The Class Struggle and Welfare: Social Policy under Capitalism
By David Matthews
978-1-68590-086-1 / 240 pages / $28
Excerpted from:
CHAPTER 8: Healthcare under Capitalism
Fundamental to the Marxist method is dialectics, with change understood as emerging from the interaction between objects and phenomena. The health status of any individual arises from the dialectical interaction between the materialism of their body and the materialism of the social context within which the body is situated. The body has its own biological structural organization, governed by its own internal biological forces. Without doubt there exists an expected way in which the body functions, reflecting its inherent structural operation, which, when operating in the expected manner, contributes to the existence of good health. Yet, both good and poor health, do not, in many incidences, simply arise from, or can be reduced to, the positive and negative functioning of the body. Instead, as crucial as the biological operation of the body is, the structural organization and operation of society plays a vital role in influencing how someone experiences their health, with differing social environments more or less conducive to good health.
Capitalism and Poor Health
Both Marx and Engels were acutely aware of the detrimental impact capitalism can have on the health of working people. Because of the material conditions of production Marx stressed “Every organ of sense is injured in an equal degree by artificial elevation of the temperature, by the dust-laden atmosphere, by the deafening noise, not to mention danger to life and limb among the thickly crowded machinery, which, with the regularity of the seasons, issues its list of the killed and wounded in the industrial battle.” Moreover, he made reference to the “victims of industry, whose number increases with the increase of dangerous machinery, of mines, chemical works, &c., the mutilated, the sickly.” As much as Marx understood how the fervent desire for increased accumulation impacted negatively upon the health of the labor force, it was Engels who provided the first detailed Marxist understanding of the relationship between capitalism and health.
Engels made clear the root cause of poor health was capitalist production, and the organization of society built upon class relations. The severe oppression and exploitation experienced by the working class had serious ramifications for the health of the labor force. The organization of capitalist society “placed the workers under conditions in which they can neither retain health nor live long.” Additionally “society knows how injurious such conditions are to the health and life of the workers, and yet does nothing to improve these conditions.” The capitalist class, Engels was arguing, were aware of the brutal impact production had on the health of the working class, but its failure to mitigate against the conditions contributing to this meant capitalism was committing social murder.
Urban growth, Engels exemplified, resulted in overcrowding and pollution, had serious health implications. Contributing to the development of respiratory complications, the burning of coal was both a common source of heat in the meagre dwellings of the working class, and integral to the productive process, consumed in abundance by industry. Consequently, air quality was severely compromised, filled with carbon dioxide, sulphur and nitrous oxide, blackening the skies, buildings, and lungs of the individuals who had no choice but to work and reside in those surroundings. “The lungs of the inhabitants fail to receive the due supply of oxygen, and the consequence is mental and physical lassitude and low vitality.” Roaming the streets of Manchester, a city at the heart of the industrial revolution in Britain, Engels observed there could be seen a working class who were “pale, lank, narrow-chested, hollowed-eyed ghosts,” having “languid, flabby faces, incapable of the slightest energetic expression.”
In addition to working within polluted and dangerous conditions, the homes of many members of the labor force were identified as severely injurious to health. Frequently, the experience of domestic life was one of overcrowding, with rooms inhabited which rarely received natural light and lacked sufficient ventilation. Furthermore, the working-class streets of industrial Britain were densely built, preventing an adequate supply of clean air, while the overwhelming majority did not have access to clean water and sanitation. As Engels posited in relation to this last point “they are deprived of all means of cleanliness…they are obliged to throw offal and garbage, all dirty water, often all disgusting drainage and excrement into the streets, being without other means of disposing of them; they are thus compelled to infect the region of their own dwellings.” The direct impact upon the health of the working class was the spread of infectious disease.
Marx and Engels demonstrated the inextricable relationship between the spread of disease and capitalism. And in the early part of the twenty first century, capitalism remains a powerful determinant of health, with the diffusion of both good and poor health broadly following the distribution of wealth and authority. However, within the advanced capitalist nations, the premise that social conditions influence the development of poor health is frequently concealed by an all-encompassing belief that health is largely related to the biological functioning of an individual’s body, or because of an individual’s behaviour. In the face of this conclusion, as Howard Waitzkin, Alina Perez and Matthew Anderson stress, with each generation there subsequently occurs a constant need to reassert the understanding that societal and material factors are essential to influencing the aetiological development of disease. It is the economic and social organization and operation of capitalist society, which give rise to social and economic inequalities, which constitute the root causes of many health issues, and exacerbate others. The essence of capitalism, such as it’s relations of production, the inherent drive for increasing accumulation, and the oppression and exploitation of many within the labor force, are the origins from which the unequal distribution of health develop.
