by Susan Rosenthal
(Chapter 8 of SICK and SICKER)
Capitalism is dedicated to generating profit. It cannot also generate health. The two are incompatible, because profit is generated at the expense of human health and the environment.
Nor can capitalism provide genuine health care. Any genuine health-care program would have to oppose profitable practices like hazardous work, adulterated food, substandard housing, industrial pollution and wars of acquisition.
Capitalism can and does develop systems of damage control that respond to problems after they develop.
Damage control, or treatment, is not the same as prevention. Prevention anticipates problems and finds solutions in advance. All existing medical systems are shaped by capitalism, so they emphasize treatment over prevention. Treatment is also profitable, whereas prevention is seldom profitable and generally interferes with profit-making.
A License to Kill
A profit-driven society cannot prevent disease because the primary source of disease is the drive for profit itself.1
The assault on health begins at work. To raise productivity, maximum effort is demanded at all times. Add a disregard for worker health and safety, and you have a recipe for disaster.
Every year, more than three million people (9,000 a day) are treated in US hospital emergency departments for work-related injuries. Every year, between 5,000 and 6,000 die from these injuries, almost twice as many as died in the 2001 World Trade Center bombing.
Globally, an estimated 250 million people are injured and 330,000 are killed on the job every year. 2
In 2002, nearly 300,000 new cases of work-related illness were reported in the US. This figure is low because many diseases, including cancer, are rarely reported as having a workplace origin.3
One study conservatively estimated that 55,200 Americans die every year from occupational injuries and illnesses. 4
Instead of mandating safer work, the State virtually grants employers a license to kill.
In 1970, the US Congress declared that causing the death of a worker by deliberately violating safety laws is a misdemeanor (not a felony) with a maximum sentence of six months in jail. This is half the maximum for harassing a wild donkey on federal land. 5
In 2003, a New York Times investigation revealed that workers were being
“decapitated on assembly lines, shredded in machinery, burned beyond recognition, electrocuted, buried alive…”6
The Occupational Safety and Health Administration investigated only 57 percent of these horrible deaths and laid charges in only seven percent of the cases it investigated, despite finding that
“Between 1982 and 2002, a total of 2,197 workers were killed on the job because their employers ‘willfully’ violated safety laws. With full knowledge of their responsibilities, they ignored accepted safety precautions, removed safety devices to speed up production or denied workers protective gear.” 7
The lust for profit kills in many ways.
- Profit drives the manufacture of defective, dangerous products and toxic chemicals that harm the worker, the consumer and the surrounding environment.
- Profit generates gross inequalities that make people sick and deny millions of people the basic necessities of life.
- Profit creates epidemics of mental distress that are rooted in social insecurity, meaningless work and hopeless lives.
- Hunger for profit fuels deadly wars that threaten human survival.
Instead of challenging the sickness generated by capitalism, all existing medical models practice damage control. They accept the system as “given” and restrict themselves to treating the casualties of the system. And it took a huge fight to get even that.
Holding the Line on Reform
Although profit-seeking generates death and disease, those who reap the profits resist paying for workers’ medical care. At the same time, productivity is linked with health, so the fitness of the working class cannot be left to chance. The capitalist class learned this lesson during Britain’s industrial revolution.
In the early 1800s, greedy employers worked malnourished men, women and children around the clock. Frederick Engels observed,
“Women made unfit for childbearing, children deformed, men enfeebled, limbs crushed, whole generations wrecked, afflicted with disease and infirmity, purely to fill the purses of the capitalist class.” 8
Drunk with profit, industrialists were killing the geese that laid their golden eggs. Unless workers could survive long enough to raise the next generation, there would be no more workers and no more profit.
Alarmed by this prospect, capitalist reformers backed workers’ demands to limit the length of the workday and to provide some support for working-class families.
Today’s capitalists understand that basic health and social services are necessary to sustain production. Here the interests of bosses and workers temporarily coincide. However, the capitalist class insists on determining how social programs will be funded, organized and administered, so they never exceed what the profit-driven system can accommodate.
Medical Models of Damage Control
Pressure to reform the American medical system has raised debate on which model of damage control is best: the market model, the State model, or hybrid models that combine elements of the other two. All of these models are business models, based on:
- commodity exchange, where medical services are sold and purchased
- exploitation of health workers, paying them less than the value of their services
- exclusion of health workers and patients from the decision-making process
- policy decisions made by corporate executives and/or government bureaucrats
- individual responsibility for health
- disregard for the social sources of illness and injury
- rationed and fragmented care
The Market Model
The market model of damage control features competing payers and providers. Because most people can’t afford pay-as-you-go care, medical insurance was developed to service a broader consumer base. By pooling the risk of needing treatment, insurance companies can lower the cost to each customer. This sounds good in theory.
In practice, insurance companies resist selling policies to sick people (or those who might become sick), and they also resist paying for services, because the less care they provide, the higher their profits.
The market model is very bad at delivering medical care and very good at generating profit.
