Over the past 30 years—during all the time we have been told that class is dead—something strange has been happening in the study of health. A generation of epidemiologists who study patterns of death (mortality) and illnesses (morbidity) have been obsessing about social inequality. Journals such as the Lancet and the British Medical Journal have published pieces presenting the latest research that talks about the most basic inequalities and social structures. The concern has been to map the link between health and inequality in a descriptive sense: to show that those with a higher social situation suffer less ill health than those with a lower one.
Stand outside any doctor’s surgery and you will see people carried there by inequalities. Their illnesses, major and minor, physical and mental, are markers of where they stand in society. When it comes to ill health, less is always more—the less your situation, the more likely you are to have a health problem. It is a short step from here to pointing to the use of class as an explanatory category: your class position causes you to be more or less sick, to live more or less long. And from here it is only another short step, though one more establishment researchers are understandably loath to take, to argue that, since capitalism is at the root of class society, it is capitalism that makes you more or less ill. If health problems are the product of social organisation, and if we want to really address them, we have to focus on the social conditions and social organisation that give rise to them. As Sir Michael Marmot, the leading epidemiologist in the UK puts it, “Inequalities in health between and within countries are avoidable”.1
Premature death arises from three sources: infectious or communicable diseases such as typhus, typhoid, smallpox, cholera, Aids, etc; non-communicable diseases such as heart disease, cancer, nutritional diseases; and violence. In the past infectious diseases played a much larger part than they do today. It is not that non-communicable diseases did not exist but that infectious diseases carried people off first. The shift towards a predominance of death from non-communicable diseases (and violence) is called the “epidemiological transition”. Infectious diseases have not gone away. In poorer parts of the world such diseases continue to play a crucial role—Aids is one example, alongside diseases of poverty that flow from dirty water, inadequate sanitation and the like. But only in Africa is infectious disease still the major cause of premature death: “Of the 45 million deaths among adults age 15 years and older in 2002, 32 million were due to non-communicable disease and a further 4.5 million to violent causes”.2
Not every disease and cause of death shows a clear socio-economic pattern but the most common diseases and causes of death do. Death does not strike randomly. There has always been a general understanding of this. What is different now is the focus on the systematic process of causation and the need to connect up different elements of an explanation of health and ill health, to seek out what has been called “the cause of the cause”. It is this that takes us to the problem of social class and health, and to a view of capitalism as a toxic form of human society.
The way that health is closely moulded by inequality and unequal power and control was set out in 1980 in the UK in The Black Report. Originally sponsored by the 1970s Labour government it was politically sidelined by the first Thatcher government.3 The opponents of the social approach to health then tried to explain away the evidence of the link between health and inequality. They attacked the reliability of the data, focusing on what is called the “health selection effect”. Causation might run not from society to health but from health to society. For example, as unemployment rises we know that the unemployed will register more illness than the employed. So does unemployment make you sick or does being sick mean that you are more likely to be unemployed? The attempts to focus on health selection, however, have failed. In most instances the causation does flow from society to health: “There is no evidence to support health selection as an explanation of broader social inequalities in health,” wrote Marmot in 1994 and the evidence against the health selection hypothesis has grown.4
In 2003 the World Health Organisation published the second edition of a document edited by Marmot and Richard Wilkinson called, The Solid Facts.5 This attempted to quash such arguments and finally establish that there is a strong “social gradient” of health and ill health. Social conditions mould people’s early lives, their work and leisure, their patterns of consumption, friendship groups, etc, and this can then explain, at the group level, patterns of disease and death to quite an astonishing degree. Wilkinson and Kate Pickett reiterate this same argument in a recent book, The Spirit Level. In rich societies, as the level of inequality rises, so average life expectancy falls and the rates of physical and mental illness rise. Inequality can also help predict levels of obesity, teenage pregnancy, illiteracy, crime, murder, people in prison, happiness—the connections seem almost endless.6 Greater inequality produces a situation where the same health risks produce different outcomes depending on who you are. Take a group of senior civil servants who smoke and compare them with a lower grade group who also smoke. Which will have the higher death rate? This is the type of question asked in the “Whitehall Studies”, led by Marmot, which tracked ill health among civil servants in the UK for many years and whose results have inspired countless other studies. Here is the answer in Marmot’s words:
An administrator who smokes 20 cigarettes a day has a lower risk of dying from lung cancer than does a lower grade civil servant who smokes the same amount even after pack years (packs per years times the number of years the person has smoked), tar content and the gradient in mortality from coronary heart diseases among non-smokers are taken into account.7
To see how this happens we need to go on a journey into the relationship between class, capitalism, health and medicine.
Class society and the health issue
Humans have not always lived in class societies. For tens of thousands of years our ancestors lived in small mobile groups, which survived by gathering and hunting. We know little about how these groups functioned save that their lifestyles were based on a basic equality and a communal reciprocity which leads to them being called “primitive communist”. For some commentators the result was lives that were nasty, brutish and short. Infanticide, for instance, was practised to make sure that supplies were sufficient to feed the number of mouths. Others suggest that life was more comfortable and that social deprivation was limited—there was a greater degree of ease than we can easily imagine, even a kind of primitive “affluence” in the satisfaction of basic wants and the absence of modern style artificially constructed needs.