Corporeal Productivity
Good physical and mental health is a fundamental need and has figured prominently within the class struggle. In response most of the advanced capitalist nations have established varying forms of universal state healthcare. To deny the benefits accrued to labor of a state healthcare system would be obstinate. Yet, it is unquestionably the case that state systems have bequeathed to capital many advantages, in particular their role in the maintenance, and enhancement, of most people to work. Within the advanced capitalist nations this constitutes a fundamental objective of any healthcare system. For capitalism, and from the perspective of capital desiring to expand surplus value production, the principal intention of a healthcare system is to ensure the labor force has a level of health which is functionally useful to be productive.
As was made clear when discussing disability, under capitalism not all labor power is considered of the same quality. Poor health is detrimental to productivity. Intervention, therefore, is required to ensure a minimum standard of physical and mental fitness is obtainable by all members of the labor force. Consequently, a universal standard against which an acceptable level of fitness is measured has evolved. In response the state has intervened in many advanced capitalist nations providing, or greatly subsidizing, the provision of healthcare, to ensure this standard is obtainable by the majority. With the state is tasked with ensuring a universal standard of physical and mental fitness for labor this means the costs of reproducing the health of the working class are socialized. Although having to support this type of system through fiscal contributions, a socialized system accrues upon capital the advantage that their contributions are much less than if they were more directly responsible for the healthcare of their own employees.
A universal standard of physical and mental fitness is essential, but this standard is not fixed. Historically, as capitalism has evolved, with old productive processes having declined new ones have emerged. During the last century the advanced capitalist nations witnessed the decline of heavy industry and manufacturing, and their subsequent replacement with service sector occupations, including the growth of the sales effort, the state, and financial activities. As capitalism evolves, the expectations of labor, in terms of skills, behaviour, aptitudes, abilities, and physicality has also evolved so that labor can adapt itself to the changing requirements of the production process. Astutely aware of the relationship between corporeal capacity and productivity, Marx recognized how a transformation in the productive process required a different type of corporeality. As capitalism became more technologically intensive during the mid-nineteenth century less muscle power was required as machinery demanded operatives who were more dexterous. The result was growth in the employment of women and children. “In so far as machinery dispenses with muscular power,” Marx claimed “it becomes a means of employing labourers of slight muscular strength, and those whose bodily development is incomplete, but whose limbs are all the more supple.” Inferred from Marx’s position is the understanding that differing methods of production requires varying forms of physical attributes and abilities. Building upon this, as Vicente Navarro made clear, as capitalism has matured and evolved so with it has grown an increasingly complex division of labor with ever greater specialization in terms of corporeal abilities and skills. And, Navarro asserts, “this specialization demands great involvement and investment from the state in order to guarantee the reproduction of labor needed for the system.” In this process health systems are essential to facilitating, and helping to equip members of the labor force, with the desired levels of physical and mental fitness required to be productive, but also a specific corporeal fitness which corresponds with capitalism’s specific historical productive needs.
The explicit use of state healthcare to promote the productivity of labor can be illustrated in recent years by the English National Health Service’s (NHS) overt incursion into supporting the employability of service users. Establishing its long-term agenda, moving into the 2020s, it was asserted that “fast and convenient access to health services plays an important role in maintaining employment.” Arguing that mental health and musculoskeletal issues are prominent causes of labor force absences, service provision for such concerns, it was argued, needed to expand. With regards to mental health, the English NHS has actively embraced the Individual Placement and Support (IPS) employment scheme, whereby, in partnership with the private sector, the purpose is to facilitate the transition to the labor market of individuals with severe mental health issues.
Healthcare as Ideology
Acting as a mechanism of social control state health services embrace a particular understanding of health which is advantageous for the continuing dominance of capital, and is reflected in their organization, operation and the knowledge-base underpinning them.
Within the advanced capitalist nations, as already indicated, health is understood overwhelmingly as a biological phenomenon, with this having significant ideological consequences. A capitalist conception of health is one which, primarily, perceives poor health as a state of physical incapacity causing suffering. The result is a biological reductionist position infuses the understanding of health under capitalism. Health assumes the status of an individual concept. Medical interventions are directed towards the individual, with the emphasis upon repairing the body to alleviate and prevent further health issues. Medicine under capitalism Leonard Rodberg and Gelvin Stevenson correctly assert “operates according to an individualistic, scientistic, machine model.” An individualistic approach to health has the consequence of diverting attention from the ways in which capitalism contributes to the cause of poor health, and influences its distribution. A biologically deterministic understanding of health “deflects attention from multifactorial origin,” Waitzkin argues “especially causes of disease that derive from the environment, work processes, or social stress.” By masking the negative consequences of capitalism’s organization and operation, the biological conception of health performs a vital ideological function. Individuals are viewed as sick, not society.
