November 20, 2009
SP: Colin, the latest Socialist Register, Morbid Symptoms: Health Under Capitalism, is gaining great accolades from health activists and practitioners, and from sections of the Left that have not traditionally been focussed on health. How did you and Leo come to focus on this issue as important for a Register audience? And how does it fit within your personal evolution as a Left intellectual in terms of your long-standing concerns with states and development in the ‘third world,’ especially Africa, on the one hand and states and parties in the advanced capitalist world, especially Britain, on the other?
CL: Given the crucial importance of health in people’s lives it struck us that there was a major lack of critical left thinking about it – about how neoliberalism was undermining the health gains of the postwar years, about what was happening to healthcare as a field of employment, and above all how healthcare was becoming a massive new field of capital accumulation, with dire implications for population health – and for democracy – everywhere. The best contribution the Register could make, we felt, was to help develop a historical materialist analysis of health under capitalism. Over the last 30 years a handful of progressive health experts, such as Vicente Navarro in the U.S., and Lesley Doyall and Julian Tudor Hart in the U.K., have laid the groundwork for this, but the Left in general has not taken it on board as much as we should have. And the extent to which the mainstream health policy literature fails to confront the neoliberal agenda is frankly shocking. Dependence on government funding for research plays an obvious role there. With some honourable exceptions everything is presented as if the political-economic determinants of ill health are a (regrettable) given. We wanted to break decisively with this pattern, foregrounding the centrality of the capitalist health industry in policy-making, and showing how ruling-class interests are served by it.
And yes, my own previous work in Africa and on development did give me a special interest in the theme. The routine normality of painful illness and early death in the global ‘south’ is so shameful, when we know that it is largely preventable; we also know that no amount of ‘aid’ is going to prevent it under the existing power relations of global capitalism. The determinants of poverty and ill-health, and of the lack of healthcare for all in the ‘south,’ are the same ones that are now driving the restoration of inequality and the dismantling of social protection in the ‘north.’ My work on British political economy under Thatcher and Blair took health policy as a test case of the way global market forces were driving domestic policy. What this revealed was a process that has ended in an amazing phenomenon – the British Labour Party, which 60 years ago set an example of universal and comprehensive healthcare that was followed all over the world – including in Canada – is now busy dismantling the integrated National Health Service and recreating a healthcare market – relying heavily on U.S. advisers and U.S. health multinationals to make it happen.
CL: There are really two core issues. One is the need to focus on the militant campaign that is now being waged by capital – the health insurance industry, the pharmaceutical and biotechnology industry, and big healthcare provider companies – to break up state-funded and provided healthcare systems in every country that has them, and turn them into fields of accumulation. In middle- and high-income countries we are talking of potential markets worth from 7 to 12% of national income or even more. The power of the corporations moving in on public health services is huge, and growing. In Canada and the U.K. and other advanced capitalist countries they are major actors in the restructuring of states on neoliberal lines that has been pushed through to a greater or lesser extent in all countries over the past 30 years. They are increasingly installed at the heart of government policy-making. Health ministries and departments have been downsized and policy development has been handed over to private sector personnel as consultants, or appointed to government posts, while ministers and career civil servants leave to take lucrative jobs in the private health sector. The boundary between public and private interests is increasingly blurred, especially in relation to health. This is not nearly as well understood as it needs to be.
The second core issue is the fact that healthcare, important as it is, is not the most important thing: the crucial determinants of health, wherever you live – India, Canada, South Africa, the USA, it makes no difference – are good food, good shelter, safety at work and protection against infections, so whether you and your family are healthy or not is above all a matter of equality. The poorest countries have the worst health, and so do the poorest people in all countries, including rich ones. Unless public policy is geared toward equality, even in rich countries most people's health will remain a lot worse than it should be. But the more neoliberal a government is, the less policy is concerned with equality. In the U.S. and the U.K., where inequality has been dramatically increased, it is condemning growing numbers of people to pain, disability and early death. The same is true internationally. As Meri Koivusalo shows in her essay in the volume, effective control over international health policy has been steadily transferred from the World Health Organisation to commercially-oriented and unaccountable organisations such as the Gates Foundation and the Global Fund to fight AIDS, tuberculosis and malaria. Even the WHO depends on ‘voluntary’ contributions from a range of sources for over four-fifths of its budget, as opposed to its core funding through UN member states. The bulk of health aid is thus increasingly controlled by agencies with links to corporate interests, especially those of big pharma. The WHO’s 1978 commitment to promoting ‘health for all’ via comprehensive primary care has given way to aid targeted at specific diseases largely chosen by these other agencies. The aim of improving people's health is compromised by the aim of making money.
SP: How have healthcare and all its associated activities and sectors become integrated into neoliberal capitalism and its global dynamics? Are there any particular contradictions that this volume of the Register reveals?
CL: There is an objective contradiction between capital's need for a workforce capable of providing reliable labour-power, and therefore being healthy enough to do so, and the compulsion on individual capitals – on companies – to constantly seek to pay less for it, well below what is needed to keep workers healthy. But this contradiction is less in evidence at present because of the huge pool of labour that is now available in China and India and other countries of the ‘south’; so far global capital has not found itself obliged to help keep this labour force healthy, and it has not.
