Over the last fifty years, neoliberalism has reshaped the social, economic and political conditions that determine health. Drawing on the second edition of our book Neoliberal Epidemics: How politics makes us sick (Schrecker & Bambra, 2025), this article sets out how neoliberalism has operated as a powerful upstream determinant of population health. Neoliberalism describes a multidimensional set of ideas, policies and forms of governance that rose to prominence following the economic crises of the 1970s, following a trajectory that can be traced at least to the 1947 establishment of the Mont-Pèlerin Society (Harvey, 2005). Neoliberalism is best understood not as a single doctrine but as an historically contingent and intellectually flexible project combining ideology, policy programmes and modes of governance (Ban, 2016; Steger & Roy, 2010; Ward & England, 2007). At its core is what Somers (2008) describes as “market fundamentalism”: the belief that markets are the most normal, natural and defensible way of organising social and economic life. Under neoliberalism, markets are assumed to maximise freedom, efficiency and welfare because exchanges are voluntary. The primary function of the state is to ensure that markets function efficiently. Institutions or policies that produce outcomes any different from those expected under idealised market conditions are suspect or even unthinkable (Gourevitch, 2013; Steger & Roy, 2010). Under neoliberalism, the state does not necessarily shrink; rather, it is repurposed to benefit different sets of actors. Here we summarise how neoliberalism shapes population health through four interlocking and mutually reinforcing pathways: widening inequality, chronic stress, pervasive insecurity, and the growing power of harmful commercial actors. Neoliberalism operates as an “inequality machine” (Halimi, 2013), concentrating income and wealth while weakening redistribution and social mobility (Chancel et al., 2021; Piketty & Saez, 2013). Neoliberalism produces widespread material insecurity through the erosion of secure employment, retrenchment of welfare systems and the shifting of risk from states and employers onto individuals. As a result, individuals and communities are exposed to sustained psychosocial stress as economic insecurity intensifies, control over work and daily life is reduced, and precarity becomes normalised as a permanent condition (Bambra, 2011). Insecure work, inadequate income protection, housing precarity and food insecurity have become routine features of neoliberal societies, with cumulative and interacting effects on health (Kalleberg, 2018; Shildrick et al., 2012). To illustrate how these pathways operate in practice, we use austerity as a case study, showing how neoliberal policy choices intensify stress, insecurity and inequality while producing measurable increases in premature mortality and stalled life expectancy (McCartney et al., 2022; Stuckler & Basu, 2013). Finally, neoliberalism amplifies the damaging effects of commercial determinants of health by enabling corporations to market and profit from harmful products while constraining public regulation. Following Virchow’s insight that politics is medicine “on a large scale”, we conclude that under neoliberalism, health inequalities are inevitable. Addressing them therefore requires public health to confront the political and economic structures that systematically generate stress, insecurity, inequality and commercial harm, rather than relying on downstream or individual-level interventions.

Neoliberalism has operated as an “inequality machine” reshaping the global and national distribution of income, wealth and life chances since the late twentieth century (Halimi, 2013; Milanovic, 2013). Globally, during the era of neoliberal globalisation, economic growth has been distributed highly unevenly: between 1980 and 2020 the bottom half of the global income distribution captured only 9 percent of growth, while the top one percent captured almost one quarter (Chancel et al., 2021). Wealth inequality is even more extreme, with a tiny global elite accumulating resources at a scale far exceeding those of billions of people combined (Chancel et al., 2021; Milanovic, 2016). Within countries, neoliberalism has also been associated with rising income and wealth concentration (Piketty, 2014). In most high-income countries, income inequality increased as welfare states retrenched and labour market protections weakened (OECD, 2011; 2015). In the United States and the United Kingdom, large shares of national income were shifted from the bottom 90 percent to the top 10 percent, especially the top one percent (Piketty & Saez, 2013; Price & Edwards, 2020; Saez & Zucman, 2016). These trends reflect declining labour shares of income, wage stagnation for most workers, and rapid income growth for a small group of high earners alongside expanding low wage and precarious work (Blanchet et al., 2024; Duménil & Lévy, 2004). Neoliberal policies have also amplified inequality through financialization and crisis management. Financial globalization increases income shares at the top while generating pressure for austerity, further magnifying inequality (Furceri et al., 2020). Responses to the 2007–08 financial crisis and Covid-19 pandemic, including quantitative easing, disproportionately raised asset prices, benefiting wealthy households and deepening wealth inequality (Green & Lavery, 2015; United Nations Department of Economic and Social Affairs, 2020).

