Zealously supporting the creation of such a system, Aneurin Bevan, democratic socialist and Minister of Health in the British Labour Government between 1945 and 1950, proclaimed: “A free health service is pure socialism and as such it is opposed to the hedonism of capitalist society.”1 Asserting the accomplishments of the British National Health Service (NHS), he strenuously argued the incompatibility between the pursuance of health care through the market and individuals achieving good health. For Bevan, a commercially oriented health service discriminated against those unable to afford market options and was socially divisive, segregating those who could not afford health care from those who could. “The essence of a satisfactory health service,” Bevan argued, “is that the rich and the poor are treated alike, that poverty is not a disability, and wealth is not advantaged.”2
For Bevan, the collective provision of health care was by far the more superior and principled method of arrangement—a position with which the contributors to Health Care Under the Knife would agree. The volume, under the editorship of Howard Waitzkin, presents a vigorous critique of health within the context of capitalism, examining the extent to which the economy and its relations of production determine how health is socially distributed, the conditions of medical practice, and the structural organization of health systems. Rather than considering health as primarily a biomedical phenomenon and health systems as autonomous institutions, the volume recognizes the intricate fundamental relationship between health and the wider political, economic, and sociological context. As Waitzkin has previously argued, any attempt to understand the nature of health care provision must accept that challenges to its effective delivery can rarely be separated from the social conditions within which it is situated.3 The essential motif of Health Care Under the Knife is that no meaningful understanding of health can be achieved without taking account of capitalism as the basis upon which society is organized. Grounding all analyses within this context, the issue of class conflict is ever present, with health as an object of class struggle, shaped by the balance of class forces. Health is conceived as intertwined with and an outcome of the political and economic forces that both shape and oppose the accumulation process. As such, Health Care Under the Knife has as central to its theoretical exposition the notion of health as a dialectical phenomenon.
A Neoliberal Health Care Agenda
Explicating the relationship between health and capitalism, the majority of contributors situate their analyses within the context of neoliberalism. Constituting a hegemonic force for nearly four decades, neoliberalism is a ruling class “political ideological project.”4 Moreover, Marxist social epidemiologist Vicente Navarro, who alongside Waitzkin has contributed significantly to elucidating the links between health and capitalism, asserts that neoliberalism is nothing less than the ideology and practice of the global capitalist class, governing how the class struggle has been fought in practice.5
The volume makes acutely clear that neoliberal influences on health care benefit capital over labor. Identifying the Affordable Care Act (ACA), or Obamacare, as the latest incarnation of how neoliberalism has shaped health care in the United States, Waitzkin and Ida Hellander explain that it has done little to strengthen the position of labor. Instead, it has further enriched the insurance industry, transferring vast amounts of public revenue to the private sector, increasing profits and dividends for shareholders, while bolstering already excessive executive salaries.6 Capital’s postwar attempt to impose itself on health, Waitzkin and Hellander illustrate, originated in the United States, influenced by methods of promoting cost-effective military expenditure during the Cold War. Once adapted to the sphere of health, these principles were incorporated within a marketized health care agenda that has risen to prominence with neoliberalism’s global hegemonic dominance, having influenced the restructuring of health systems over the last quarter of a century or more, particularly within the advanced capitalist nations and Latin America.
Embracing the idea of market-driven health care, neoliberal health care reforms have been promoted globally by the United States, World Bank, International Monetary Fund, and World Health Organization (WHO).7 Although the impact on nation-states has been uneven, as Waitzkin and Hellander correctly proclaim, where neoliberalism has obtained influence, health care has been redesigned in its image. Overwhelmingly, such restructuring is characterized by a fragmented system of varying private sector actors. In the United States and to an extent Latin America, Managed Care Organizations (MCOs) and for-profit companies that are often subsidiaries of private health care corporations have assumed growing responsibility for providing services within a given locality or to a section of the population. Under Obamacare, Waitzkin and Hellander explain, these new marketized health systems take the form of Accountable Care Organizations. Moreover, MCOs operate in close proximity with private-sector organizations that purchase health care provisions from private insurers and then contract MCOs for its delivery.8
Agreeing with Waitzkin and Hellander, Adam Gaffney and Carlos Muntaner succinctly illustrate how, in Europe, austerity, which was embraced as the means to restore economic growth after the Great Recession of 2007–09, was seized on to force through neoliberal health policies. In the cases of Spain, Greece, and Britain, health systems have been subjected to neoliberal restructuring characterized by reduced public funding, a retreat from universalism, an increase of copayments, and privatization. Although building on previous policies, especially those of the English NHS, Gaffney and Muntaner forcefully claim that the ultimate intention of such restructuring was to attack the concept and existence of public health care provision.9 Whether in the United States, Latin America, or Europe, David Himmelstein and Steffie Woolhandler accurately assert that health care has increasingly become reconceptualized as a commodity, with market values penetrating its delivery.10
Crucially, Waitzkin, Hellander, Gaffney, and Muntaner recognize the state as complicit within all neoliberal-influenced reforms. Neoliberalism advocates the subsumption of government to the market. Hence, the state has remained active but its relative autonomy is reduced. As Navarro argued over a decade ago: the “neoliberal narrative about the declining role of the state…is easily falsified by the facts.”11 Even if the state has withdrawn directly from economic activity, the neoliberal state has become more interventionist in its attempt to advance the ethic of the market throughout society in such arenas as education, communications, the environment, and health care.12 Exemplifying this, Waitzkin and Hellander argue that Obamacare, as a system that has overwhelmingly assisted the augmentation of profit for the insurance industry and pharmaceutical corporations at the expense of health care for the majority, epitomizes the state’s efforts to promote the logic of capital within the field of health. For all the contributors of Health Care Under the Knife, there exists no doubt that neoliberal health care reforms have done little to advance the interests of labor, and are instead a further example of the extent to which capital has struggled against the working class.