What is more important from our point of view is that, once settled human societies begin to emerge from 10,000 BC to 6,000 BC, class organisation also developed with them. The ruling groups seized control of the social surplus, consuming more of it and also organising society to perpetuate their rule and their control. The paradox of the development of class society is that, although in the long run it develops the material wealth of society, it does so in such a way that the benefits go disproportionately to the few. This led to inequality being marked not only in differing life expectancies but in the degree to which lives are marked by disease.
To make sense of this we need some basic demographic concepts. Infant mortality refers to deaths under the age of one, child mortality to deaths under the age of five and adult mortality to deaths over the age of 15. The fourth crucial concept is life expectancy. This is usually measured from birth. It is an average of the length of time those born live, so if life expectancy is low this does not necessarily mean that there are no old people. Rather life expectancy will be pulled down if large numbers die in the first years of life.
With the development of class society new social forces emerged which moulded the patterns of life and death. Access to material resources now became unequal, along the lines of the class nature of society. This was true of normal times but it was even more true in years of famine. The regularity of famine reflected the interaction between nature and the economic and social systems, and the way that these determined the nature of agricultural production. Malnourishment was extensive. You could often determine a person’s place in society by how they looked physically. As Wilkinson puts it, “The rich were fat and the poor were thin”.8
The concentration of population in urban centres, albeit on a scale incomparably smaller than today, created a new vulnerability to infectious disease agents. In the towns not only were social conditions often bad, but also the water supply was polluted, sanitation systems were primitive and the air foul. The result was epidemic diseases such as typhus, typhoid, smallpox and endemic diseases (there all the time) such as tuberculosis. And every so often there was a good chance of pandemic diseases such as plague.
In these settled societies violence now became more organised, whether it was the violence within societies or the violence between societies. War became a regular feature of social development and in its wake came not only death and destruction on the battlefield but social immiseration in the areas through which armies marched and fought.9
With low productivity and diseases rife, population grew slowly for thousands of years, as is apparent in table 1.
Table 1: World population and percentage urban share
Source: www.census.gov/ipc/www/worldhis.html early urban estimates Kingsley Davis, UN World Urbanisation Prospects. The 2005 Revision; The 2007 Revision.
The key issue here was the combination of material deprivation, infectious diseases and weakened bodily resistance. The social effects of this were uneven. The rich who ate better could hope to live better. “Countries in which access to nutritious food varies by social class for whatever reasons tend to show class gradients in height and health status,” write two modern researchers.10 But the rich could not escape from the patterns of infectious disease. In an urban environment epidemic diseases easily jumped from a poor house to a richer one, and both houses might draw on the same water supplies or buy food in the same markets. In 1694 Queen Mary died of smallpox, one of a long line of European monarchs to go this way. Almost 170 years later, in 1861, Prince Albert, the husband of Queen Victoria, was carried off by typhoid. Similarly, lack of knowledge of how to deal with the complications of childbirth could kill rich women as easily as it could poor and in the early weeks all babies were vulnerable.
This helps to explain the fact that, although lifestyles differed considerably between classes, when it comes to measuring mortality rates the class differences were less than might be imagined.
In Western Europe capitalism began to emerge from feudalism in the 16th century, and as it did so it began to change the pattern of disease. But the really dramatic shifts came with the industrial revolution and the development of industrial capitalism at the turn of the 19th century. Technological change and increased production created a larger surplus, which allowed societies to begin the “demographic transition”. They shifted from a pattern of high birth rates and high death rates to low birth rates and low death rates. In this transition, however, the death rate initially fell faster than the birth rate. The result was that rapid population growth occurred before a new balance was reached. Table 1 shows how world population has grown and its projected new equilibrium at around nine to ten billion (despite the fears of Thomas Malthus who believed that population growth would outrun the food supply).
In the first instance urban and industrial growth intensified health and mortality problems, not least in the big cities. Britain led the way, becoming in 1851 the first urban state with more than half its population in towns. Others followed in the 20th century. Today on a global scale half the world’s population is now urban, as can also be seen from table 1.
Over time the falling death rate led to an increase in life expectancy. This fall in the death rate is commonly thought to have been bound up with medical advance but this was not the case. Some specific diseases like smallpox were reduced because of medical advance, but until the mid_20th century medical knowledge was so slight (and often mistaken) that it had a limited impact on population growth. Critics like the early 18th century essayist Joseph Addison could comment that “we may lay it down as a maxim, that when a nation abounds of physicians, it grows thin of people”.11
There are four genuine causes of the improvement in life expectancy. The first was the increase in the standard of living. Where this occurred better nutrition led to healthier bodies. Height and weight grew, and so did resistance to disease. The second, closely related, was the possibility of better standards of public hygiene. The third was the improvements in public health that came with the development of clean water systems, sewage systems and measures to deal with pollution. It should never be forgotten that one of the greatest killers of infants throughout history is dehydration brought on by diarrhoea. In 19th century England, for example, diarrhoea is reckoned to have killed as many infants every two years as all the 19th century cholera outbreaks put together.12 Today diarrhoea is still estimated to be the second biggest killer of children worldwide, overwhelmingly in poor countries. The fourth factor worth noting is that some diseases may have mutated into less virulent strains.
These four elements help to explain the ways in which infectious diseases eventually came to be contained by rich countries. The result has been the shift to a pattern of ill health and death from non-communicable diseases to the so-called “diseases of affluence”, except that these now began to fall disproportionately on the lower classes in wealthier societies. Capitalism’s potential to solve humanity’s problems is not and cannot be realised because of the ways in which the system also traps us into putting human need second to profit and competition. To see this we have only to look at the patterns of mortality that exist in the world today.