Focusing on individuals rather than society has come to dominate state healthcare approaches to health prevention and intervention. The health promotion agenda of many healthcare systems coalesce around behaviour, often employing the knowledge and methods of health psychology, to promote and reinforce the positive and negative consequences of various behaviors. Under capitalism prevention methods inordinately pivot upon behaviour modification of individuals, rather than identifying the need for social and economic change. Behaviours such as drug and alcohol abuse, smoking, and unhealthy eating, among others, are identified as having negative consequences for individuals, but effort is placed upon individuals changing their behavior rather than considering the wider social and economic circumstances contributing to unhealthy behavior. Additionally, although rarely explicitly stated, prevention has ingrained within it a victim blaming approach, as often the individual is characterized as at fault for their own poor health, having actively chosen to engage in unhealthy behaviours, with the state having the responsibility to educate them, and provide the resources, to allow them to change their behavior. For capitalism, Navarro argues, this has the advantage of reinforcing “the basic ethical tenets of bourgeois individualism…this life-style politics complements and is easily co-optable by the controllers of the system, and it leaves the economic and political structures of our society unchanged.”
In the Image of the Market: The English NHS
Up to this point it has been argued that state healthcare systems are advantageous for capitalism, first, through their role in reproducing labor power. Secondly, they have a vital ideological function, with their operation dominated by a biological explanation of health which emphasises the individual and obscures the relationship between poor health, inequality, exploitation and oppression. With increasing penetration over the last near four decades of market values into many spheres of society the relationship between capitalism and state healthcare can be further exemplified with reference to the way capitalism has attempted to shape state provision in its own image. During this period many state systems in the advanced capitalist nations, including those in Scandinavia, once a bastion of social democracy, have witnessed reforms of varying degrees of magnitude reflecting market values. In particular privatization. England has arguably been at the forefront of this process, with successive governments since the 1980s forcing the NHS to operate upon principles such as choice and competition, and being opened as a lucrative market for global private healthcare operations. While healthcare in England remains primarily publicly funded, its once universal nature as a state service has been especially challenged over the last decade, exemplified none more so by the introduction of the Health and Social Care Act (HSCA) in 2012, and subsequent legislation which has followed.
In an attempt to model a state health system which reflects the values of the free market the HSCA had to strike a blow at the heart of one of the fundamental principles upon which the NHS was established in 1948; that of universalism where all within society, regardless of social and economic division, are entitled to receive the same care and support. The HSCA abolished the NHS’s foundational guarantee of universal care, instead requiring only “the Secretary of State…continue the promotion in England of a comprehensive health service.” While the onus remains on government to fund health care for individuals who live in England, responsibility of government to provide health care for all citizens was withdrawn. The provision of health care has been transferred to an autonomous public body, NHS England, controlling most health expenditure and directing the overall operation of the English NHS.
Prior to 2012, the administrative regional provision of the NHS was managed mainly by Primary Care Trusts (PCT), which executed the government’s health priorities. With the abrogation of the universal care requirement, however, this administrative system became obsolete. PCTs were superseded by Clinical Commissioning Groups (CCG). Composed of health professionals, including general practitioners, as well as financial administrators, their purpose was to secure the provision of services relating to secondary care, community health, and mental health and learning disabilities services. It is to these independent, quasi-private consortia that much of the delivery of the English NHS was devolved. The language of the HSCA allowed CCGs a broad margin of discretion regarding what services they provide: a group “may arrange for the provision of services or facilities as it considers appropriate” to “such extent as it considers necessary.” Freed from any legal mandate the services and resources provided through NHS England can now vary widely by clinic, city, and region. Further, in an act that strikes at the heart of the principle of universalism, the HSCA permitted CCG service providers to set their own eligibility and selection criteria for patients. In July 2022, CCGs were abolished and replaced with Integrated Care Systems (ICS). Although an administrative reorganization, the fundamental principles underpinning them remain the same as those supporting the operation of CCGs. To limit the state’s authority over the provision of healthcare, lacking any democratic control, ICS are under the authority of Integrated Care Boards (ICB), with the opportunity for the private sector to be represented on these boards.
