Socialism and Health

The title deals with two issues:

• Socialism – the topic is around a distinctly socialist conception of health this is different from one which merely aims to improve health provision within the framework of capitalism.

• Health – this is much more than medicine. It is useful to think of medicine as the retail side of helping people with their health. The wholesale side is how society organises itself to ensure that people are as healthy as is possible. This includes the traditional concerns which obviously and directly affect the possibility of sickness. These are things like the provision of clean water and air, sewers, decent housing, good food. But they go further to involve the possibilities for the right kinds of exercise, knowledge about factors that help and harm health. More widely our well-being depends on a safe society without violent crime, good means of transport etc.

I am going to suggest that we need to go much further than even the above. We need to see that our health or its absence is a vital way in which we connect to the natural world. In this sense it is another aspect of last month’s discussion on environmental issues led off by Paul. Our organisation of society and its provision for our personal fitness is a vital question about the way that society works. The forces that enable us to deal with the environment are the same forces that allow us to deal with health.

Let’s start at the retail end.

In Britain we have had a NHS since 1948. It is presented as offering a free service when we need it and being paid for collectively through taxation (it is reasonable to treat National Insurance as a form of taxation).

The original idea was that a government service would provide a GP for everybody. Generally, if we are sick this is our first contact with the service. Most NHS transactions begin and end there. If we need more support we turn to a hospital’s specialist services. There is no charge for these services even though the cost could be very high.

Nye Bevan, the Health Minster who introduced the system resigned from the government in 1951 when prescription charges were introduced.

The system gave great pride to the Labour movement and was very effective in making a lot out of scarce resources. It was always underfunded. It also had deep flaws from the start:

• democratic control was negligible;

• the hospital consultants were the main power in the system;

• the private element of consultants’ work meant that some could exploit the system to benefit their private practices;

• GPs and dentists were private contractors;

• The major hospitals were the teaching hospitals and they remained independent within the system.

• Most important of all, it was mainly a medical not a health service;

As the system developed the regional inequalities of provision were slowly reduced but nowhere near eliminated.

Funding fell behind comparable countries and problems got worse. The development of waiting lists was a key way in which the problems were expressed.

One of the rarely discussed ways in which the health service worked was through GPs acting as gatekeepers to other services. Their role was not openly discussed which meant that they were not openly seen to deny treatment. Another large factor was that despite the limited radicalism that saw Labour elected in 1945 this was an age of deference. We tended to not challenge doctors.

Various reorganisations were undertaken (esp. 1974 changes of Sir Keith Joseph).

Thatcherism raised the core issue of what the NHS was for. Was it part of a project to include all in a kind of social citizenship or was a safety net for the poor?

Since Thatcher we have had a number of developments:

• Privatisation of many services. This started with cleaning and crept up the hierarchy of activity. It now includes many operations;
• PFI: massively expensive way of funding change which leaves the hospitals owned by private companies;
• Reorganisation of GPs and opening them up to business takeovers
• Shift of funding from hospitals to PCTs
• NICHE – offers guidelines on the basis of both the effectiveness of drugs and the value for money.
• The struggle to reduce the power of doctors, especially consultants, in favour of managers, accountants, even (within limits) patients. Giving money to PCTs is a way of reducing consultants’ power.
• Salami slicing of health. Wait long enough and something private will come along. Private glasses, dentistry, appointments to skip queues, etc.
• Competition within the public sector – instead of an integrated service we have a disintegrated service. Hospitals are set against each other and the NHS against social services.

The overall strategy has commodification at its heart. The point is to make health care a marketable service like many others.

Any gains have been minimal when set against the technological changes which make improvement easy (scanners, microsurgery, new drugs etc). The small benefits are all at risk because of the bizarre new cost regimes.

Note that all the changes to bring capitalism into public services mark out the weakness of capital not its strength. They are not part of a spontaneous development of a system that is so much more effective than anything else that it sweeps pre-capitalist forms away. They are part of an imposition of an archaic form and need, not free competition, but endless regulation.

Wholesale health

It has long been known that things like exercise, good housing, a decent diet, a healthy environment are supportive of health. Avoiding bad habits like smoking, excessive drinking, slobbing around, not buttoning up your coat on cold nights will also help.

We are told that changes like the post-war decline in TB predated the introduction of antibiotics. The major factors here were improved nutrition and housing.

However, the point of my argument is that although these are big issues they play a smaller part than we have traditionally thought.

I suggest that capitalism cannot solve the problems by rises in absolute standards. We can see this in a more general manner. While living standards have gone up this has done nothing for the sum total of human happiness. Evidence suggests that we are less happy, less sane and more violent than 50 years ago.

We should explore some of the paradoxes of our age. For example, even the poorest are much better off than 50 or even 20 years ago the health gaps are widening.

Thus in 1972 to 76 unskilled men could expect to live 5.5 years less than professional. By 1997 – 99 the gap was 7.4 years.1

New Labour joins old Tory in arguing for general economic development helping all. This view is fundamentally wrong. Most of the poor today have things undreamed of in the past. Washing machines, fridges, freezers, microwaves, TVs with DVD players, etc. Yet they are still much less healthy than the better off.

Why is this?

The core argument is that there is what may be termed “the epidemiological transition”. When incomes move upwards towards this level health goes up with incomes. Beyond this point health improvements are principally dependant on narrowing the gap between rich and poor.