The first thing to note is the huge gaps in life expectancy that still exist between countries. In 2004 life expectancy in Japan was 82 years; in Sierra Leone it was only 34. This is not because there is a lack of food and other basics. The world today produces more than enough to go round. For decades now global food supplies have risen ahead of population growth. In 1961 there were 2255 calories available per head of world population. By 2000 the figure was 2,805, a 25 percent increase despite the huge growth in numbers.13 The resources exist then to create the basis for a healthy life for everyone—the problem is that they are not used this way. In this situation the most vulnerable continue to be the youngest. Infant mortality in Sierra Leone is 316 per 1,000 live births, whereas in countries like Japan and Finland it is only 4.5 per 1,000.
The second element is the size of the differentials in mortality that exist within countries and the fact that, despite improvements in health, such gaps have been widening in key countries. This is not least the case in the UK and the US. These gaps can be measured in the pattern of infant and child mortality, adult deaths and life expectancy. To illustrate this table 2 shows life expectancy gaps in the UK using the official social classification.
Table 2: Changing male life expectancy at birth in the UK
Source: ONS, news release, “Variations Persist in Life Expectancy by Social Class”, 27 October 2007.
There is good reason to think that per capita income (in today’s values) of around $10,000 is sufficient to solve the material problems underpinning health inequality. At this level there is enough go around and enough to provide the resources for adequate public health. What separates societies, therefore, is less the per capita income over this level (in the UK/US case we are looking at roughly three times this) than the degree to which it is unequally distributed, and the scale of relative deprivation between different social groups. The greater the degree of inequality, the greater the health gaps. As Wilkinson has put it, “People in a country can be twice as well off on average as those in another country without benefit to their mortality rates” if the distribution of income and wealth is unequal.14
This is explained by a third element, which is the way that capitalism not only generates material inequality, but also social mechanisms, that lead to ill health. The problem is both the material pressures on human beings—our basic work security, the environment, pollution, etc—and the uneven social and psychological means we have for dealing with the unequal outcomes that follow.
This leads to a fourth element, which is that when these patterns are revealed the system can also encourage perverse responses. If society makes you ill, the obvious solution is to deal with the diseases of ill health at the societal level. But the temptation is often to push resources into dealing with the consequences. If the procedures to deal with consequences are themselves a source of profit, then the temptation will be to bend further discussion away from causes and social solutions towards a self-perpetuating pattern focused on medical technologies, drugs, therapies and the like.
Fortunately capitalism also creates a fifth element: the knowledge base to understand the real relationship along with groups of people, those at the bottom and “professionals”, who should better understand the situation and can join together to demand change. However, the extent to which this will happen is a political issue. For a century now the medical profession has been divided between what have been called mercenaries, seeking to exploit ill health for gain, and missionaries, who are concerned to remove its social causes.15 But the mercenaries have now been supplemented by the managers who have benefited from the commercialisation and privatisation of health and who tell us that the way forward is health markets that they can run jointly with the mercenaries.
Class society makes you ill
“I ask myself how, as a physician, I find myself up to my ears with the problems of society,” writes Michael Marmot. It is a question that committed doctors have been asking for several generations as they try to explain and cope with the way that illness is moulded by society.16 Evidence for the social gradient is astonishingly widespread. It affects us all. It is not just about the contrast between the rich and poor but is so “fine grained” that if we graph illness against some indicator of relative position we see that as relative position improves so does health. Wilkinson calculated that 50 to 75 percent of the differences in average life expectancy in rich countries are now determined by differences bound up in the distribution of income and related factors. Table 3 shows how this is reflected in the pattern of key illnesses in the UK.
Why should this be? Material need cannot be ignored. Income poverty is not the basis for a good life, and societies with the greatest levels of inequality will also have the largest numbers of poor people. But it is relative poverty and position that matter most. So what is going on? The biomedical answer seems to be that vulnerability and susceptibility to illness and death are related to the degree of adversity in our lives. Some exercise is good for you but relentless physical demands in circumstances over which you have no control drain the body. Similarly, some stress is good for you but relentless worrying about job, home, family, etc not only drains you emotionally but feeds back into physical and mental ill health:
The relationship among the nervous system, the endocrine system, and the immune system is emerging as the pathway that can help our understanding of the changes in health which are associated with changing social and economic conditions.17
In other words, although illness arises from bodily processes it is really a product of social organisation. And—this is crucial—because health follows the social gradient it is not just about improving the conditions of the poorest. In health terms it is in our collective and individual interest to tackle the problem more systematically. As Marmot puts it:
Much of the discussion about social inequities in heath has focused on the health disadvantage of the lower class. This is analogous to seeing social problems as particular to a disadvantaged minority, rather than a problem for society as a whole.18
Table 3: The UK disease pattern by social group 1991-3, standardised rates per 100,000 for men aged 20-64.
