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Decommodifying the most important determinant of health
  1. Arianne Shahvisi
  1. Ethics, Brighton and Sussex Medical School, Brighton, UK
  1. Correspondence to Dr Arianne Shahvisi, Ethics, Brighton and Sussex Medical School, Brighton, East Sussex, UK; A.Shahvisi{at}

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Among the most harrowing visuals of Britain’s ongoing ‘cost of living crisis’ are the security tags that began to appear on cheese, butter, chicken, sweets and infant formula milk in 2022. A week’s worth of formula milk—the sole or main food of the vast majority of infants for the first 6 months of life—now costs between £9.39 and £15.95.1 Low-income households are entitled to a ‘Healthy Start’ welfare payment, intended to avert malnutrition among the poorest children, but the weekly allowance is just £8.50.2 There are reports of parents watering down formula, skipping or limiting feeds and initiating early weaning, all of which jeopardise the health of infants, with potentially lifelong consequences.3

No determinant of health is more critical than food. A 2019 study found that diet is the most significant risk factor for non-communicable disease, and that one in five deaths globally could be prevented by improving nutrition.4 Globally, 1 in 10 people cannot meet their daily energy needs,1 and the proportion of undernourished people is rising.5 In more than 50 countries, most of them in Africa, over a quarter of children are stunted or wasted due to undernourishment, with long-term effects on their cognitive and physical development.

These are not problems of absolute scarcity; enough food is produced globally to feed ten billion people.6 In the UK, there is, at any given moment, sufficient food on supermarket shelves to meet the calorie and nutrient needs of the population. Yet the equivalent of nearly 200 million meals a year are discarded,7 while almost a quarter of parents report having skipped meals in the last year in order to afford to feed their children.8 Most food insecurity is the result of manufactured scarcity: wages are kept low relative to the cost of basic necessities. That is an economic choice, and its consequences are widespread hunger and ill health.

In the short term, welfare payments should be increased, and wages should be more closely linked to the cost of the needs they are supposed to meet. But the issue is serious enough to demand engagement with a more radical question: Should a person’s nutritional intake be determined by their household income and the whims of the market? In the case of children, something like luck egalitarianism provides easy justification for the intuitive ‘no’: a child’s circumstances are wholly unchosen, and no-one should be worse off for reasons that are beyond their control.

Returning to the problem of infant nutrition, one robust proposal is the provision of free or heavily subsidised milk for all children.9 10 This is not as impractical or extraordinary as it sounds. A National Dried Milk Scheme ran from 1940 to 1976 in the UK, distributing state manufactured milk powder to as many as 85% of infants, as part of a broader ‘Welfare Foods’ scheme, which included orange juice and cod liver oil. The reintroduction of such a scheme would be consistent with recent measures to offer free school lunches to all primary school children2 in Scotland and Wales,11 and would likely be met with similar popular support. Almost three-quarters of survey respondents support universal free school meals for children,12 and 87% believe that the government bears responsibility for feeding children affected by food poverty.13

Why stop there? We might reasonably ask whether any food should be commodified. In the UK, 90% of people support the idea that healthcare should be free.14 Could we be persuaded to think of food, that most fundamental determinant of health, as a coherent complement to a free healthcare system? Luck egalitarianism appears to run out; adults lead lives of their own choosing. Yet even to the hardened libertarian, that last clause surely rings false when it comes to food in the present context. Can children who grow up hungry simply choose lives in which they can protect their adult selves, and their children, against hunger? A significant proportion of nurses and teachers are among the three million people who relied on UK food banks over the last year.15 16 Are those foolish career choices for those seeking secure access to food? We must either discard luck egalitarianism and its political relatives in favour of a more sensible ethics, or else admit that our choices are limited, and rigged, and have nothing to do with whether or not we should be able to fill our stomachs.

One option is to explicitly recognise the continuity between food and medicine and issue free prescriptions for nutritious food on the basis of health risk, income, or both. At the end of 2022, two London boroughs launched a pilot scheme which prescribes fresh fruit and vegetables to low-income residents living with chronic diseases.17 Similar programmes have been trialled in the USA, Canada and Australia.18 Schemes of this kind are often criticised for being patronising and ineffective. While there are good arguments for clinicians discussing food insecurity with patients,19 asking doctors to be responsible for gatekeeping access to food is surely a sign of system failure. Such schemes also often fail to account for structural barriers to good eating. More than a million people in the UK live in ‘food deserts’, most of them deprived areas, and would struggle to redeem healthy food tokens.20 Many of those who would qualify for such schemes would be unable to afford the fuel for cooking, access to a well-equipped kitchen, and the time, energy, and well-being required for food preparation.

Another wartime initiative might offer a more promising solution. From 1940 to the 1970s, state-owned ‘British restaurants’ across the UK served nutritionally balanced food, with prices capped at nine imperial pence per meal. That would be the equivalent of providing healthy meals today for around £1.50. The physical infrastructure already exists: every evening, there are unused school cafeterias in the heart of communities that could be used to provide free or low-cost nutritious dinners to local residents. Initiatives of this kind sidestep the constraints of limited time and fuel, and communal eating has been shown to promote a sense of connection,21 which could also tackle the health effects of loneliness.

We could also turn our attention to supermarkets, those great stores of necessities on which we all depend for our survival, who are currently free to raise prices and fasten security tags as they see fit. There are vital lessons to learn: the ability of supermarket giants to supply food at scale without the need for internal markets demonstrates that economic planning at the level of nations is not only possible,3 but can be highly successful.22 Nationalising that infrastructure could allow the state to focus on ensuring adequate provision of affordable, nutritious, convenience food that answers to people’s needs, public health goals and environmental considerations, rather than pursuing profits for shareholders.

This July was our planet’s hottest month since records began. Severe crop losses and marine mortality events are expected, with catastrophic effects on food security and therefore on health.23 We are getting closer to being one bad season away from a real and deadly scarcity. Our collective margin for error in keeping everyone fed is dwindling, and we cannot afford to keep failing on the question of distribution. Something needs to change; this is no time to waste, and there is no time to waste.

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  • Twitter @ArianneShahvisi

  • Contributors AS is sole and corresponding author.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • That is without even studying the nutrient content of those calories.

  • And to all infant school children in England, as well as to others based on household income.

  • Contra economists like von Mises and Hayek

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