Monday, 7 June 2010

Socialist Register 2010: Morbid Symptoms

Morbid Symptoms, Health Under Capitalism, Socialist Register, 2010. Edited by Leo Panitch and Colin Leys. Merlin Press, London, Monthly Review Press, New York and Fernwood Publishing Halifax. 2009.

Confuse and Conceal: The NHS and Independent Sector Treatment Centres, Stewart Player and Colin Leys, Merlin Press, 2008.

The Spirit Level, Why Equality is Better for Everyone, Richard Wilkinson and Kate Pickett, Allen Lane, 2009.

Nick Matthews

This, the 46th edition of the Socialist Register, is quite an achievement for a left publication of this quality. 2010 also marks the fiftieth anniversary of the New Left Review, both publications were born out of the post war new left. This was a rebellion led predominantly by intellectuals who found their followers in the huge post-war expansion of the universities. It is unsurprising therefore that the format of these journals follow that of the academic journal.

The New Left Review was the result of the coming together of the New Reasoner and the Universities and Left Review. The Reasoner was a product of dissident communist voices drawn largely from the distinguished British Communist historians group whilst the ULR drew its support from those growing Universities. The publisher of the Register, the Merlin Press, had been started by Martin Eve in 1956 (a very significant year in the creation of the New left with the Soviet invasion of Hungary) a time when many intellectuals had left or been pushed out of the Communist Party as a vehicle for the new left. The first Socialist Register, published in 1964 was born of a split in the original editorial team of the New Left Review in 1963.

That could be caricatured as an ideological split between experience, the socialist humanism of E.P.Thompson and youth, the continental Marxism of Perry Anderson. Martin Eve wanted to recreate the New Reasoner and asked E.P Thompson to join with Ralph Milliband and John Saville (who became the joint editors) on the editorial board of the Register. He declined however as he said he was exhausted from the editorship of the New`Reasoner. The Register always had an international flavour with a relationship with the Monthly Review its current joint publisher from the beginning.

The title Register was taken from William Cobbett’s (1762-1835) the Weekly Political Register showing the historical continuity the new publication sought to draw upon. Cobbett, was an early radical voice for democracy and he used his Register to make his case.

“When all newspapers were viewed with suspicion, it was not surprising that working-class newspapers were considered especially dangerous. In particular radical papers like Cobbett’s Weekly Political Register and Wooler’s Black Dwarf (1817-24) were condemned for trying to turn simple people into dupes ‘of the basest and most profligate of men’. Before the ‘gagging acts’ were passed Cobbett fled to America in 1817 – he returned carrying the bones of Tom Paine two years later – and there were such incidents as a Shropshire magistrate ordering two men to be ‘well flogged at the whipping post’, (under the Vagrancy Act) for distributing copies of Cobbett’s Register”. Asa Briggs, England in the Age of Improvement 1783-1867, Longmans, 1959.

So almost 50 years on does the Register still carry the genes of its inheritance? In the preface the new editors, Leo Panitch and Colin Leys, quote John Saville on why he joined the Communist Party in 1934, “For young intellectuals with any generosity of sprit there were additional factors beyond the poverty of so many of their own people, and the brutalities of fascism. Bourgeois society was under increasing criticism for its callousness, greed and cultural emptiness.”

Having lived through a UK general election during which these characteristics have been on show in abundance there is no doubt that under whatever party contemporary capitalism continues to be deeply ingrained with “callousness, greed and cultural emptiness”.

For the contemporary editors the predominant theme of the Register for the last 15 years has been a critique of neo-liberal globalisation.

This volume explores that process on “the most important area of human life: health. All the elements of public health, from a balanced diet to decent housing, job security and job satisfaction are crucial in determining how well and how long people live. This is partly a matter of giving the human body what it needs to reach its full potential, but is also a matter of preventing disease and to a lesser extent of curing illnesses. The turn that capitalism has taken in recent decades has, in both these respects been replete with Morbid Symptoms”.

This is a very impressive collection of essays (seventeen in total) which collectively give a comprehensive picture of the global healthcare “industry” including contributions about, China, Cuba, India, and Africa as well as the developed world. They set out to articulate the struggle between commodification and solidarity in health care provision.

The opening essay by Colin Leys (Health, Health Care and Capitalism) is a particularly good opening shot encompassing many of the issues explored in greater depth in the other essays. If you find you are pressed for time this essay alone is worth reading.

His key point is that contrary to conventional wisdom “that capitalism is responsible for the huge improvements in health that have occurred over the last century and quarter” there is considerable evidence that poorer countries often have better health than rich ones.

The fact is that the rich countries have reached the limits of what capitalist economic growth can do for us. The cartoons of Cobbett’s day or indeed the early Wobblies always showed the rich as fat and the poor as thin yet in today’s rich societies it is the poor that are fat and the rich that are thin!

We have always known that in capitalist societies the poor had worse health than the rich but it is now apparent that in deeply unequal societies life expectancy is reduced for both the poor and the rich! There is a wonderful resource for this argument in Richard Wilkinson and Kate Pickett’s book (The Sprit Level, Allen Lane, 2009), they have demonstrated from a huge study of all the available data “how almost everything – from life expectancy to mental illness, violence to illiteracy – is affected not by how wealthy a society is, but how equal it is”.