Source: Acheson, 1997.
|Coronary heart disease
|Accidents, poisonings violence
Marmot’s argument here is partly a reformulation of RH Tawney’s famous comment that “what thoughtful rich people call the problem of poverty, thoughtful poor people call with equal justice the problem of riches” but it is more. The steeper the social gradient, not only the bigger the health gap between those at the top and those at the bottom, but also the lower the average position of all. “The countries with the longest life expectancy are not the wealthiest but those with the smallest spread of income and the smallest proportion of the population in relative poverty.” There is therefore a problem with thinking that because I am near the top in UK terms (and the level of inequality in the UK is one of the highest) I will live longer than someone at the bottom or in the middle. This is true. But it is also true that you would live longer still if society were more equal. It was realised in the 1990s that “the mortality rate for the lowest social class in Sweden [with less inequality] is less than that for the top social class in the United Kingdom”.19
The narrow biomedical mechanism that produces this has three elements. The first is the psycho-social impact of pressure on bodily processes. This is socially determined. The second is our health behaviour and how we respond in terms of what we eat, whether we smoke and drink, take exercise, etc. This too is socially determined. The third is how supportive our family, friends and social networks are. This is also socially determined. Only then does the fourth issue, healthcare, become a central issue and, when it does, it too is socially determined.
If we look at our lifestyles as a whole, their patterns reflect either the accumulation of advantage or disadvantage. The story starts in the womb with fetal development, it is manifest in the early years, at primary and secondary school. It is then compounded by what type of job we get and how precarious our employment is, and so on. But why can this not be explained by people at the top choosing wisely and those at the bottom choosing badly?
The really interesting aspect of the social approach to health is how careful the analysis is of what conditions our behaviour. The cleverness of the Whitehall Studies of UK civil servants is a good example. The researchers took a large group in which the members appeared to be similar and apparently had some more positive elements in their work conditions. They then designed a study of how work, position, life, social situation, etc interacted and combined. This analysis allowed them to nail the myth that top managers are prone to more heart attacks because of “pressure”. They are not and we now know why. With responsibility comes status, power, control, means to relieve stress (membership of the gym, a night at the opera, a holiday villa) often arranged by your secretary and so on. As you move lower down, so people’s lives become more bound up with lower status, less control and the need to battle and juggle a host of other commitments. It is the harassed worker on the shopfloor or in the office who is more at risk of a heart attack and, beneath them, the cleaner doing two jobs on the minimum wage. This also explains negative health behaviours and why these should give rise to different incidences of disease when the same immediate causal factors, eg smoking, appear to be present.
But some readers may be puzzling about a theoretical problem in the link between social class and the health gradient. Those who insist that we live in a class society have to defend themselves not only against those who deny the reality of class but also those who want to define it simply in terms of hierarchy. It is here that we run up against the fundamental weakness of the argument about social gradients in health. It is clear that they exist, but what causes them? What is the “cause of the cause”? To solve this problem we have to look behind the gradients and explore what determines the different incomes, jobs and degree of control that people have over their lives. This means that the central thing has to be class analysis and showing how any gradient is structured by ownership and control and not least, in capitalism, by ownership and control of the means of production.
Here several related concepts are absolutely central—alienation, exploitation, class and class conflict. Inequalities are a consequence of how these interact and it is from this that social gradients and gradients of ill health flow. Marmot makes occasional gestures towards this but they are weak and inconsistent. The same is true of Wilkinson even though he has a more systematic grasp of the social side. To insist on the importance of this is not just about adding an additional layer of possibly superfluous explanation. It makes the argument stronger in terms of its logic and explanatory power, and it gives it a clearer political thrust because it also forces us to consistently address the political economy of both health causation and the limits of reform within the system.
Alienation, for example, is fundamental to explaining both our loss of control of social processes and the way that they are turned against us, and our resulting inability to relate to one another as proper human beings.20 Exploitation gives us the possibility of understanding how and why the rewards go to the few who make so little contribution to our real wealth. And class and class conflict help us to understand the resulting texture of social relationships and their antagonisms.21
We can make these arguments work in a more precise fashion too. As organisations have become more powerful the argument arises about who has effective disposition of capital and labour within them. The key social argument here is that the more your position gives you control over capital and labour, control over yourself, your work, the work and lives of others, the lower the levels of ill health. The more your life is controlled by others the less the level of health. The social gradient is not simply about “who has what” but the capacity to command people and resources—the very issue that is at the centre of class analysis.
But to take this analysis further we need people whose expertise is the analysis of capitalism’s social structures to link up with the people whose expertise is in health and illness. One of the most creative ways of making the connection was set out nearly three decades ago by Eric Olin Wright. Wright took on the argument that class was disappearing in modern society because of the alleged explosion of groups in the middle. These groups appeared to stand between capital and labour; they had what he called “contradictory class locations”. He then devised a way of mapping these contradictions, focusing crucially on how much control of capital and labour they had. It becomes obvious in his analysis that these intermediate groups often have little and are therefore closer to labour than capital. This reflects what many of us understand intuitively: the badge may say manager but we all know that in reality it means some low grade supervisory responsibilities that do not preclude trade union membership and even militancy.
Using these ideas to map how capitalism really operates and divides us has an obvious attraction for those seeking to more systematically underpin the analysis of health gradients, and some researchers have already looked in this direction. But here’s the problem. Almost immediately Wright had set out this argument he retreated under the pressure of the anti-class theorists. This has meant that it has fallen to others to defend this extension of class analysis as a way to understand capitalism.22 But it has also acted as a disincentive to use the argument to tighten the theoretical and empirical links between class and health.
Medical myths and medical madness
But this argument raises other political issues and not least for the medical establishment. Prevention, as everyone knows, is better than cure. “The most sophisticated and effective healthcare in the world cannot produce results as good as simply remaining healthy in the first place.” But “creating healthy societies and individuals largely results from action outside the health sector”.23 Healthcare can never remove the gradients in causation, only deal with some of the consequences.