Repealing government responsibility and delegating care provision to independent regional authorities has exposed the English NHS to an unprecedented threat of privatization. As part of the HSCA, NHS was authorized to administer services directly or subcontract them to private providers. Although the circumstances for public provision remain, providers are legally compelled to outsource services. Couched in the language of “consumer choice” and patients’ rights the private sector must have an opportunity to provide services; any state monopoly over health care would be illegal. For this rapid privatization to occur, it was necessary for the legal duty to provide universal care to be repealed. Universal services allocate resources based upon need, while the private sector is always concerned above all with the pursuit of profit. The costs involved in delivery mean that some health services, communities, and patients, are more profitable than others. Far from guaranteeing patients a fair “choice” of services and providers, private contractors are freed from any obligation to deliver services that might threaten their bottom line.
Working Class Struggle for Healthcare.
Having illustrated some of the advantages state healthcare has for capitalism and how capital has attempted to shape the state’s provision, that a system of state healthcare was historically central to working class struggles in Britain must also be acknowledged. For many among the ranks of the working class it was, as it remains the case, abundantly clear of how beneficial a state healthcare system is for protection against the worst excesses of the free market and exploitation.
Reflecting the argument made so far, at the start of the twentieth century the health of the labor force was an issue of great concern for British capital. Introduced in 1907, legislation allowed, for the first time, the provision of free medical inspections in school. Furthermore, in 1911, with the passing of the National Insurance Act, the state assumed responsibility for the provision of health insurance, of which more affluent members of the working class would benefit from. Except for broad public health legislation during the 19th century, both pieces of legislation exemplified the emerging acceptance by the state to directly intervene within the health of the population. That this intervention was considered essential to enhance productivity among the labor force is best reflected by the assertions of the then Chancellor of the Exchequer, David Lloyd George, proclaiming, ‘Money which is spent on maintaining the health, the vigour, the efficiency of mind and body in our workers is the best investment in the market.’xxvii
Notwithstanding capital’s concerns the introduction of health reforms did not solely arise because of the need for enhanced productivity. Behind the introduction of health insurance was the working class. As Navarro argues ”The main reasons for that legislation were: first, the social demands by labour for increased wages, improved working conditions…and strengthened job protection and security.”xliii Reflecting working-class concerns, the State Medical Service Association (SMSA) was prominent among radical voices campaigning for universal state healthcare. For the SMSA public ownership of hospitals and health facilities, under the authority of municipalities was essential, with all medical professionals becoming salaried employees of the state. Asserting the centrality of municipal government to aid access to healthcare, the position of the SMSA broadly reflected that of the Second International, where it was argued that municipalities were important sites of collectivism and socialist activity, with it being the responsibility of municipalities to ensure the collective provision of medical services and hospitals. Stimulated particularly by the experience of the First World War, by 1918 the position of the SMSA was endorsed by a majority within the labor movement. Even its more radical wing embraced the idea, with the Communist Party of Great Britain (CPGB), in 1924, advocating for a free medical service. By the end of the decade CPGB vehemently endorsed the establishment of a state medical service, free for all, under which most health services would be provided.
Successor to the SMSA, the Socialist Medical Association (SMA), established in the early 1930s, continued to commit itself to the municipal provision of healthcare. Affiliated with the Labour Party, it was established upon the core principles of a state health system providing both curative and preventive services. State healthcare was understood as having the potential to be fundamentally socialist in nature offering equitable universal care provided upon collective principles. Exercising authority among labor’s political organizations the influence of the SMA was evident when the Labour Party obtained control of the largest English municipal authority, the London County Council (LCC), in 1934. Although constrained by the limited authority of municipal government, the actions of the Labour Party in London reflected the socialist value of state healthcare in practice where the objective of a “socialist programme for health in London.” was pursued
Under the authority of the Labour Party the LCC championed the ’municipalization‘ of London’s hospitals, expanding the authority of the municipality over the hospital system. The result was approximately 76 percent of all hospital capacity in London came under the jurisdiction of the local state. Municipal ownership was considered integral to ensure hospital care was universally available. Moreover, further committing to the universal provision of healthcare, in response to calls within the SMA to ensure that maternity provision was under public control, the decision was made guaranteeing that all women could expect a free ambulance service when they went into labour. Although the limitations of municipal socialism within the context of capitalism was apparent, the influence of the SMA in London illustrated the potential of establishing a democratically controlled municipal health service, whereby provision traversed class boundaries and decision making was devolved to the locality within which services were delivered.
