The snake on the Rod of Asclepius has twisted the symbol of the healing arts into a dollar sign. This cartoon announces Socialist Register 2010 as the annual publication begins its forty-sixth year with vigor. Morbid Symptoms: Health Under Capitalism boldly proposes that it is possible “to make the fundamental contradiction of health under capitalism the pivotal issue of a revitalized socialist strategy.” The work will raise consciousness and, in the best tradition of scientific socialism, compel political action.
The seventeen essays present rigorous social science. The topics extend from “commodification versus solidarity” to medical TV dramas, from “the practices of big pharma” to China’s need to restore universal access to health care, from neoliberal economics in India to Cuba’s health politics, from “the shaping of global health policy” to “mental health in a sick society.” So many of the articles will inspire discussion among groups of caregivers—or health reform advocates, or trade unionists—or for that matter all with an interest in the issues of health and caregiving.
The lead essay by Colin Leys exposes several contradictions. The enormous increase in life expectancy in England between 1870 and 1950 advanced the illusion that “capitalism promotes health.” Through an elegant synopsis of the contradictory results of science under capitalism, Leys discloses how the “mortality revolution” came about—not from better nutrition, not from rising incomes—but from the construction of sewers and water mains and the regulation of housing and food. Sanitation reforms were won in spite of opposition by capitalists. Leys writes:
The sanitation movement that sparked the mortality revolution in England was, then, hardly an achievement, in the sense of an intended effect, of capitalism, any more than the Russian revolution was an achievement of the Czarist autocracy, or the Indian independence an achievement of the British Raj. The sanitation movement that produced the mortality revolution was a reaction against the social costs of capitalism, not a benefit that the capitalist class sought to confer.
Like Morbid Symptoms as a whole, most of Leys’ essay presents data that reveal the unnecessary cruelty that profit-seeking imposes upon us. The drive to commodify human health, justified by false promises of cost-containment and efficiency, leaves neoliberal ideology progressively disconnected from reality. In the context of the present economic crisis, Leys concludes, a “new common sense” can emerge. “The situation,” he writes, “has all the makings of Gramsci’s definition of an ‘organic’ crisis, a ‘real crisis of ruling class hegemony.’”
Many contributors take note of contradictions in global health systems. Kalman Applbaum reminds us that, thanks to marketing, “the managerial techniques and outlooks of private industry have been widely adopted by public sector providers.” The corporate defense of intellectual property rights, Meri Koivusalo recounts, has managed to become a priority for global public health policy, thanks to the influence of private agencies. Pat Armstrong and Hugh Armstrong note that, thanks to the effort to commodify health services in Canada, “evidence-based medicine” has been co-opted from a tool to support patient-centered decision making to a means to control physicians’ and nurses’ workdays. Robert Albritton contrasts the drive for profits by giant U.S. food corporations with the vast environmental damage they have wrought and with the rising incidence of hunger and starvation, with a disproportionate toll among women, across the globe.
In “Maternal mortality in Africa: A gendered lens on health system failure,” Paula Tibandebage and Maureen Mackintosh write:
Charges for both publicly and privately provided services create a barrier to access in time of need and generate further impoverishment. Exclusion from health care thereby becomes not only a generator of poverty but also a defining aspect of the experience of being poor. To be sent away from a health facility without care when you or a child is ill is truly to know how poor you are.
Tibandebage and Mackintosh report that the lifetime “chance that a 15-year-old woman will die of maternal causes” in sub-Saharan Africa “was estimated at 1 in 26 in 2005, and in Niger, the worst case, 1 in 7. In Ireland, the lowest-risk country, it was 1 in 48,000.” They give a riveting account of how marketization of health care—together with a public sector “gender bias against the health needs of women of child-bearing age”—worsened the entirely preventable crisis in obstetric care. Out-of-pocket expenses grew, especially for rural women, including transportation costs and new fees that were introduced as health services were commodified.
In an overview of health politics in Cuba, Julie Feinsilver writes: “More than any other government, Cuba’s leaders consider health indicators, particularly the infant mortality rate and life expectancy at birth, to be measures of government effectiveness,” she writes. “As a result, the health of the population becomes a metaphor for the health of the body politic.” Cuba’s traditions now include community self-reliance and health system experimentation, more doctors per person than any other nation (twice that in the U.S.), an official emphasis on the social determinants of health, and international “medical diplomacy.”