But there is also an immediate contradiction between healthcare's role in making capitalism acceptable to workers – its legitimation function – and healthcare capital's drive for profits. An important essay in the volume by Shaoguang Wang shows that in order to maintain political stability the Chinese government has felt obliged, for the sake of social stability, to give up its market approach to healthcare and at least aim to restore universal access to healthcare. Whether western electorates who have come to take universal access to healthcare for granted will accept seeing it converted back into a commodity, very unequally available, is a question that the Left needs to focus on as a matter of urgency. Will people be ready to accept the idea that it is no longer the responsibility of governments to keep everyone well?
SP: It is striking that the volume is coming out in the midst of the U.S. healthcare struggle. Even as a Bill passes the House it seems it will be blocked and transformed in the Senate. What is your assessment of this struggle and what insights does the new volume bring to it?
CL: Yes, the struggle over healthcare reform in the U.S. shows just how deeply access to healthcare goes to the heart of politics today. But it's also very significant that Obama and many Democrats in Congress felt unable to win what they had previously supported – a ‘single-payer’ (i.e. tax-funded) system, doing away with the grossly inefficient and rapacious health insurance industry. On top of that they then even proved unable to secure their alternative, extremely weak, market-friendly option – a public insurance plan that would compete with the private ones. Only a taxpayer-subsidised adjustment to the existing private sector oligopoly will – perhaps – be allowed to pass. What the story shows above all is just how far the private healthcare industry controls senators and congressmen by funding their campaigns. The health industry also devotes enormous resources to influencing public opinion against any form of ‘state medicine.’ In spite of that, in this instance public opinion supported a single payer system – but Congressmen have again proved more answerable to capital than to voters. The book had to go to press before this story had run very far, and we are still waiting to see the outcome; it's a measure of the quality of Marie Gottschalk's analysis of the U.S. situation that her essay stressed the severe limitations of the ‘public plan’ and assessed what was likely to happen very accurately. The lack of an anti-capitalist movement in the U.S. that could mobilise a powerful response has again denied the American working class what it voted for. It should and could prove to be a catalyst for change in this regard, as the consequences become clear.
SP: Colin, another big issue right now is the H1N1 pandemic. This is being portrayed in the most narrow of terms as a public health issue to be managed by cleanliness, on the one hand, and mass vaccines, on the other, with other dimensions going unmentioned. One wonders whether we might see similar dynamic to that of a few years ago with respect to AIDS, which began as a technical issue seen as a minority problem but led to great struggles about social inequalities, sexuality and big pharma. Is it any more rational to treat swine flu as simply technical issue separate from the inequalities, institutions and dynamics of capitalism, or should we be looking at the linkages between the two?
CL: If it does develop as a serious killer disease like AIDS we will surely quickly become aware of those linkages. It spreads easily and affects everyone more or less equally and so can’t be attributed to ‘lifestyle choices’ the way sexually transmitted diseases or lung cancer often are. But given that those most liable to become seriously ill and even die from it are those whose health is already compromised, and that these are typically poorer people than the average, the class dimension of it will be there to see if it becomes more lethal. The issue of who gets the vaccine first has already revealed class privileges in Canada and elsewhere. A related question is whether the price charged by the big pharmaceutical companies such as GlaxoSmithKline who are supplying the vaccine to governments is right: how far should collective protection against a collective threat yield windfall profits for capital?
SP: The IMF has now called for a decade of austerity in the public sector and in wages and benefits for workers. This comes on top of a long period of struggles against healthcare privatization and the working conditions of healthcare workers. You have been engaged in a lot of these struggles with the NHS in Britain and have, no doubt, kept up with some of the struggles in Canada given your frequent visits and continuing close contacts here. What do you expect might be coming in the way of confrontations?
CL: This is a very important issue. In OECD countries other than the USA (where health is still treated as a commodity) people have been resisting – with varying degrees of success, depending on circumstances – the privatization of the publicly-funded and managed healthcare systems that were established after WWII. In Canada, for example, the reality of the American healthcare market is there to be seen just across the border. Many Canadians have relatives there and know all about it. They didn’t need to see Michael Moore's film Sicko. Many Canadians are also relatively recent immigrants who are keenly aware of the ‘freedom from fear’ of illness or accidents that the universal healthcare system in their adopted country gives them. On top of this the labour unions have put resources into the fight to defend Canadian healthcare: the Canada Health Coalition has a high media profile and widespread support. The result is as near unanimity as you can ever get on anything in a free and democratic country – a recent poll found 89.9% of Canadians support or somewhat support universal healthcare.
In spite of this massive public endorsement, the Canadian healthcare system has also been subjected to the application of neo-Taylorism in hospitals, to contracting out of the ‘ancillary’ work of hospital cleaning, laundry and cooking, and to the offloading of healthcare to the unpaid labour of families, and especially women. This comes across clearly in the essay by Pat and Hugh Armstrong on struggles for control in the Canadian healthcare workplace. The call for more public sector cutbacks and assaults on the rights of public sector workers will undoubtedly worsen these trends, but as the Armstrongs also show, there is a growing potential for alliances among ancillary workers, nurses and even doctors to confront further attacks.