The Second World War and a National Health Service
Securing the commitment of the British people to fight the Second World War could not rely upon calls to patriotism alone. Having endured he First World War followed by the proceeding two decades which for many was an experience of poverty and unemployment, there existed recognition by both capital and the governing elite for the need for pivotal social and economic reforms once the war was over to avert what was felt to be a real threat to the social and economic order by the working class if change was not implemented. Moreover, the war itself gave rise to a spirit of rebellion which was of deep concern for capital. This desire for change manifested itself, politically, in the landslide election victory in 1945 of the Labour Party. Although not as radical as the mood of the national labor movement underpinning it, this Government introduced notable social reforms, including a national system of state healthcare in the form of the NHS.
That the NHS was imperfect once established is not in doubt. Its very existence owes much to a conservative medical profession, fearful of losing its independence, being offered financial concessions to support its establishment and granted the ability to continue to operate privately as well as working for the state. Furthermore, rather than empowering municipalities with the delivery of healthcare and promoting democratic control, the NHS reflected a centralized approach to implementing socialist ideals encapsulating a preference towards central state ownership. But the NHS did broadly reflect working class values. If a single individual is associated with the establishment of the NHS it is Aneurin Bevan, Welsh democratic socialist, and Minister for Health and Housing during the post-war Labour Government, who, steeped in the labor movement, having been a coal miner and trade unionist, argued “A free health service is pure socialism and as such it is opposed to the hedonism of capitalist society.” The introduction of the NHS was without doubt a major victory for labor. It was the culmination of almost half a century of agitation for a socialized system of healthcare. In its original form the NHS must be accepted as going some way to reflect, as Bevan himself argued, a socialist system of healthcare as a service collectively provided, delivered by the state and free at the point of use. Support for the principle of the NHS ranged from the Labour Party, the organized labor movement, to more radical elements such as the CPGB. Although being to a degree a class compromise its creation undoubtedly enhanced, as it continues to do so, everyday life for most of the British population.
Opposing the Neoliberal Agenda
Moving forwards to the present day, the NHS and its principles remain central to the lives of many working-class people in Britain. With nurses going on strike in the winter of 2022, and early 2023, for the first time since the creation of NHS over pay and working conditions, a majority of the British public were in support recognizing the value the service provides on an everyday basis and the need to defend it against underfunding. Alongside the actions of nurses and doctors who unleased a wave of strike action across the NHS, efforts to defend the original principles of the NHS have been to some degree reflected over the last twenty years in the actions of Welsh governments. In contrast to its counterpart in England, the Welsh NHS has experienced a deliberate attempt to protect it from some of the worst excesses of neoliberal reforms, especially privatization.
Since political devolution to the nations of Britain which saw the initial establishment of the National Assembly for Wales, and now the Welsh Senedd (Parliament), Wales has been continually governed by a more overtly left-wing Labour Party, in comparison to the character of its English counterpart, except for the brief period under which the British Labour Party was under the leadership of Jeremy Corbyn. Responsibility for most core health care functions have been devolved to Wales. As with NHS England, the Welsh NHS receives the great majority of its funding from the British Treasury. However, in opposition to the developments in England, the overall organization and planning of health care remains the direct duty of the Welsh Government who delegates responsibility to regional state organizations in the form of Local Health Boards (LHBs). In Wales there is very little market-driven distinction between purchaser and provider as this was abolished in 2009, eradicating a previous system of fragmented competition. LHBs plan, design, and commission primary and secondary health care regionally, engaging with local government during the process. Therefore, the state is responsible for funding, planning and delivering healthcare.
The Welsh NHS has rejected the ideology of competition and the fragmented service it produces; instead, health care remains a planned system, directly achieved through mechanisms of the state. Privatization, which has become rampant in England, is minimal in Wales. If anything, it has been rolled back: the years since the inception of the Senedd (with law-making powers first granted in 2006, with this authority being enhanced further in 2011) have seen a continued reduction in the use of private facilities by the NHS, and little use of the controversial public finance initiative (PFI), whereby private consortia raise capital to finance the construction of health care facilities which are then leased to the NHS at inflated prices until eventually becoming public property often decades later.
The continuing strength of public provision in Wales reflects not only a preference for planning over competition, but also a deeper ideological resistance to the neoliberal agenda that has now dominated English politics for more than three decades. The Labour Party in Wales has rejected this path, often invoking the proletarian national culture that shaped Bevan’s worldview. Even as much of Wales’ industrial base has disappeared, the Welsh Labour Party has framed its health policy agenda in Bevanite terms of solidarity, community, and universalism. Subsequently, opposing developments in England, in Wales the last two decades has witnessed an explicit effort to defend the original socialist values which underpinned the establishment of the NHS and formulate them for the twenty-first century and the working class of the nation….
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