Grenfell Tower fire: why we cannot ignore the political determinants of health

The questions began within hours of the tragedy. Could it have been foreseen? Was there a design fault? Why had the victims been concentrated among the poor and marginalised? More questions followed a few days later. How could politicians appear so insensitive in the face of such suffering? Why were so many warnings ignored? Who was responsible for the budget cuts that increasing numbers of people blamed for the disaster?

This was not London in 2017, in the aftermath of the fire in Grenfell Tower, a residential block that turned into an inferno trapping scores of people, with at least 79 people dead or missing. It was 2005, in New Orleans. The official line, repeated by President George W Bush, was that the flooding that followed Hurricane Katrina could not have been foreseen. Yet, it soon became clear that the Federal Emergency Management Agency had predicted that flood protection would be overwhelmed only four days before the event.1 Others noted how, while those with the means to escape did so, the poor and dispossessed were left behind.

Soon, people began asking how this could have happened in one of the world’s richest countries. How could those in power fail to empathise with their fellow citizens, as when Barbara Bush, wife of President George Bush senior, said of those in temporary shelters that “so many of the people in the arena here, you know, were underprivileged anyway, so this is working very well for them”?2

Some argued that what happened could only be understood by looking at the underlying political determinants of the tragedy,3 4 while others argued the opposite 5

Many watching events unfold in June 2017 in west London felt that history was repeating itself. Even while the fire engulfing Grenfell Tower was still burning, local residents described how they had repeatedly attempted to draw the authorities’ attention to the risk of fire. With tragic prescience, they predicted that “only a catastrophic event will expose the ineptitude and incompetence of our landlord.”6 Soon afterwards, attention focused on earlier fires in similar tower blocks, amid allegations that ministers had failed to act on recommendations from coroners.7

The response from the people of London was extraordinary, but the political response was not. The prime minister was accused of lacking humanity for not meeting relatives.8 The local council attracted particular criticism: Emma Dent Coad, Kensington and Chelsea’s new member of parliament, told newspapers that “there was no council presence” and “they weren’t making sure that [those affected had] any kind of support.”9 As evidence of local government failings accumulated, central government had to intervene with its own task force.10

As with Hurricane Katrina, some of those affected quickly invoked the political determinants of the tragedy. They highlighted an unwillingness to impose stronger safety regulations on landlords, the cuts imposed on the fire service, and the restrictions in legal aid that had prevented residents from advancing their case in the courts.9 As in New Orleans, views were divided. Those on the left highlighted the political dimension; those on the right condemned politicising the tragedy.11 12

But if public health is concerned with the prevention of illness, injury, and premature death, it must work to avoid tragedies such as the Grenfell Tower fire by seeking to address the causes of the causes13 and, above all, by confronting those with power. It is the powerful who define the narrative in the media and in political discourse, decide who is to blame, what policies are acceptable, and even whose lives are important. They set the rules that relax standards on safety and employment rights. And they silence the weak, ignoring or discounting their views.

In response, public health professionals must make the invisible visible. They must emulate those who asked why 76% of third class passengers on the Titanic perished but only 39% of those in first class,14 those who showed that inequality is “killing people on a grand scale,”15 and those who measured then exposed the human cost of austerity.16 They must also make visible the often hidden corporate determinants of health, such as the tactics used by tobacco,17 food,18 and alcohol19 industries in subverting healthy public policies.

In giving voice to the voiceless, health professionals can take inspiration from Rudolf Virchow, whose investigation of a typhus epidemic led him to conclude that the ultimate cause was the power of the aristocracy, propped up by the church.20 Speaking truth to power has become more difficult in England since the 2012 NHS reforms, when large parts of the public health function were moved into local government, but it is impossible to achieve a comprehensive understanding of events such as Grenfell Tower without confronting the political determinants of health and challenging the forces that shape them.