In England, where the assault on the public system has gone much further, campaigners against it are handicapped by the fact that it has been pushed through not by the Conservatives (who of course are happy to see it happen), but by a Labour government – and the trade unions are affiliated to the Labour Party. Even UNISON, the main health service workers’ union, is unwilling to attack Labour's marketization of the National Health Service publicly, even though its members are overwhelmingly opposed to it. As a result, while the NHS remains the most popular institution in the country there is limited understanding of how far and fast it is being broken up and privatized. Now that all the main political parties have signed up to the idea that everyone must just put their hands up and pay for the bankers’ greed by accepting a decade of cuts in public services, it will be interesting to see what happens when the cuts start to make a major impact on health services. There is an urgent need – and a major opportunity – for the Left to make the connections clear. The impact of austerity on health services could and should force the unions to finally detach themselves from their subservience to the neo-Thatcherite Labour elite, and encourage new political forces to coalesce around the need to reassert the right to healthcare as a basic political right, a component of equal citizenship.
SP: Do you see the book as a handbook for healthcare activists?
CL: We certainly hope it will be, and the essay by Sanjay Basu on what activists can learn from HIV/AIDS mobilizations to build a comprehensive public health movement is very important in this respect. But the book is aimed at a wider readership as well. One of the problems to be overcome is that what is happening to health and healthcare is so poorly reported and analysed in the media. The owners of most newspapers, magazines, TV channels and radio stations are part of the neoliberal order. This means that health features in just two ways: amazing stories about medical ‘breakthroughs’ in individual treatments, usually in surgery; and failures and scandals – and never the successes – of publicly-funded and managed healthcare systems. On the other hand editors working for public-service broadcasting or more critical newspapers tend to see health policy as too complex for most viewers and readers. Even medical students get shockingly little exposure to issues of health policy. Most medical training pays scant attention to the social and economic context of disease and its treatment, or to what forces are determining health policy, or how far current health policies fall short of reflecting what medical science tells us. You don’t need to be a socialist to see that this is wrong. You just need to have a concern for scientific evidence and the welfare of the society you live in. Morbid Symptoms should be read by medical students and doctors and nurses and everyone in the caring professions – in fact by everyone who thinks health matters.
SP: The Socialist Register has always tried to have a vision of practical utopias for socialist struggles. This is something we have encountered as a problem in Canada in relation to healthcare – the need to go beyond just blocking any further erosion of public health. What contribution does the new Register add to practical utopias today and a programme for the Left in terms of health?
CL: The principles that a socialist health programme should rest on come across clearly enough from the volume. In general, a socialist health policy would aim at making economic policy serve the goal of making everyone as healthy as possible, rather than making a few people as rich as possible. As Hans-Ulrich Deppe, an eminent German professor of medicine, says in his essay on the nature of healthcare, health is a universal need that should be a universal right, and this means that every aspect of health policy must be grounded in the principle of social solidarity. What this means in practice will vary widely, depending on the health system that already exists, public attitudes to health and medicine, country-specific variations in need, etc. And it can only be worked out in practice; blueprints made in advance are not going to help much. But a more democratic health policy, which must be the starting-point, will always imply some striking changes. For instance Julian Tudor Hart's powerful closing essay in the volume points out that in advanced capitalist countries an amazing third of all adults experience a mental health problem of one kind or another, but only a tiny fraction of the misery that this represents is even acknowledged, let alone treated – even in health systems that are supposedly equally accessible by all. A socialist health policy must obviously confront this, implying some major shifts of attitudes and resources, and a radical change in the social conditions that cause so much of the problem. It would aim to bring medical priorities into line with the findings of medical science – a very different thing from the priority now assigned to high-tech medical care for conditions that represent a tiny fraction of the burden of disease among the population at large (not to mention the populations of the global ‘south’).
Thinking through what a socialist health policy would look like in any given society in fact opens up several extremely exciting vistas. It also opens up the possibility of new alliances in the struggle for socialism generally.
For example, once it is recognised that good health depends more on social and economic equality than on healthcare – crucially important though healthcare is – healthcare activists thinking about the kind of politics needed to secure good health for all find they have natural allies in a whole range of movements struggling for equality – for labour, for women, for the unemployed, for undocumented people, and for minorities of many kinds. In the same way, envisaging the kind of state, and the kinds of democratic accountability, that could ensure that maximizing people’s health became and remained a core commitment of society, is a powerful way of focusing on the kind of state needed for achieving other solidaristic goals.
Health is a deeply emotive matter, and the Left has every reason to make it a core issue of its own. And not just in defending publicly-provided, universal-access healthcare, but in a more radical sense too, as Leo and I suggest in the Preface to the book: “the contradiction between capitalism and health should become a pivotal dimension of a revitalized socialist strategy.” •
In addition to co-editing the Socialist Register Colin Leys is the author of various books including Underdevelopment in Kenya, Politics in Britain: From Labourism to Thatcherism, The Rise and Fall of Development Theory, and Market-Driven Politics: Neoliberal democracy and the public interest.