Health care beyond neoliberalism?
When it comes to critically analysing health care in capitalist society there are few better scholars alive today than the sociologist, activist, and physician Howard Waitzkin. The author of highly influential works including The Second Sickness: Contradictions of Capitalist Health Care (1983) and Medicine and Public Health at the End of Empire (2011), returns with another important contribution, Health Care Under the Knife: Moving Beyond Capitalism for Our Health (2018), written in collaboration with the Working Group on Health Beyond Capitalism (a collection of scholars, practitioners, activists, and researchers working in health, mainly in the United States). That capitalist medicine prioritises the generation of surplus value over the health of populations should be obvious to any critical student or scholar in the field, but where Waitzkin and colleagues depart from this basic assumption is in demonstrating the political economy of health in the current phase of neoliberalism where, for example, the processes of financialization have eclipsed material production. Consisting of 15 substantive chapters over five sections, the book outlines the implications of such changes in the generation of capital along with potential points of resistance and struggle towards more progressive forms of health care. In this way, the book is a very welcome return to structural analysis which will prove invaluable to students, scholars, health activists, and community organisers who wish not only to understand the social, political, cultural, and economic dimensions of health and health care in the contemporary moment, but also to actively organise towards changes in such conditions.
Chapters in part one of the collection (‘Social Class and Medical Work’) outline how the increased corporatisation of health care in the US is leading to an ever-greater alienation of the workforce, to the point where even the power of doctors is now curtailed by the demands of expanding private healthcare bureaucracies and, with them, the proliferation of corporate management. An unprecedented ‘proletarianisation’ of health professionals is argued to be taking place where, as Schiff and Winch (Ch. 3) recount, “we have lost control of the purpose, content, design, and products that we generate in our work” (46). In the name of increasing ‘quality’ and ‘efficiency,’ examples are given across the chapters (including the increased focus on health metrics, electronic medical records, and patient satisfaction surveys) of how market ideology has replaced care-based with ‘evidence-based’ practice to the detriment of patient and health worker alike. This proletarianisation of doctoring has been facilitated by the increased conglomeration of medical institutions into ever larger corporate entities; a situation examined in part two of the book (‘The Medical-Industrial Complex in the Age of Financialization’) where recent not-for-profit health establishment mergers with finance, insurance, property, and pharmaceutical corporations in the US have resulted in the expansion of for-profit institutions. As Burlage and Anderson (Ch. 5) outline, this situation has only served to intensify the power of the medical-industrial complex, with academic medicine now fully incorporated into these profit-generating operations, a relationship described by the authors as “symbiotic” (74). With companies spending just 1% of their turnover on basic research, and the majority of new drugs produced over the last decade offering no significant advantage over older drugs, Lexchin (Ch. 6) recounts how pharmaceutical corporations have addressed this crisis in production by focusing more on ‘innovative’ financial strategies such as stronger enforcement of intellectual property ‘rights’ (IPRs) and intensified marketing of ‘nichebuster’ rather than ‘blockbuster’ drugs (that is, drugs which can be sold to smaller numbers of western consumers at ever-more exorbitant prices—for example, new cancer drugs priced at up to US $100,000 per person, per year).
Part three (‘Neoliberalism and Health Reform’) presents the reader with the historical and contemporary policy setting as the politics of neoliberalism have continued to resist efforts to establish a single-payer national health programme (NHP) in the US and, in contrast, undermine such systems in parts of Europe under austerity measures (Greece, Spain, and England are all examined in detail). Despite the Affordable Care Act (ACA, or Obamacare) of 2010 expanding health coverage to some of the poorest Americans, Waitzkin and Hellander (Ch. 7) explain how the legislation represents a continuation of mid-twentieth century politics to define health care through private, for-profit institutions. It is estimated that at least 27 million people will remain uninsured once Obamacare is fully implemented, with twice that number underinsured. Administrative waste along with overall costs have continued to increase, with families now spending greater proportions of their income (up to one-half) on health care. ACA has solidified corporate power in health care, argue the authors, and this may go some way to explaining why Trump’s recent attempts to repeal the Act decidedly failed. Political attempts to weaken and privatise national healthcare systems in Europe, meanwhile, have gained some support from right wing and populist governments following the financial recession of 2007–2008. Gaffney and Muntaner (Ch. 8) note that a discourse of ‘austerity’ has been readily utilised to promote the neoliberal ideology of the marketplace as a solution to (falsely estimated) rising public costs and continued state control of public health care.