Feinsilver is by no means uncritical, explaining that while an emphasis on health produces benefits for the government, it also carries significant risks for government legitimacy. She notes the authoritarian implications of sending Cuban women “with high-risk pregnancies, or who live far from an appropriate institution in which to give birth” to special maternity homes for the last weeks of pregnancy, a result of the government obsession over “any infant death.”
Feinsilver also explores the legitimacy Cuba has earned through international medical diplomacy. “Overall since 1961, Cuba has conducted medical diplomacy with 103 countries,” she enumerates, “deploying 113,585 medical professionals abroad. As of April 2008 over 30,000 Cuban medical personnel were collaborating in 74 countries across the globe. Cuban data indicate that Cuban medical personnel abroad have saved more than 1.6 million lives, treated over 85 million patients (of which more than 19.5 million were seen on ‘house calls’ at patients’ homes, schools, jobs, etc.), performed 2.2 million operations, assisted 768,858 births, and vaccinated with complete dosages more than 9.2 million people.” She reminds us too of Cuba’s contributions to disaster relief, including the provision of “a team of highly experienced disaster relief specialists, comprising 2,564 doctors (57 percent), nurses and medical technicians” to Pakistan after an earthquake there in 2005.
Shaoguang Wang also incorporates the idea that health plays a crucial role in the legitimacy of the government of China, “a country that still professes to uphold the socialist principle of equity.” Wang asks: “Why, with higher disposable income per capita, better nourishment, and a bigger proportion of its national income devoted to health and health care, has China’s health performance been so disappointing during the reform era?” His answer: economic inequality has worsened. For example, Wang shows that between 1998 and 2003 illness emerged as the leading cause of rural poverty in China.
In “Inequality and health” David Coburn synthesizes international trends. “The balance of class forces,” Coburn writes, “lies behind both national differences in health status, and the inequality in health within nations.”
Several essays in Morbid Symptoms augment Coburn’s analysis. Among them, Mohan Rao traces how, in India, worsening inequalities result from “policies that reflect an ideological commitment to unbridled market principles” thanks to the influence of institutions like the World Bank. Cristoph Hermann writes that privatization in Europe has brought economically regressive out-of-pocket payments and private insurance premiums, Robin-Hood-in-reverse penalties upon people with low incomes. Privatization increases costs and undermines quality. Hermann notes, for example, that “national statistics show that private hospitals in Germany tend to operate with lower ratios of staff to beds.”
Rodney Loeppky teaches that efforts to privatize and marketize run up against “political realities, including widespread extra-economic attachment by local populations to the institutions that provide care. This is why the specific forms these institutions take constitute the industry’s most serious strategic concern.” Loeppky’s exposition gives us hope, for the vital point emerges that local resistance can have profound, global implication. Community struggles against hospital mergers and closings, a worldwide phenomenon, come to mind.
In a similar vein, Sanjay Basu writes that campaigns around specific human needs are crucial to “building a comprehensive public health movement.” The “critical lesson” of organizing around HIV/AIDS, he writes, is that “community mobilization and attention to global health, is capable of dramatically expanding the availability of funds and their appropriate use, as well as what is considered ‘possible’ in resource-denied settings.”
Marie Gottschalk writes, “Time and again major attempts to reform the U.S. health system fall victim to the ‘Stockholm syndrome’—like the famous Swedish bank hostages who became emotionally attached to their captors and even defended them after they were released.” Writing in mid–2009, Gottschalk offers not only a brilliant metaphor but remarkable prescience:
If they calculated that the political conditions were not fortuitous to secure a single-payer plan, at least they might have pushed for a seriously regulated insurance system. Failure to attempt even that is perilous for the cause of universal health care and for their political futures. The president and the Democrats risk looking in a couple of years like Herbert Hoover and the Republicans on the eve of their historic 1932 defeat rather than FDR and the Democrats on their march to a triumphant re-election in 1936.
“Health care today,” Leo Panitch writes on the back cover, “is the object of struggle between commercial forces seeking to make it a field of capital accumulation, and popular forces fighting to keep it—or make it—a public service with equal access for all.” Morbid Symptoms will be studied, and indeed enjoyed, and also help stir political action, far beyond the worldwide community of socialist minded activists and scholars. These essays deserve the widest possible readership and discussion.