Health Care and Monopoly-Finance Capital
The impact of neoliberalism pervades Health Care Under the Knife, but as a version of capitalism it has not simply emerged as a chosen paradigm by capital that could be replaced easily by an alternative framework through which to organize the accumulation process. Neoliberalism is a product of late capitalism, inextricably associated with the emergence of monopoly-finance capital as stagnation in the productive base of the advanced capitalist nations has prevailed.13 In a welcome attempt, an explicit effort is made in Health Care Under the Knife to relate the economic structure of the health care industry to the current era of monopoly-finance capital. Drawing on the Marxism of Paul Baran and Paul Sweezy, Health Care Under the Knife positions its economic analysis firmly within the context of monopoly capital, characterized by a tendency of surplus to rise and chronic problems of surplus absorption, manifested in growing inequality, high unemployment, underemployment, and excess productive capacity, as demand grows at a lesser rate relative to production. As a consequence, stagnation prevails as the incentive to invest is weakened in an environment of overaccumulation. Subsequently, rising surplus requires methods of absorption.14 In recent decades, financialization, in the form of the explosive growth of debt and credit, and varying financial instruments have attempted to absorb existing surplus and stimulate new investment opportunities.15
For Joel Lexchin, the stagnationist tendencies of monopoly capitalism are visibly present within the health care sector, in particular the pharmaceutical industry. Invoking notions of overaccumulation, Lexchin argues that the industry is characterized by an exhaustion of markets for its output. In response, he illustrates how product differentiation has been embraced by pharmaceutical manufacturers, modifying existing products to stimulate demand.16 Concurrently, Robb Burlage and Matthew Anderson maintain that capital accumulation within the industry has come to rely less on production and more on debt-fueled speculation.17 Burlage and Anderson show astutely the extent to which monopolization has infiltrated the health care sector, as well as how the industry has adopted methods of financialization to stimulate economic growth. In the United States, hospitals, MCOs, and insurance companies have merged in order to attain the unassailable position that comes with being supposedly too big to fail. Furthermore, the pharmaceutical industry has rapidly monopolized, facilitating a dramatic increase in drug prices.18
Aside from the benefits of monopoly price fixing, which allows for the short-term expansion of profit that, however, exacerbates the crisis of surplus absorption in the long term, the growth of mergers and acquisitions has provided short-term investment outlets for surplus capital. These have come from within the health care sector itself as well as the wider economy, with the process also aided by large quantities of surplus in the form of credit, fueling the growing levels of debt within the sector. This has allowed for the immediate generation of new sources of income. As Burlage and Anderson rightly claim, with opportunities for income-generation from capital investment in production declining, the health care industry has engaged in financial practices to generate profits, enthusiastically embracing debt and the manipulation of financial instruments.
The insightful analyses of Waitzkin, Rebeca Jasso-Aguilar, Anne-Emanuelle Birn, and Judith Richter illustrate the extent to which the provision of health care—though perhaps not immediately thought of as an obvious mechanism of imperialism—supports imperialist practices, while the health care industry, like other capitalist enterprises, frequently asserts itself in an imperialist manner.
