saez/saez-UStopincomes-2010.pdf.
[xxvi] “The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system.” World Health Organization. http://www.who.int/social_determinants/en/.
[xxvii] The American Public Health Association has the notoriety of vigorously supporting the fall 2008 “Bank Bailout” legislation called TARP, Troubled Assets Relief Program”. During this period Congress once voted the legislation down and calls to Congressional offices were running 100-1 against the bailout. The APHA sent numerous email appeals to its members to contact their congressional representatives to support TARP because there was some pittance of funding placed in the bill for public health to secure the APHA’s support.
[xxviii] Williams, Callum and Mahiben Maruthappu. ‘“Healthconomic Crises”: Public Health and Neoliberal Economic Crises.’ American Journal of Public Health, Volume 103, Issue 1, January 2013.
[xxix] Layton, Julia. “What causes Stockholm syndrome?” Discovery Fit & Health. http://health.howstuffworks.com/mental-health/mental-disorders/stockholm-syndrome.htm. ND.
[xxx] “Turpitude” means literally moral degeneracy but the colloquialism “moral turpitude” is commonly used.
[xxxi] Foucault, Michel. The Order of Things. NYC: random house. 1970.
[xxxii] A report from the annual meeting of neoliberal elites at Davos, Switzerland reads: The message this year is that the improvement in sentiment seen in 2011 and 2012 has stalled. As far as business confidence is concerned there is a global double-dip recession…It’s not hard to see why. Everywhere executives look there are problems… “Denial, panic and doubt in Davos,” The Guardian Economics Blog. http://www.guardian.co.uk/business/economics-blog/2013/jan/23/davos-2013-denial-panic-doubt.
[xxxiii] Kuhn, Thomas. The Structure of Scientific Revolutions. Chicago: University of Chicago Press. 1962.
[xxxiv] See: “(Pierre) Bourdieu and ‘Habitus’.” Powercube: Understanding power for social change. http://www.powercube.net/other-forms-of-power/bourdieu-and-habitus/.
[xxxv] Steve Ludlum notes, “If there is no borrowing there is no business! This is why the banks and finance are bailed out … exponential growth of credit is why the finance system is inundated with debts and debt-related costs.” This cycle of debt servicing debt is breaking down as natural resources become scarce and expensive. It is at the core of the unsustainability of neoliberalism. “Watch the Banks.” Economic Undertow, February 2, 2013.http://www.economic-undertow.com/2013/02/02/watch-the-banks/.
[xxxvi] Frankfurt, Harry. “On bullshit.” PDF: http://www.linguistik.tu-berlin.de/fileadmin/fg72/PDF/Peters_PDF/FRANKFURT__H._G.__2005._On_Bullshit..pdf.
[xxxvii] Georgescu-Roegen, Nicholas.
- Energy and Economic Myths: Institutional and Analytical Economic Essays. Pergamon Press: New York. 1976.
- The Entropy Law and the Economic Process. Harvard University Press: Cambridge, Massachusetts. 1971.
Hall, Charles A.S. and Kent Kiltgaard. Energy and the Wealth of Nations: Understanding Biophysical Economy. NYC: Springer, 2012.
Odum, Howard. Environment, Power, and Society for the Twenty-First Century: The Hierarchy of Energy. NYC: Columbia University Press. 2007.
Soddy, Frederick. Wealth, Virtual Wealth and Debt: The Solution of the Economic Paradox. Dutton, 1926.
Daly, Herman E. Beyond Growth. Boston: Beacon. 1996.
Keen, Steve. Debunking Economics. NYC: Zed Books. 2011.
[xxxix] Karen Sternheimer. “Inequality and Life Chances: Going to Law School or Going to Prison.” Everyday Sociology. September 27, 2010. http://nortonbooks.typepad.com/everydaysociology/2010/09/inequality-and-life-chances-going-to-law-school-or-going-to-prison.html.
[xl] A brief example: if you have a 1970s vintage natural gas furnace in your home it runs at 60% efficiency, at best. You can replace it with a furnace rated at 90+ efficiency thereby saving energy if you keep your home at the same temperature as before. If you decide to set your thermostat back several degrees you are conserving energy. If you decide to remove the furnace –perhaps in favor of a wood stove- you are reducing your use of complex technology –no more use of natural gas, some electricity (for the blower), service technicians, and so on. If everyone reduced complexity there would be systemic consequences for no longer heating with natural gas.
[xli] They are increasing in the United States by virtue of yet another “bubble” of cheap loans to people, primarily for housing and cars, likely to default on them.
[xlii] “President Obama Establishes Bipartisan National Commission on Fiscal Responsibility and Reform.” http://www.whitehouse.gov/the-press-office/president-obama-establishes-bipartisan-national-commission-fiscal-responsibility-an.
[xliii] The difference between Democrats and Republicans is about the esthetics of each party’s base: the Democrats need to beguile its base with progressive rhetoric as they deliver death by a thousand cuts, while the Republicans favor oratory appeasing their base with the imagery of the swiftness of a scimitar beheading.
[xliv] The International Monetary Fund, IMF, has consistently recommended austerity for European nations. See: Mark Weisbrot and Helene Jorgensen, “Macroeconomic Policy Advice and the Article IV Consultations: A European Union Case Study,” Center for Economic and Policy Research, January 2013. http://www.cepr.net/documents/publications/article-IV-2013-01.pdf. They review IMF policy recommendations and conclude:
“Fiscal consolidation is recommended for all 27 EU countries, and expenditure cuts are generally preferred to tax increases. In some cases there are targets or limits on public debt/GDP ratios or fiscal deficits that are below those of the Maastricht treaty. There is repeated emphasis on cutting public pensions and “increasing the efficiency” of health care expenditures.”