After this transition the diseases of affluence (heart disease, cancer, obesity, etc.) become the problems of the poor in rich societies.

The evidence for this massive.

…the poorest areas of the United States, such as Harlem in New York or the South Side of Chicago, have death rates that are higher at most ages than in Bangladesh – one of the poorest countries in the world.2  

In North America areas with the longest lives are those with the narrowest gaps between rich and poor.3

In 1996 black US males had a median income of $26,522 and a life expectancy of 66.1 years; while men in Costa Rica had $6,410 and an expected 75 years of life.4

It is vital to re-assert that poverty is not a thing it is a social status. Thus, the social exclusion, lack of respect, etc. are what matters, the problem is not the lack of material things.

These are not just health issues in the traditional sense. Being murdered is unhealthy. Yet your chances of being murdered are greatest in the countries and areas of the greatest inequality.

Why is status so important?

This is essentially a social issue inside ourselves. It is about our social relationships. It affects our health on an individual level in two ways:

1. Through the nervous system and stress. The hormonal impact of continuous stress damages health. It weakens the immune system and opens the way for disease.

2. Socially. People at the bottom of the heap are likely to engage in risky behaviour. For example, smoking is disproportionately done by poor people. It could be argued that poor people get the worst education and do not know about the hazards. I suggest that this is nonsense. Everybody has a fair idea of the risks – they would have to be incapable of grasping what is happening in the world around them (or read the warning on the packet) to be unaware. Attitudes to risk and to authority are central here.

What does this say about socialism?

Many traditional Marxists have seen the basis of a transition to a new society in the increased misery of the mass of people. As capitalism fails to deal with its own contradictions millions are thrown out of work and into dire poverty. Their rage is expressed through the structures of solidarity (trade unions, political parties, etc.) already established and a revolutionary struggle opens the way to a golden socialist future.

The models of the Paris Commune of 1871 and the Russian Revolution of October 1917 are there.

And yet we know that living standards in the west have risen considerably in the post war world. A number of depressions have appeared but they have not created the revolutionary movements many of us anticipated. For a large number of Marxists it seems that if capitalism does not bring new cuts in living standards the case for socialism falls. There are a lot of anti-Marxists who agree with them.

I am arguing that these Marxists and their opponents have got it wrong. Capitalism lives through a series of contradictions in which we seem to face all sorts of advances and advantages which have a double edged impact.

The most obvious that is relevant here is that the poor are materially better-off than ever and yet are no more satisfied. An obvious example is that people suffer stress and depression under conditions that are not just better than their parents could have envisaged but massively so. We understand more about the mythical nature of the old discriminations of racism and sexism yet bigotry is rampant. We live lives of anxiety. Children are often not allowed out to play, taken to school by car etc. We are more worried about our food than ever and yet it is probably safer than ever. We all have the vote but nobody worth giving it to.

The socialist response to this situation is naturally to defend what we have. Thus, we support the campaigns to protect the health service. However, we need to go further. Health is a centre for the demand for participation. The government has promoted a half-hearted rather controlled version of this. We need to be encouraging every step to participation in all the decisions but all the time showing how health needs radically different policies affecting every sphere of government. Most particularly we need to find ways to promote the core argument presented here – that without moves to a society founded on equality the health improvements possible are very limited.

I am suggesting that an intensification of the problems of capital is not about the traditional concerns of collapse. It is about our lives becoming insufferable amid plenty. It may be argued that this only concerns people in rich countries. In the short term this is true. However, the integration of much of the world into the grasp of capital is also something deeply ambiguous. People in many poor countries are ruthlessly exploited. Yet they are often rushing at the chance to be exploited. I am sure that they will find their feet and form movements of opposition, trade unions, pressure groups, parties, etc.

To sum up, a socialist future has to be founded on equality. Mass participation in actions for equality in health open the way to a socialist future.

PS: The Genetic Revolution

This was seen by many as the answer to all heath questions. If you first define health care narrowly you can see why. Every disease attacks our cells. If our genes could be modified we could defend ourselves against the diseases. We could also alter all the faulty genes and wipe out genetic conditions.

However, it is not that simple. Genes are much more complex than has been believed. They work together in ways that have not been understood. Infections agents are also remarkably adaptable and they will fight back. The social issues mean that our diseases are not simply genetically defined. Thus, as I understand it, genetics may play some part in some illnesses but it will not be the magic bullet that early enthusiasts thought. Many of the enthusiasts are extreme individualists who imagine that health is an individual problem. Their methods tend to be reductionist. Thus, they work on the basis that understanding and manipulating the simplest unit of the body will solve all problems.

Some Reading I have been doing

Richard Wilkinson, The Impact of Inequality: How to Make Sick Societies Healthier, (2005, New York, The New Press)

Allyson Pollock, NHS plc: The Privatisation of Our Health Care, (2004, London, Verso)

Charles Webster, The National Health Service: A Political History, 2002, Oxford, OUP

Erving Goffman, Stigma: Notes on the Management of Spoilt Identity, (1963, Harmondsworth, Penguin)

A useful website: The campaign to Keep Our NHS Public http://www.keepournhspublic.com/index.php Join the campaign!

1 Richard Wilkinson, The Impact of Inequality: How to Make Sick Societies Healthier, (2005, New York, The New Press) p. 17

2 Wilkinson, p. 15

3 Wilkinson pp. 106 - 8

4 Wilkinson p. 76

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