This is borne out by the way the food industry works in contemporary capitalism when everyone could get a healthy diet and yet the industry generates both obesity and hunger as Robert Albritton points out in his contribution to the Register (Between Obesity and Hunger: The Capitalist Food Industry). The private health industry unsurprisingly works in much the same way. Large parts of the developed world’s health industry simply exploit our fears and insecurities like any other part of consumer capitalism contributing little or nothing to improved levels of health.

The health industry also has “a history of struggles for control of the work involved. These struggles have been highly gendered and racialised as well as class-based”, this can be seen on any visit to a major hospital as Pat and Hugh Armstrong show in their contribution to the Register (Contradictions at Work: Struggles for Control in Canadian Health Care).

One essay in the Register I found disappointing was the one on the way the health care industry is presented in TV medical dramas. (Lesley Henderson, Medical TV dramas: health care as soap opera). Doctors and nurses have been a mainstay of TV light entertainment since its inception and yet the impact of the way medicine and health care is presented to the viewers is little understood. It would seem to me that they have greatly contributed to the ‘medicalisation’ of problems that are essentially social and economic in nature. The author admits that, “On the whole, therefore, contemporary audiences are neither educated about the health care system nor invited to become engaged in health policy debates”. Is this a surprise as these programs are soap operas, maybe above average quality soaps, like ER, but soaps nonetheless ie designed to sell soap or today unnecessary medical products and procedures!

This essay feels lightweight compared to Kalman Applbaum’s contribution to the Register on the marketing of healthcare (Marketing of Global Healthcare: The Practices of Big Pharma). Applbaum shows that marketing drives the overconsumption of pharmaceuticals in affluent countries by what is known in the industry as strategic medicalisation or “what some writers call disease mongering”. This is coupled with a secondary but none the less important phenomenon that of ‘strategic pharmceuticalisation’ – the use of drugs to treat most ailments.

In countries where drugs have to go through rigorous cost benefit analysis before public health authorities make them available to patients the drug industry are expert at whipping up public fears to fast track drugs so that Doctors can prescribe them at what ever cost to the public purse.

This also distorts the type of research and product development that the pharmaceutical companies undertake. Whilst they develop expensive placebos for western consumers, “most of the rest of the world suffer from diseases whose incidence would be dramatically reduced if they had access to the medicines already in use in the West fifty years ago.”

Julian Tudor Hart’s contribution to the Register, (Mental Health in a Sick Society: What are people for?) shows how capitalism drives us mad. I cannot say I am surprised it has been driving me mad for years. I was reminded of John Ruskin’s comment, “We have much studied and much perfected of late the great civilised invention of the division of labour; only we give it a false name. It is not, truly speaking, the labour that is divided; but the men - Divided into mere segments of men – broken into small fragments and crumbs of life; so that all the little piece of intelligence that is left in man is not enough to make a pin.” (John Ruskin, The Nature of Gothic 1853)

There is no doubt in Europe that in search of profits the private sector is desperately trying to get a share of state healthcare budgets and in the United States the Obama administration is seems to be trying to spread the cost of healthcare away from businesses and across the population more generally. The collapse of the US car industry for example seems to owe much to the legacy heath care costs of tens of thousands of former employees. The US system must be benefiting someone other than its patients as it is the least efficient anywhere in the world costing twice as much per capita yet leaving 50 million people uninsured placing the US near the bottom of the league table for many of the key heath indicators.

As Christoph Herman points out in his contribution to the Register (The Marketisation of Health Care in Europe) European healthcare systems fall into two types, whilst both are based on public planning and to a large extent based on services delivered by public organisations, they are funded in different ways. One model the German or Bismark model based on social insurance deducted from salaries was begun by the German Chanceller in the nineteenth century and the other is the Beveridge model or the British model is funded by tax revenue. William Beveridge was the mastermind behind the reorganisation of the British welfare system in 1945.

Most countries in Europe have adopted one model of the other and they have proved to be remarkably resilient and very popular. Despite this the growing costs of healthcare have driven all governments to try and involve the private sector in the provision of healthcare. The process has varied but in most cases it has been by the commoditisation of basic healthcare activities and the outsourcing of them to the private sector.

Herman points out that “the effect of the reforms has been not so much a reduction in costs as a shift from public to private healthcare spending. Increasing healthcare costs – in most countries the proportion of GDP spent on health care has continued to increase – are not considered a problem as long as they do not weigh on public budgets”.

The politicians then are keen to introduce private providers into the state system without frightening the public. Collusion between politicians and the private health industry to get a share of the public spending on health in the UK is highlighted in a short report, Confuse and Conceal: The NHS and Independent Sector Treatment Centres, Stewart Player and Colin Leys, Merlin 2008.

The ISTC program was presented to the public in Britain as a way of using the private sector to shorten waiting times for elective surgery and diagnostic tests and increasing patient ‘choice’.