Since the turn of the millennium, U.S. hegemony over the global health care agenda has been solidified, not just through its influence upon WHO and the World Bank, but in the form of philanthrocapitalism, a combination of philanthropic principles and capitalist practices within low- and medium-income countries. While not a new phenomenon—for example, the Rockefeller Foundation intervened as a global health actor starting in the early twentieth century—philanthrocapitalism has in recent years been most influential through the Bill and Melinda Gates Foundation.19 As a consequence of having a budget for global health activities that surpasses that of WHO, as well as having grown to rival and partner with institutions such as UNICEF, the World Bank, and WHO, the Gates Foundation’s ability to set the agenda is immense. Obscuring the consequences of capitalism for health, the Gates Foundation’s prevailing model of public health focuses on disease control through investment in technological developments, in particular vaccinations.20 Correctly, Waitzkin and Jasso-Aguilar argue that philanthrocapitalist organizations are an expression of imperialism, because while they claim to be “investing in health,” they facilitate the conditions for expanded accumulation, primarily for monopoly corporations located in the advanced capitalist nations.21
In an era of stagnation, where new opportunities for investment are relatively limited within domestic markets, monopoly-finance capital has become a truly global phenomenon.22 Identifying a reduction in the costs of variable capital as a means to increase profits, monopoly corporations have frequently relocated production to regions of cheap labor in the Global South. But, as Waitzkin and Jasso-Aguilar argue, this labor must be efficient if it is to be exploited profitably. Public health initiatives such as those promoted by philanthrocapitalists contribute to the creation of a healthier and more productive labor force in the Global South, which in turn makes those locations more attractive as sources of surplus capital investment and sites of accumulation. In addition, with the health care industry itself plagued by market saturation, countries in the periphery represent new markets and investment outlets for the pharmaceutical and medical equipment industries.23 For instance, operating in partnership with philanthrocapitalist organizations, the enactment of global public health initiatives commonly requires the participation of pharmaceutical corporations, as well private insurers and MCOs.
Personal and Professional Consequences
While detailing structural developments at the macro level, Health Care Under the Knife is careful to clarify the relationship between structural organization and the experiences of social groups. Exemplifying this, Muntaner and Rob Wallace illustrate the need to recognize the societal distribution of health as inextricably related to social determinants that emerge from and reflect the organization of society’s social structures.24 The individual experience of health is always an embodied one, but this experience is overwhelmingly related to an individual’s location within the social structure. Under capitalism, this is exacerbated by the extent an individual’s location exposes them to oppression and exploitation. Using contemporary examples, Muntaner and Wallace forcefully argue that some of the most debilitating social determinants of health derive from the operation of a social system organized around the prerequisite of accumulation, with the distribution of positive and negative health experiences determined by an individual’s class position.
Much of Muntaner and Wallace’s understanding of society fits the concept of pathological normalcy, around which Carl Ratner’s discussion is anchored.25 Associated with Marxist psychoanalyst Erich Fromm, pathological normalcy, Ratner argues, illustrates the extent to which so-called normal taken-for-granted conditions of everyday life are conducive to pathological developments, not just physically, but also in regard to mental health. What tends to be accepted as mental illness under capitalism primarily emerges from the pathological normality of society.26 Unemployment, low wages, and polluted environments, among other phenomena, are largely accepted as inherent to the way society operates, yet they cause great distress. Little hope of relief, Ratner proclaims, can emerge from sources of mainstream medicine, in particular the psychological professions, which primarily intervene in an individual’s life through medication and psychological practices and largely aim to ensure individuals adapt to the pathological normal conditions that have contributed to their distress, obscuring the social determinants.27
Related issues arise with respect to the provision of actual medical practice. Reflecting on his own experience, Waitzkin argues that the infiltration of market values within health care has resulted in professionals increasingly losing their autonomy over the conditions of employment. The result is the rapid proletarianization of the medical profession.28 A dominant factor is the corporate attempt to standardize and regulate outcomes and behaviors by imposing objective goals and targets on professionals under the guise of quality. Few would argue against ensuring and improving quality within health care. But, as Gordon Schiff and Sarah Winch argue, a market-driven understanding of quality prevails.29 From the perspective of professionals, quality health care is ultimately about establishing healing relationships, providing the optimal care and support tailored to an individual’s specific needs in an empathetic manner. But under a neoliberal-inspired health care system, quality becomes objectified, with imposed targets, standards, and quantitative goals against which professionals are measured. As a result, as Matthew Anderson contends, an artificial distance is created between professional and patient that acts as a barrier preventing medical professionals from exhibiting effective interpersonal skills and that treats the patient as a statistic and an object.30 In such an environment, alienation pervasively spreads among professionals, making them lose meaningful connections to their work.31
Constituting a rich theoretical resource, Health Care Under the Knife provides a perceptive and penetrating clarification of the real-world conditions of health care. The volume’s intentions, as laid out by Waitzkin, are successfully achieved. The book provides a vital foundation to stimulate movements for change, equipping activists with essential knowledge and ensuring they have the correct tools to fight for a progressive health care future. Yet, meaningful change cannot successfully occur within capitalism. To be sure, the existence of universal and largely public health care systems in many of the advanced capitalist nations (except, notably, the United States) demonstrates to activists, and the population at large, that single-payer systems can be established within the context of advanced capitalism. But as crucial as this is, a single-payer system is only one step on the road to a society designed to care for all people. As Muntaner and Wallace make abundantly clear, the injustices and inequalities that emerge from the social determinants of health are explicitly evident within nations with single-payer systems as well. Guaranteeing everyone optimal health will only be achieved with the radical reorganization of society, with the aim of putting people before profit and health before accumulation.