This type of argument is difficult to make. We are rightly appalled by inadequacies in healthcare but we tend to take for granted the inequalities in health causation. It is awful that when Julie had her heart attack in her fifties she had to wait 30 minutes for an ambulance; then there was the four-hour wait in accident & emergency and the dirty wards on which she eventually died. But the prior question is why she had a heart attack in her fifties and why Jane, who worked as a cleaner in the same office, had one a couple of years later and died before help could get there?
We need to take any argument about the role of medicine in health in two stages. The first is to stress the absolute importance of what is called primary prevention and not to fall into the trap of thinking that we can leave the causes of illness alone and focus on better treatment. Primary prevention saves lives but primary prevention may not involve medical measures in the narrow sense at all. Only three out of the 39 proposals made by the 1997 Acheson Report of the Inquiry into Inequalities in Health related directly to health service provision.24 If the problem is a choice between a worse treatment and a better one, we should obviously demand the better one. But the issue should not be about whether we can afford treatments but whether we can afford people to be ill. It is often said that medical costs will always rise. This is an absurd argument in itself because it ignores the way in which the drive for profit is behind the cost rises that exist. But even if it were true, reducing the numbers of ill people in the first place would reduce the cost problems. The less people that you have to treat, the more you can afford to spend on making those who have the genuine misfortune (and not the socially determined one) to fall ill. The real problem then is to alter the fundamentals of the generation of illness caused by class society.
Primary prevention is therefore politically challenging. There has always been a minority tendency in the medical establishment that links health improvement to real social reform, and within this group a smaller one still who continue to insist that so long as capitalism and class society exist we will remain trapped in unequal lives and unequal deaths.25 But many health professionals also see the immediate attraction of the medical fix. And so do we as patients once we get trapped in ill health. Even the members of the team that produced the original Black Report were split on this issue. According to Sir Douglas Black:
We were all agreed that education and preventative measures, specifically directed towards the socially deprived, were necessary. But the sociological members of the group…considered that the consequent expenditure should be obtained by diversion from acute services. On the other hand the medical members…felt that the acute services played a vital role in the prevention of chronic disability and could not be further cut back without serious effects on emergency care, on the training of doctors for both hospital work and for family practice and on the length of waiting lists. We spent a long time, without real success trying to resolve this matter.26
This fudge is not enough. Consider the problem of mental ill health. Its burden continues to rise in the advanced world. There is a big question over whether the medical fix actually works. But suppose the evidence was clearer that it did. It would still not be enough for three reasons. First, “it is inconceivable that enough professionals could be trained and employed to treat the many millions of causalities of our psychologically toxic social environment one at a time”. Second, if the problem is the toxic environment then once people are returned to it their symptoms are likely to recur. Third, this approach does nothing to stop new cases appearing.27 But the same logic applies to other areas. Britain, for example, is acknowledged to have one of the poorest records in the advanced world for longer-term survival after major incidents like cancer and heart attacks. You can now guess that there may be two explanations for this. One is medical—the weaknesses of early identification, treatment and follow up. The other is inequality. If inequality increases your chances of getting a life threatening disease, then however good the medical fix the pressure will be on again once you return to the environment that helped to cause the illness in the first place.
At this point, however, many take fright. It seems easier to imagine that the way forward is to work on medical solutions to ill health and demand more resources for these. But this takes us to the second issue of whether a health system run for profit can ever rationally answer human need. The answer is an unequivocal no. The first simple rule of healthcare is Tudor Hart’s “inverse care law”, which says that “the availability of good medical care tends to vary inversely with the need for the population served [and this] operates more completely where medical care is most exposed to market forces”.28 A national health system has to be based on principles of comprehensiveness, universality and equitability. “Supply and demand”, internal and external markets, subvert these principles and undermine the capacity of rational health planning. They even undermine the very sources of information which would make such planning possible. The result is variation in the coverage of basic services. With this comes a huge loss in real efficiency.
A second simple rule of healthcare then emerges: the more the logic of capitalism determines the supply of healthcare, the higher the costs, the larger the management layer, and the greater the diversion of resources away from treatment and care and into private hands. With this level of irrationality in the system we can then move to a third simple rule of healthcare: the more the logic of capitalism determines the supply of healthcare, the more the healthcare system itself may become a threat to social health.
A genuine national health system would seek to minimise the causes of ill health in society at large and to maximise the coverage, comprehensiveness and efficiency of healthcare when it was needed. The focus on “bringing the market in” does just the opposite. It helps to maximise the stresses that produce poor health and it fatally compromises the ability of any healthcare system to rationally deal with the resulting patterns of ill health. In the 1990s attention in the UK was for a time focused on Dr Harold Shipman who turned out to be a doctor who was also a serial killer, dispatching his older patients. But the real story of the last decades is that the biggest serial killer in the health system is the market, and in the dock alongside Shipman should have been all those who pushed it and the consequent break up of the NHS. Sadly, if this sounds like rhetoric, it is supported by a grotesque trail of evidence, and not least in the statistics of lives lost and the stories of grieving relatives, of how healthcare is failing in market driven systems.