Neoliberalism systematically produces insecurity as a normal condition of life, with severe social and health consequences. It has generated pervasive and multidimensional expansion of insecurity, reshaping work, income, welfare and the social determinants of health. Central to this neoliberal epidemic of insecurity is the transformation of labour markets. Since the 1970s, policies promoting labour market “flexibility” have reduced job security, weakened workplace rights, lowered pay, and curtailed welfare entitlements, shifting risks from employers and states onto individuals and households (Kalleberg, 2011; Standing, 2014). Secure, well paid manufacturing jobs—historically accessible to those without formal qualifications and often protected by trade unions—have been displaced by deindustrialization, offshoring and outsourcing, producing geographically concentrated job losses and health impacts (Bluestone & Harrison, 1982; Schrecker, 2009). Neoliberal labour markets are characterised by the growth of precarious work, including temporary contracts, involuntary part time employment and zero hours contracts, in which workers bear uncertainty over hours, income and benefits (Kalleberg, 2018). Rather than serving as transitional phases, such arrangements now define working lives for many, producing the “low pay, no pay cycle” that normalises movements in and out of employment and poverty (Shildrick et al., 2012). This insecurity is exacerbated by declines in union power, falling real minimum wages (particularly in the US), and explicit policy acceptance of unemployment and worker insecurity as tools for disciplining wages and controlling inflation (Brown et al., 1997; House of Commons, 1991; U.S. House of Representatives, 1997). Beyond work, neoliberalism has extended insecurity by way of the “great risk shift,” in which responsibility for managing economic risk has been transferred from collective institutions to individuals (Hacker, 2008). For example, welfare retrenchment has sharply reduced the protection offered during unemployment, illness and retirement, leaving households highly exposed to income shocks (Sowula et al., 2024). Insecurity increasingly spills across domains through “risk contagion” (Thelen & Wiedemann, 2021), linking events such as job loss to food insecurity, loss of housing and health care (in the US) and, in some cases, criminalization (De Sousa et al., 2024; Loopstra, 2024; Rajagopal & De Schutter, 2024).

Neoliberalism exacerbates chronic stress through interconnected material, psychosocial and biological pathways that operate across the life course and are patterned by social position. The production of material insecurity is central to these pathways (Sapolsky, 2005). Insufficient income, insecure employment and the erosion of collective resources increase exposure to the adverse living conditions that generate chronic stress (Lynch et al., 2000). A key psychosocial pathway linking neoliberal labour markets to elevated stress is through reduced control and heightened demands at work. The demand–control model shows that jobs characterised by high demands and low control generate high stress and are strongly associated with cardiovascular disease, mental ill health, unhealthy behaviours and obesity (Backhaus et al., 2023; Karasek & Theorell, 1990). Neoliberal restructuring has spread insecure, low-paid and low control work, including temporary and precarious employment, which is associated with worse general health, depression, anxiety, high blood pressure and higher mortality (Bambra, 2011; Siegrist, 2023). These psychosocial stressors have direct biological consequences. Chronic exposure to stress activates neuroendocrine pathways involving the sympathetic–adrenomedullary and hypothalamic–pituitary–adrenocortical systems, leading to repeated cortisol secretion with pathogenic effects on metabolism, immunity and cardiovascular function (Brunner, 1997; 2007). Over time, this produces elevated allostatic load - biological “wear and tear” - which predicts increased morbidity and premature mortality (McEwen & Gianaros, 2010; McEwen & Seeman, 2009). Stress pathways under neoliberalism accumulate across the life course. Research on “weathering” and the exposome shows that repeated exposure to social disadvantage, insecurity and discrimination becomes biologically embedded, accelerating physiological ageing and amplifying health inequalities over time (Geronimus et al., 2006; Vineis et al., 2020; Vineis & Barouki, 2022).

Austerity provides a particularly clear case study of how neoliberalism translates from ideology into lived experiences and negative health outcomes. Austerity mirrors earlier structural adjustment programmes imposed on low and middle income countries, reinforcing its status as a neoliberal policy export rather than an unavoidable response to crisis (Kentikelenis & Stubbs, 2023). After the 2008 Global Financial Crisis, structural adjustment “travelled north” (Kentikelenis, 2017) as a politically chosen neoliberal response that prioritised deficit reduction through cuts to welfare, social protection and public services, while leaving the structural power of finance capital and corporations largely intact (Stuckler & Basu, 2013). As such, austerity intensified chronic stress, normalised economic insecurity, widened existing inequalities and weakened the social security system, producing measurable and avoidable harms, particularly in Greece, Spain, Portugal and the UK. Austerity exemplifies neoliberalism in practice by converting its core commitments—market primacy, individual responsibility and the reconfiguration of the state—into crisis policy. Although the financial crash was rooted in decades of neoliberal deregulation and close alignment between governments and the financial sector, the costs of market failure were externalised onto populations rather than capital (Johnson & Kwak, 2011; Krippner, 2011). Risks were socialised through publicly funded bank bailouts, while subsequent “fiscal consolidation” shifted costs downward onto households, communities and public services in what is best described as a large-scale human experiment on non-consenting populations (Stuckler & Basu, 2013). Public spending was not reduced evenly; instead, social protection, local government capacity, preventive public health and welfare benefits were disproportionately cut, while state functions that support markets, enforce discipline or subsidise corporations were preserved. For example, in the UK, this took the form of substantial cuts to local authority budgets, social care, public health grants and working-age benefits, alongside historically low growth in NHS funding (Dorling, 2022; National Audit Office, 2018). These changes disproportionately affected lower income households that rely most on public services. As Richard Horton, editor of The Lancet, argued, austerity functioned as neoliberalism’s “calling card,” deepening inequality and producing preventable harm under the guise of fiscal discipline (Horton, 2017). Ideologically, austerity was underpinned by neoliberal narratives of deservingness, dependency and personal responsibility. UK welfare reforms intensified conditionality and sanctions through policies such as Universal Credit, the benefit cap and the two child limit, echoing earlier US welfare reforms that framed poverty as moral failure rather than structural outcome (Murray, 1984; Wacquant, 2009). This asymmetrical moral economy subjected benefit claimants to heightened surveillance and punishment, while corporate recipients of public support – such as the banking sector - faced minimal scrutiny (Alston, 2019). Health outcomes provide particularly clear evidence of austerity as a neoliberal project. A substantial international literature shows that countries pursuing austerity experienced worse mortality trends and increased health inequalities than those adopting stimulus measures (Karanikolos et al., 2013; Stuckler et al., 2009). In the UK, austerity coincided with stalled life expectancy improvements, widening geographic inequalities, rising suicides in deprived areas, increased infant mortality inequalities and estimated excess deaths linked to pressures on health and social care systems (Barr et al., 2012; Leon et al., 2019; Walsh & McCartney, 2025).