While the US economy grows less than three percent a year, annual profits for the drug and insurance industries range between 15 and 20 percent.
Profit is generated by paying health workers less than the value of the products and services they provide and by charging for medical services that are never delivered.
Legislation that forces people to purchase insurance (mandated insurance) supports the market model.
The State Model
State models of damage control come in two forms, socialized insurance (commonly called “single-payer”) and socialized medicine.
Under the single-payer model, the State functions as a giant insurance company, paying competing providers (for-profit and not-for-profit). Medicare and Medicaid are American examples of the single-payer model.
Under socialized medicine, the State pays and provides medical services, so that all health workers (including doctors) are salaried government employees. The US Veterans’ Health Administration is an example of socialized medicine.
Compared to the market model, State models of damage control benefit from economies of scale and reduced profit-taking,9 so they can deliver more services to more people at less cost.
Most countries that provide national medical programs spend half as much as the US, per-capita, on medical expenditures.
State-funded medical systems provide other benefits. Patients are protected from having to pay exorbitant medical bills. Workers can change jobs without fear of losing access to care. Businesses profit when governments shoulder the cost of employee medical expenses. And most physicians (including those in the US) prefer national medical plans that cover everyone.10
Despite its many advantages, the State model meets all seven criteria for the business model, including commodity exchange.
The only way to eliminate the selling and buying of medical services is to nationalize the entire medical sector (manufacture and distribution of pharmaceuticals, medical devices and supplies), employ all health workers, including doctors and dentists, and fund the system so generously that even the rich feel no need to purchase upgrades. However, any nation that managed to eliminate its internal market would still be confronted with an international market in medical technology. As long as profit rules society, business will dominate medicine.
As the global economy slows, all States strive for “cost efficiency” and “cost containment” by reducing medical services, forcing health workers to do more with less, and outsourcing to the private sector. All of these measures spur the growth of the privatized, market model.
The market model leaves out too many people, and the State model limits opportunities for profit-taking. The result is compromise – hybrid systems that mix elements of the market and State models.
Most nations divide their medical systems into component parts that are priced and parcelled out. The most profitable parts, like pharmaceuticals, are reserved for the private sector, while the least profitable parts remain in the public sector. The in-between parts are up for grabs.
The hybrid model is cost-effective from a business point of view. However, like all business models, it fragments care, making it impossible to plan medical services to meet population needs and to integrate prevention and treatment, hospital and community care.
Hybrid models reflect and perpetuate the class system. A basic basket of State-funded medical services provides for the majority (or at least for the indigent); insurance companies and employers fund additional services for middle-class professionals and more productive workers; and elite “boutique” services are reserved for the rich and well-connected.
In Canada’s hybrid medical system, 13 provinces and territories fund medical services, alongside a medical insurance market and individual payment for drugs and services.
In America’s hybrid medical system, a for-profit medical industry co-exists with government-funded medical programs for seniors, the very poor, government employees and the military.
Hybrid medical systems are dominated by debates over the extent to which they should be socialized (publicly funded and administered) or privatized, with supporters of the State model arguing for more social control and supporters of the market model arguing for more private control.
The working-class majority supports access to medical care as a human right and believes that government should provide for those in need. In contrast, the capitalist class believes that healthy people should not have to subsidize the care of sick people and defends the right of business to profit from sickness. The middle class takes a middle position, advocating a mix of socialized and privatized medicine. Can the State resolve this conflict?
“The State is guarantor of the conditions, the social relations, of capitalism and the protector of the ever more unequal distribution of property which this system brings about.” 11
While the capitalist State manages the system for the benefit of the capitalist class, that’s not how it looks.
The State presents itself as a class-neutral force that serves society as a whole. As a result, most people look to the State to solve the problems of the market, and their faith is strengthened when the State battles medical corporations over the regulation of drugs, medical devices and medical practices. However, the State is simply practising damage control.
Blatant examples of greed and corruption must be contained (or be seen to be contained) to preserve the legitimacy of a system that is based on greed and corruption.
At times, the State will even fight large sections of the capitalist class to preserve the system as a whole, as it did in Britain during the industrial revolution and in the United States during the Great Depression. However, at all times, State solutions to social problems never challenge the profit system that created those problems in the first place.
Advocates of State-funded medicine argue that, unlike insurance companies that are out for profit, the State will make decisions based on what people need. That would be true if the State was committed to meeting human needs. However, the State serves the capitalist system and provides only what penny-pinching government bureaucrats decide to fund. The US public education system is a prime example.
Ultimately, the quality of any State-funded medical system is decided by the power of the labor movement to wring reforms from the capitalist class.
What is Health?
Under capitalism, health is defined as the ability to work, and sickness is defined as the inability to work.
Medical damage-control systems research, diagnose and treat individuals whose ability to work has been compromised. The goal is to return sick and injured workers to the job as soon as possible, and preferably sooner.