In the UK the NHS that was built up after the Second Word War had serious faults and these were not helped by systematic underfunding. But it was based on a developing sense of comprehensiveness, universality and equity, and in comparative terms it was one of the most, if not the most, efficient healthcare systems in the world. Its dismantling through the development of first internal, and then external, markets—the creation of what Allyson Pollock calls the NHS PLC has broken this and begun to reproduce some of the worst irrationalities of private healthcare systems and their scandals. Worse, although this process began under the Tories, if anything it proceeded faster under New Labour.29
It is true that over time more money has been pushed into health but the market-based health reforms have also created more routes by which this money could be devoted to non-health outcomes and into private pockets. Part of the systematic underfunding of the NHS in the past has been reflected in low pay in its lower levels, and nobody could object to this being improved. But additional resources have also been sucked to the top and out of the system by the market privatisation process, building better offices for the likes of global accountancy and consultancy firms such as KPMG or PriceWaterhouseCoopers, rather than providing more hospital beds. Health is big business. In Europe the health service consumes around 8 to 10 percent of output. In the US it is nearer to 15 percent. Add in all other forms of healthcare and we are nearer to 10 to 20 percent. This is such a huge amount that the pressure is to grab as much as possible for privatised control and private profit. Any number of examples could be given but it will be sufficient to sketch the perverse consequences in terms of the pharmaceutical industry. It is not the case, as is sometimes argued, that “big pharma” has no interest in cures. Of course it does. The problem is the way it operates under capitalism systematically compromises a rational allocation of resources to meet human need.
First note the scale and interlocking character of this industry—not just the huge drug companies but also biotech, the food supplement manufacturers, the vitamin producers, even homeopathy, far from being “alternative”, are big business. Few in number, these companies are diversified global giants in their own right but they are far from averse to underhand linkages. The biggest corporate criminal fine in history was of $1.5 billion levied by the US government against the “vitamin cartel” for price fixing.30 But it is easy to see the attraction of fleecing the market. Medical drug sales alone in the UK work out at £200 per person anually or over 1 percent of national income—a huge amount. In the US the figure is nearer 2 percent of national income.
Getting as much of this income as possible means big profits. This helps to explain the fact that the pharmaceutical industry spends only around 14 percent of income on research and development but 30 percent plus on marketing and administration. It also helps to explain the startling fact that 10 percent of the world’s health burden gets 90 percent of the research and development. Money follows the patients and the systems with spending power. Ninety percent of the human health burden gets a mere 10 percent of R&D, and even more grotesquely this is probably less than the amount now spent to provide better drugs for pets in rich countries. Plus all this research is now becoming less effective. In the middle decades of the previous century there were major medical advances in drugs, techniques and treatments but in recent decades the rate of real improvement has declined. That means that companies now have to push copycat, “me too”, drugs that barely differ from one another, or encourage us to believe in new diseases for which they can then sell us old cures. In this battle patents are crucial. Eighty percent of drug expenditure is on patented drugs in advanced countries. Patents keep prices high and allow profits to be squeezed even if the drug could be lifesaving for those who cannot afford it. These same pressures then lead on to the systematic undermining of ethical standards in research as companies pressure researchers into exaggerating the efficacy of their copycat drug over someone else’s.
But the pressure of these big companies is also highly political. They are a formidable lobby, spending billions, and leaning on governments and international organisations. They practise a revolving door system whereby politicians, regulators and top health service people are regularly invited to join them and effectively rewarded for their past compromises. They subvert the health debate. Systematic bribery is practised in the health trade with all sorts of inducements to prescribe one product over another. Front organisations are set up. Some patient groups have stupidly allowed themselves to be compromised by accepting drug company money and becoming advocates demanding costly drugs whose real benefits are doubtful. And if all else fails, these companies follow the trail pioneered by the tobacco industry of sowing doubt where there should be none and intimidating their critics.31
This is not a pretty picture. But it is made worse by the way that the drive towards more markets and privatisation in health service provision further sideline real solutions. This is perhaps best seen as an attempt to enable the private sector to plunder the state by means of legalised corruption—the private finance initiative disaster in the UK is the best example. Of course the ideological preference for markets reflects something more than the veniality of the pocket but it is important to stress how much material interest there is in profiting from health privatisation.
What cements this is the managerialisation of state health provision. In Britain this now permeates all levels of the NHS, co-opting medical staff, but the most obvious indicator is the rise in the number of people who are specifically employed as “managers and senior managers”. In 1998 there were 22,000 of them; by 2008 there were 40,000. This has led to a fall in the number of staff per “manager” from 48:1 to 34:1.32 And presiding over them all, the NHS board at the very top had eight people in 2004-5 and cost £1.2 million. By 2008 it had 24 and cost £3.5 million.33 And alongside these are a huge army of management and IT consultants so that the NHS alone vies with UK manufacturing each year for the title of the fourth largest funder of UK consultancy firms.34 While this may make little sense in its own terms, it is a necessary step in enabling a more systematic distortion of healthcare, leading towards the creation of a “medico-industrial complex”.
But the most disturbing issue is the extent to which healthcare itself can become a source of ill health—indirectly though the diversion of resources and directly through the systematic failure to offer patients the cures that they expect and, on occasion, even giving them new illnesses.