Commercial determinants of health are strategies and practices through which private sector actors drive unhealthy consumption and influence policy, particularly in sectors such as food, alcohol, gambling, tobacco, pharmaceuticals and fossil fuels (Gilmore et al., 2023; Kickbusch et al., 2016). Neoliberalism’s emphasis on deregulation, privatization, trade liberalization and financialization has amplified corporate power and expanded markets for unhealthy commodities (Freudenberg, 2014), notably by enabling industries to resist regulation if not delegitimising regulation itself. Corporations routinely deploy tactics perfected by the tobacco industry, including lobbying, capturing advisory bodies, framing health problems as matters of individual choice, and “manufacturing uncertainty” by funding and distorting scientific research (Freudenberg, 2014; Michaels, 2006; 2020). Governments often align with commercial interests, prioritizing industry profitability over public health (Baker et al., 2025; Moss, 2013). A key example is the global rise of obesity and diet related diseases since the 1980s (Koliaki et al., 2023; Offer et al., 2012). Neoliberal economic and social policies increase food insecurity and reduce the affordability of healthy diets, pushing low income households toward cheaper, energy dense foods (Drewnowski, 2009; Drewnowski & Eichelsdoerfer, 2010). At the same time, transnational food corporations (“big food”) dominate global food systems, devoting vast resources to engineering hyper-palatable ultra processed foods (UPFs) and aggressively marketing them, particularly to children (Dalton et al., 2017; Linn & Novosat, 2008; Moss, 2013). UPFs account for a large and growing share of diets in many countries and are strongly associated with increases in obesity, cardiovascular disease, type 2 diabetes, cancer, mental disorders and premature mortality (Monteiro et al., 2025). Their global spread is closely linked to neoliberal trade and investment regimes that facilitate foreign direct investment, supermarket expansion, and cross border flows of subsidized ingredients such as high fructose corn syrup (Clark et al., 2012; Hawkes et al., 2009; Stuckler et al., 2012). Fossil fuels represent another crucial commercial determinant of health, by way of their contribution to climate change (Romanello et al., 2025). A small number of corporations account for a large share of historical greenhouse gas emissions and yet they receive help from extensive subsidies and political protection (Heede, 2014; OECD, 2025). Like tobacco and food corporations, fossil fuel companies have systematically obscured scientific evidence, influenced policy, and used trade and investment agreements to constrain government action on climate change, with severe consequences for health and health equity (Oreskes & Conway, 2010; Supran & Oreskes, 2017; Tienhaara et al., 2023). Further, individuals at the very top of national and global income and wealth distributions not only account for a disproportionate share of greenhouse gas emissions (Chancel & Mohren, 2025) but also are the primary beneficiaries of windfall gains when fossil fuel prices rise on global markets (Semieniuk et al., 2025).

Neoliberalism is not merely an economic, political or ideological framework but a powerful upstream determinant of health, operating through four interlocking and mutually reinforcing pathways: chronic stress, pervasive insecurity, widening inequality and the growing influence of harmful commercial actors. Across these domains, neoliberalism restructures the conditions of everyday life in ways that are biologically embodied over time, generating patterned and preventable health inequalities. The case study of austerity brings these pathways into sharp empirical focus. Taken together, the evidence presented here shows that the health harms associated with neoliberalism are intrinsic and unavoidable. They are the predictable outcomes of political and economic choices that prioritise markets over social protection and individual responsibility over collective security. Reducing health inequalities therefore requires more than the traditional, incremental, individual-focused interventions of mainstream public health practice, which are the equivalent of sticking plasters on a sucking chest wound - completely incommensurate with the scale of change required. What is really needed are fundamental changes to the political and economic structures that produce stress, insecurity, inequality and commercial harm in the first place. Public health needs to understand that it is politics writ large.

Notes

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