The decision of how long a disabled worker can be absent from work is seldom left to the worker, who cannot be trusted to put her employer’s interests above her own. Not so the physician, who is trusted with rooting out the “fakers” and “malingerers” who want time off “at the boss’s expense.”
Capitalism’s self-serving definition of health treats people like biological machines. In contrast, the World Health Organization defines health as:
“A dynamic state of complete physical, mental, spiritual and social well-being and not merely the absence of disease or infirmity.”
We know what people need to be healthy. In Determinants of Health: The Solid Facts, Wilkinson and Marmot explain,
“What is striking is the…need for a more just and caring society, economically and socially…It is not simply that poor material circumstances are harmful to health; the social meaning of being poor, unemployed, socially excluded, or otherwise stigmatized also matters. As social beings, we need not only good material conditions but, from early childhood onwards, we need to feel valued and appreciated. We need friends, we need more sociable societies, we need to feel useful, and we need to exercise a significant degree of control over meaningful work. Without these we become prone to depression, drug use, anxiety, hostility and feelings of hopelessness, which all rebound on physical health.”12
While medical care is a commodity that can be bought and sold, health is priceless.
Health is generated when people have control over their lives. Health is generated when people refuse to be divided, and when they pull together for everyone’s benefit.
Genuine Health Care
In order to generate health, we must begin by identifying what people need and then proceed to meet those needs. Profit cannot be allowed to enter the equation.
How work is organized affects the health of individuals, society and the environment more than any other factor. A genuine health-care system would place healthful work and healthy workers at the core of its priorities.
Capitalism organizes work to maximize profit, not health. As a result, working conditions injure, sicken and kill workers, products are manufactured without regard to their harmful effects, and the production process depletes and damages the environment.
A genuine health-care system would support workers to redesign their work so that it generates health and not sickness. Only a health-generating workplace can be expected to produce healthful products and services in a socially-responsible way.
When profits no longer matter, we will be able to provide everyone with nutritious food, safe housing, clean water, sanitation, quality education and top-notch medical care. Instead of depleting the environment, industry can be designed to replenish it.
Teamwork nourishes the soul and produces a sense of connection and belonging. As we produce for each other and consume what we all produce, the current, alienating division between workers and consumers will break down. Human creativity will be unleashed, providing new options for generating health that are beyond our current imagining.
A genuine health care system would:
- emphasize prevention over treatment
- view health as the sum of all human activity and a shared social responsibility
- place work at the center of health and social policy
- ensure collective decision-making at work and in society
- pool all available resources to meet human needs Health care or damage control?
- promote shared responsibility for one another, the environment and future generations
Healthy Profits or Healthy People?
The basic principles for building a genuine health-care system are the same as those required to build a healthgenerating society.
A health-generating society wouldn’t need a massive medical system. Of course, there will always be accidents, injuries, illnesses and deaths. However, the scale of these problems is anything but natural under capitalism.
Because capitalism damages people faster than medical systems can repair them (when they can repair them at all), even the best medical systems must constantly expand to treat the growing ranks of sick and injured.
Under capitalism, “healthy” profits will always be more important than healthy people. To advance human health, we must sacrifice the capitalist system. The cost of compromise, of curbing our demands to what capitalism can manage, is an escalating loss of health and life.
Every day, the gap grows between what people need and what capitalism is willing to provide. And every day, the world becomes a sicker place. Yet, no matter how many people suffer and die, capitalism will prevail until the working class organizes a collective, socialist alternative.
We don’t have to restrict ourselves to choosing the best way to manage the misery that capitalism creates. We can end it. The fight for universal health care is the first step to building a fundamentally different society, one that will generate health for all the people of the world.
1. Capitalism has delivered effective vaccines, but they must be purchased. As a result, preventable diseases like polio continue to ravage poor populations.
2. Traumatic Occupational Injuries. National Institute for Occupational Health and Safety. Accessed February 18, 2008.
3. US Department of Labor, Bureau of Labor Statistics. Industry injury and illness data – 2002. Summary News Release.
4. Steenland, K. et. al (2003). Dying for work: The magnitude of US mortality from selected causes of death associated with occupation. Am J Ind Med. May. Vol. 43, No.5, pp.461-482.
5. Cited in Barstow, D. (2003). US rarely seeks charges for deaths in workplace. New York Times, December 22.
6. Barstow, D. (2003). US rarely seeks charges for deaths in workplace. New York Times, December 22.
7. Editorial. (2003). Occupational hazards. New York Times, December 23.
9. Like military contractors, government-funded medical providers will over-bill for services they provide and bill for services they don’t deliver.
10. McCormick, D., Himmelstein, D.U., Woolhandler, S. & Bor, D.H. (2004). Single-payer national health insurance: Physicians’ views. Archives of Internal Medicine. February 9, Vol. 164, pp.300-304.
11. Braverman, H. (1974). Labor and monopoly capital: The degradation of work in the twentieth century. New York: Monthly Review Press, p.284.
12. Wilkinson, R. & Marmot, M. (2003). The social determinants of health: The solid facts. Second edition. World Health Organization.