In the previous century enormous progress was finally made in developing medicine that had some hope of curing some patients. But the limitations of medicine are still more serious than is often imagined. Not the least of these is that treatment can have unintended consequences. Cases of adverse drug reaction are well known and these often received huge publicity. But there are bigger issues. Even in the best systems, all hospitals, anywhere in the world, are unsafe places. You can make them better or worse but the problems will never be removed completely, so the best approach is to reduce the numbers needing their services. In the UK, for example, the National Audit Office estimates that as many as one in 12 to one in ten patients will experience an adverse incident. These can range from negative reactions to treatment to mistakes, care and neglect problems and, most serious of all in terms of large numbers, cross-infection. This can lead to illness, disability and death. Unnecessary deaths in NHS hospitals have been as high as 34,000 a year but the government report which gave this figure added that “in reality the NHS simply does not know”.35
Most attention has been focused on “superbugs”, such as MRSA and clostridium difficile, to which the weak and elderly are especially vulnerable. The rise of this type of infection appears to be in part a consequence of new antibiotic-resistant strains. But more immediate causes appear to be at work. One is ward cleanliness—what those in the trade call “the mop and matron” problem, looking back to an age when matrons reputedly directly supervised nurse and ancillary staff performance. The second is rates of bed occupancy that are the highest in the advanced world.36 The third is insufficient appreciation of the danger of cross-infection by medical staff and visitors and therefore their lack of care in contact. The first and second issues are unambiguously related to the NHS profit/target driven culture. And if the three issues were properly addressed in the short term, they could cut cross-infection and death but the threat would still be there. Although better hospital design adds a further long-term element, it seems that we will have to live for the foreseeable future with a greater degree of cross-infection risk. On top of this we can then add poor case management. Again this can unambiguously be related to the profit/target culture, as was revealed in the notorious case in Staffordshire where managers manipulated patients to hit targets, leading to an estimated 400 to 1,200 unnecessary deaths. But as critics pointed out, Staffordshire is only the tip of the iceberg and the practices here, albeit perhaps pursued more systematically, are apparent across the NHS.
The case for radical change
In how radical a direction do these arguments really push us? Since inequality varies between countries it cannot be the case that there is no space within capitalism to improve things. Reducing the levels of inequality in the US and the UK to those in Sweden is clearly compatible with the continued existence of capitalism since Sweden is a capitalist country. Moreover this would dramatically improve the lives of people in the US and the UK. This is the obvious case for reform and this is the immediate punch of the inequality argument and the argument of those who appeal to the self_interest of governments in facilitating change. But this is too easy, for even in Sweden the gaps and the inequalities, although less, are real.
In economic terms Sweden is actually a very unequal society. We can measure inequality before and after transfer spending. Transfers are taxes that are paid and then redirected as welfare, social and health spending. A country such as Sweden combines a high pre-tax inequality with a low one after tax and transfers. It allows the basic inequalities of capitalism but offers a “compensating mechanism”. In the rich countries levels of social expenditure run at just over 20 percent of total output. In Sweden they are about 30 percent of output. The result is evident in the comparative poverty statistics. According to one set, before transfers the poverty rate in the UK was 28.8 percent, higher than even the US at 23 percent. Sweden was almost as high as the UK at 28.3 percent. Welfare spending of all kinds transformed this situation. The US poverty rate fell to 18.6 percent, the UK to 16.4 percent but the Swedish to just 3.3 percent.37 In comparative terms this is an enormous difference. But the big point in terms of the health argument is that the Swedish system is still built around very significant core inequalities and therefore the social processes that generate unequal health. What Sweden is much better at is using welfare and social policies to limit some of the consequences but not, crucially, eliminating them, as workers in Sweden know to their cost.
We know, for example, that the massive rise in unemployment will damage people’s health through its financial and psychological effects. The impact will be worse in a country like the UK where benefits are low, means tested and stigmatising compared to a country such as Sweden where the welfare state is more comprehensive and generous in funding and attitudes. But all the care in the world can only take second place as a solution to not losing your job in the first place and knowing that you can rely on having decent work and a decent life. The best solution to the problem of unemployment leading to ill health is therefore a system which does not put your heath at risk by putting your job at risk in the first place.
In addition, we must not make the mistake of assuming that progress in the longer term will always be positive. Although there have been widespread increases in life expectancy during the past two to three decades, a significant minority of countries have gone backwards. Since the 1990s 16 countries have experienced sharp falls in life expectancy—mostly in Africa but also in the states of the former Soviet bloc. This has been catastrophic for the countries concerned and it is no exaggeration to say that lives shortened and lost run into many millions.38
And the recent pressures across the globe, including in countries such as Sweden, have been towards weakening both people’s economic positions and the systems available to deal with the consequences. The extent of real labour market “flexibility” and of precarious work is a matter of dispute, and we should be the last people to exaggerate it. Fear can weaken people’s resolve to defend what they have and a strongly organised labour force is likely to be a healthier one. But we cannot ignore the pressures to undermine past achievements and the attrition that is still ongoing. This is the lesson in the UK of two decades of Labour and Tory commitment to the market, whatever its health costs.39 State policies to bolster the strength of capital, however they are presented, are not simply based on intellectual errors and misunderstandings. They reflect the intrinsic need of the state to support capitalism. And this is taken to a whole new level during a crisis.