Choice is the great nonsense in the British health debate leading to increasing marketisation and privatisation. The choice that is being offered is not that of treating the patient as an equal participant in the design of their healthcare but that of having the choice between a commodified procedure undertaken in a public or a private space.

Restrictions on the capacity of the public healthcare system are being used to drive patients into the private sector. Further a patient has to be in the position to be able to exercise any choice. In complex cases patients have to rely on expert opinion and in an emergency having a ‘choice’ is not the first thing that comes to mind. In many private sector hospitals in the UK if the patients’ condition gets too difficult they are handed back to the public hospitals.
Many of the criticisms of state healthcare provision about, bureaucracy and industrialisation of healthcare which originally came from the left are now being used by the right to drive marketisation or patient ‘choice’. We all know however who has the real choice in a market situation. Any perceived choice in public health care provision has always been exploited by the articulate middle classes and the so-called ‘worried-well’ as Leys points out, Julian Tudor Harts famous ‘inverse care law’ tends to hold – the amount of health care given is inversely related to the need for it.

Re-reading some of the pre-war arguments which lead to the formation of European state run health care systems today they do sound rather authoritarian with the feel of eugenicist about them. Something that has been forgotten in the Left’s defence of state healthcare provision is that prior to nationalisation there was a small but significant socially owned and worker managed health care sector. For example before World War Two the South Wales Miners Federation had a strong concern for the medical care of its members. The Miners Welfare Commission was founded in 1920, funded by miners and mine owners by 1923 it had established the Talygarn Convalescent home. It became a Miners Rehabilitation Centre in 1943 earning a world-wide reputation for its treatment of injured miners before being taken over by the Ministry of Health in 1951. (See: The Fed, a History of the South Wales Miners Federation in the twentieth Century, Hywel Francis and David Smith, Lawrence and Wishart, 1980).

Reading this Socialist Register it seems that the mainstream left has become locked into defending the welfare state from marketisation and can no longer see the possibility of welfare without the state.

As the late Colin Ward has pointed out (Anarchy in Action, Colin Ward, Freedom Press, 1988) we may, “conclude that there is an essential paradox in the fact that the state whose symbols are the policeman, the jailor and the solider should have become the administrator and organiser of social welfare. The connection between warfare and welfare is in fact very close. Until late in the nineteenth century the state conducted its wars with professional soldiers and mercenaries, but the increasing scope of wars forced states to pay more and more attention to the physical quality of recruits.”

Ward argues that the biggest challenge for modern health care provision is that of institutionalisation. Ward argued that,” When we compare the Victorian antecedents of our public institutions with the organs of working-class mutual aid in the same period the very names speak volumes. On the one side is the Workhouse, the Poor-Law Infirmary, The National Society for the Education of the Poor in Accordance with the Principles of the Established Church; and on the other, the Friendly Society, the Sick Club, the Co-operative Society, the Trade Union. One represents the tradition pf fraternal and autonomous associations springing up from below, the other that of authoritarian institutions directed form above.”

We can see that this institutionalisation is a cradle to the grave affair. Childbirth itself has become institutionalised to an almost industrial scale with women struggling against huge bureaucracy to avoid the birthing factories and give birth in their own homes. The needs of the ‘institution’ come ahead of the mother. The situation is no better at the other end of the spectrum when it comes to looking after the elderly and end of life care.

Ward argues that an anarchist approach would be clear - the breakdown of institutions into small units in the wider society, based on self-help and mutual support, like Synanon or Alcoholics Anonymous, or the many other supportive groups of this kind which have sprung up outside the official machinery of social welfare.

This is of course the exact opposite of the way modern health care is moving as the needs of increasingly large and complex technology and pharmacy are creating larger and ever more centralised hospitals. As they become more dependent on private providers for equipment and drugs is it surprising that European Hospitals become ever more ripe for privatisation?

As modern consumer capitalism makes more of us sick this is itself a market opportunity. Rodney Loeppky points out in his contribution to the Register (Certain Wealth: Accumulation in the Health Industry) worldwide health spending reached $4.5 trillion in 2006. $2trillion was accounted for by the US and US spending is set to reach $3.5 trillion by 2014. This is not an industry responding to the demands of patients. Rising costs are regularly blamed on an aging population but the steady growth of the elderly cannot explain the vast explosion in health spending.

Health care has become a ‘growth sector’ in most OECD economies and its growth is universally treated as a good thing. Loeppky asks how much health is enough? This is a crucial question given that all the indicators tell us that life expectancy in the advanced societies has reached a plateau.

There are glimmers of hope like the work the IWW is doing to keep the market out of the UK Blood Transfusion Service. This is a service based on pure social solidarity people freely give blood not knowing whom it will benefit.

After all as Colin Ward reminds us, a multiplicity of mutual aid organisations amongst, claimants, patients, victims, represents the most potent lever for change in transforming the welfare state into a genuine welfare society, in turning community care into a caring community.
You will not be flogged for reading and distributing this Register but it does contribute to the debate about how we care for the sick or injured members of society. Is care to be based on solidarity or the market?