- ↩ Aneurin Bevan, In Place of Fear (New York: Simon and Schuster, 1952), 86.
- ↩ Bevan, In Place of Fear, 81.
- ↩ Howard Waitzkin, The Second Sickness (Lanham: Rowman and Littlefield, 2000), 4.
- ↩ John Bellamy Foster, “Absolute Capitalism,” Monthly Review 71, no. 1 (May 2019): 1.
- ↩ Vicente Navarro, “Neoliberalism and Class Ideology,” International Journal of Health Services 37, no. 1 (2007): 53.
- ↩ Howard Waitzkin and Ida Hellander, “Obamacare,” in Health Care Under the Knife, ed. Howard Waitzkin (New York: Monthly Review Press, 2018), 99–100.
- ↩ Waitzkin and Hellander, “Obamacare,” 102–4.
- ↩ Waitzkin and Hellander, “Obamacare,” 104–11.
- ↩ Adam Gaffney and Carles Muntaner “Austerity and Healthcare,” in Health Care Under the Knife.
- ↩ David Himmelstein and Steffie Woolhandler “The Political Economy of Health Reform,” in Health Care Under the Knife, 57.
- ↩ Navarro, “Neoliberalism and Class Ideology,” 50.
- ↩ Foster, “Absolute Capitalism,” 6.
- ↩ John Bellamy Foster, “Capitalism Has Failed—What Next?,” Monthly Review 70, no. 9 (February 2019): 7.
- ↩ Paul A. Baran and Paul M. Sweezy, Monopoly Capital (New York: Monthly Review Press, 1966), 114.
- ↩ John Bellamy Foster and Fred Magdoff, The Great Financial Crisis (New York: Monthly Review Press, 2009).
- ↩ Joel Lexchin, “The Pharmaceutical Industry in the Context of Contemporary Capitalism,” in Health Care Under the Knife, 85.
- ↩ Robb Burlage and Matthew Anderson, “The Medical-Industrial Complex in the Age of Financialization,” in Health Care Under the Knife, 81.
- ↩ Burlage and Anderson, “The Medical-Industrial Complex in the Age of Financialization,” 77–79.
- ↩ Anne-Emanuelle Birn and Judith Richter, “U.S. Philanthrocapitalism and the Global Health Agenda,” in Health Care Under the Knife, 155.
- ↩ Birn and Richter, “U.S. Philanthrocapitalism and the Global Health Agenda,” 164–65.
- ↩ Howard Waitzkin and Rebeca Jasso-Aguilar, “Imperialism’s Health Component,” in Health Care Under the Knife.
- ↩ John Bellamy Foster and Robert W. McChesney, The Endless Crisis (New York, Monthly Review Press, 2012).
- ↩ Waitzkin and Jasso-Aguilar, “Imperialism’s Health Component,” 138–39.
- ↩ Carles Muntaner and Rob Wallace, “Confronting the Social and Environmental Determinants of Health,” in Health Care Under the Knife.
- ↩ Carl Ratner, “Overcoming Pathological Normalcy: Mental Health Challenges in the Coming Transformation,” in Health Care Under the Knife.
- ↩ For an illustration of the extent monopoly-capitalist society impacts mental health, see David Matthews, “Capitalism and Mental Health,” Monthly Review 70, no. 8 (January 2019).
- ↩ Ratner, “Overcoming Pathological Normalcy,” 219.
- ↩ Howard Waitzkin, “Disobedience: Doctor Workers, Unite!,” in Health Care Under the Knife, 26.
- ↩ Gordon D. Schiff and Sarah Winch, “The Degradation of Medical Labor and the Meaning of Quality in Health Care,” in Health Care Under the Knife, 44.
- ↩ Matthew Anderson, “Becoming Employees,” in Health Care Under the Knife, 37.
- ↩ Schiff and Winch, “The Degradation of Medical Labor and the Meaning of Quality in Health Care,” 45.