Crisis, by reducing economic activity, cuts some causes of death such as accidents at work and on the road, but it increases others as the pressure of the crisis is felt. The focus on profit now leads to mass unemployment, and governments panic over how much to spend and how much to cut. The pressure of crisis undermines the possibility of making an appeal to enlightened self-interest. The bosses who jump ship or practise crisis management by slash and burn are hardly likely to slow down in the face of appeals about the human misery that will follow. If you are closing a plant at a day or even a few hours notice, the issue of a “fair” redundancy process and the availability of counselling for redundant or surviving workers is unlikely to be a priority. Nor should we imagine that because there has been a catastrophic failure of global capitalism this will in itself prompt a systematic rethinking. Without a fight it will not even necessarily undermine the influence of those who brought about the crisis. It should never be forgotten that the economic crisis of 1929 did not lead to a radical change in establishment ideas. The people running the system in the 1930s were the same as those in charge in the 1920s, or their subordinates or worse. This helps explain why the greatest crisis that capitalism produced what WH Auden dismissed as “a low dishonest decade”. Without a radical alternative we risk the same scenario for ourselves.
This points to the need to understand that the balance of class forces is not only crucial to patterns of ill health and death but also to the solution. We know from history, for example, that war and revolution can radically change patterns of health, illness and health service delivery, and often in a remarkably short time. Problems which are deep rooted do not disappear overnight but they can be confronted in new ways. For instance, in the UK in the Second World War, despite the conflict, civilian health improved as radical changes had a dramatic short-term effect and health delivery was shifted towards a new basis. Elsewhere more rapid political change has had the same effect. It acts this way because it challenges the whole basis on which society is run and resources are allocated, and in so doing leads to a more fundamental questioning of the mechanisms that produce ill health and are supposed to lead to its solution. Not least, it leads to people being able to see themselves less as isolated, alienated and exploited victims than as part of a more collective solution.
The real solution then has to be a radical one and it has to raise the nature of capitalism as a system. But this cannot be achieved by shouting from the sidelines. A battle against the inequalities of the system and the crisis has to be fought at all levels: to sustain and improve conditions in the workplace; to oppose redundancies; to resist budget cuts; to fight against housing repossessions. Those who will be most useful, resilient and successful will be those who understand that not only are such campaigns important in their own right but make best sense if they link up and become part of an argument for a general change. This can then lay the basis of a decent society that will also be a healthy one—one in which social inequality will no longer give rise to unequal lives and unequal deaths.
1: Marmot, 2005, p1103.
2: Marmot, 2005, pp1100, 1101.
3: Townsend and Davidson, 1982.
4: Marmot, 1994, 2003. If causation flowed the other way it would not make “selection” acceptable-merely the process of ill health different. And there is now considerable evidence to show that poor health results from an accumulation of disadvantage that begins in the womb.
5: Marmot and Wilkinson, 2003.
6: Wilkinson and Pickett, 2009.
7: Marmot, 1994.
8: Wilkinson, 1994.
9: Haynes, 2008.
10: Frank and Mustard, 1994.
11: Shorter, 2006, p109; Wootton, 2006.
12: Wootton, 2006.
13: Fogel, 2004. There was an 11 percent increase in calories per head in the developed world and a 39 percent in the developing world in this period.
14: Wilkinson, 1994.
15: Widgery, 1979.
16: Marmot, 2003, p8.
17: Frank and Mustard, 1994.
18: Marmot, 1994.
19: Wilkinson, 1994.
20: See Yuill, 2005; Crinson and Yuill, 2008.
21: See Muntaner and Lynch, 1999; Muntaner and others, 2003.
22: See Callinicos and Harman, 1987.
23: Evans 1994; Marmot, 1994.
24: Marmot, 2004, pp260, 267-276.
25: In the UK the Socialist Health Association is a good example. Its website contains a mass of valuable material but, associated with the Labour Party, it oscillates between radicalism one day and bland commentary the next. See www.sochealth.co.uk. Julian Tudor Hart, associated for many years with the Communist Party, has been a doctor and key individual researcher for half a century pushing for a more consistently radical position see-www.juliantudorhart.org. The Politics of Health group has some excellent material. See www.pohg.org.uk
26: Townsend and Davidson, 1982.
27: Fryer, 2000.
28: Tudor Hart, 1971.
29: Pollock, 2005; Shaw and others, 2005a, 2005b; Player and Leys, 2008.
30: The vitamin cartel included some of the top pharmaceutical companies. For all its faults, the US enforcement agency can be quite blunt: “The international vitamin cartel, which affected over $5 billion in US commerce, was the most harmful and elaborate conspiracy ever uncovered by the Antitrust Division. The members of the vitamin cartel reached agreements on everything from how much product each company would produce, to how much they would charge, to which customers they would sell. The victims who purchased directly from the cartel members included companies with household names such as General Mills, Kellogg, Coca-Cola, Tyson Foods and Proctor & Gamble. However, these companies were just the first to feel the effects of this conspiracy. In the end, for nearly a decade, every American consumer-anyone who took a vitamin, drank a glass of milk, or had a bowl of cereal-ended up paying more so that the conspirators could reap hundreds of millions of dollars in additional revenues”- www.usdoj.gov/atr/public/4523e.htm
31: Widgery, 1979; Goldacre 2008.
32: Calculated from NHS Information Centre, 2009. The full-time equivalent fall was from a ratio of 39:1 to one of 30:1.
33: Independent, 14 November 2008.
34: Every autumn Accountancy Age reports on the fees of UK Management consultancy.
35: National Audit Office, 2005.
36: Orendi, 2008.
37: Bryant and Raphael, 2005.
38: Haynes and Husan, 2003.
39: Shaw and others, 1999, 2005a, 2005b.
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