Focusing on health imperialism (Waitzkin and Jasso-Aguilar, Ch. 9) and philanthrocapitalism’s (Birn and Richter, Ch. 10) ability to shape (and distort) the public health agenda, the amount of notes I took from part four of the book (‘The Trajectory of Imperialism’s Health Component’) is testament to the quality of the two chapters within. Waitzkin and Jasso-Aguilar set the scene by reminding us of the role of the health system in furthering imperialist aims of capitalist society for productive labour, both in the Global North and (neo)colonial conquests of the Global South. Tracing the historical development of international health organisations such as the World Health Organization (WHO) over the course of the twentieth century, the authors analyse how dominant understandings of global public health have been successfully framed in reductionist, economic terms. Consequently, health policies prioritise ‘vertical’ rather than ‘horizontal’ interventions, such as the introduction of vaccines as “technological fixes for social diseases” (153) as opposed to enhancing local public health infrastructures. These vertical solutions continue to facilitate Empire through both expanding the financial operations of multinational corporations into the Global South as well as extracting cheaper labour and resources to the Global North. This discussion is nicely complemented by Birn and Richter’s chapter on philanthrocapitalism, which analyses the highly troubling effects of the Bill and Melinda Gates Foundation (BMGF) on global health policy. Formed in 2000, the BMGF now spends more money on global health than any government apart from the United States. Through a comparison with the Rockefeller Foundation, the authors argue that such neoliberal mega-charities are a fundamental threat to public health governance through closed-door agenda-setting, active promotion of public–private partnerships, and control of IPRs from their research and development of new medicines and health technologies. In encouraging vertical interventions, argue the authors, the BMGF and their partners in global health are advocating simple solutions to complex issues, ignoring the wider social, cultural, economic, and political dimensions of health, and the need for universal systems of public health which focus on disease prevention rather than ‘silver bullet’ cures.
If I were participating in this book, I would have recommended that the last section, part five (‘The Road Ahead’), be laid-out somewhat differently. Though interesting discussions, the chapters on mental health (Ratner, Ch. 13) and the social and environmental determinants of health (Muntaner and Wallace, Ch. 14) are better suited for an earlier section of the book. In contrast, Gaffney and colleagues (Ch. 12) analysis of Obamacare and the alternative, single-payer NHP in the US, has repetition from previous chapters and feels less necessary to include here again. This leaves Jasso-Aguilar and Waitzkin’s (Ch. 11) useful cases studies of broad-based local resistance to neoliberal politics and the privatisation of health services in Latin America (including El Salvador, Bolivia, and Mexico), alongside Gaffney and Waitzkin’s (Ch. 15) conclusionary chapter which discusses key points raised in the book towards a more progressive form of healthcare and better outcomes for population health. It is perhaps significant that both these chapters are co-authored with Waitzkin, demonstrating thoughtful and sustained political economic analyses of health in this contemporary phase of neoliberal capitalism, alongside progressive ways towards more equitable and fairer systems of health care.
As a critical scholar of health, I can highly recommend Health Care Under the Knife: Moving Beyond Capitalism for Our Health as an up-to-date analysis of neoliberalism’s effects on health and health care as well as potential ways of usefully addressing these issues. I found something new and dynamic in every section of the book—a sign that my copy will become seriously worn and dog-eared over the next few years! That said, I would recommend that the Working Group on Health Beyond Capitalism now turn more explicitly to the specific revolutionary changes that we need to move beyond capitalism. In this future work, the Working Group and others struggling to change our world could emphasize the specific steps that move us towards a post-capitalist society; ones which will not replicate the mistakes of previous social democratic or state socialist regimes, including the difficult challenges involved in transitioning beyond the capitalist state. In sum, such a vision of praxis promotes public health across all economic activities and, as Gaffney and Waitzkin point out, encourages bottom-up communal health initiatives. How specifically to transform capitalist structures of exploitation in health care and in the social determination of health itself deserve much deeper consideration and action. Perhaps this is a gap which Waitzkin himself would be willing to fill with his next book? Until then, Health Care Under the Knife will be a solid addition to your library on critical social theory and health.
- Waitzkin, H. 1983. The Second Sickness: Contradictions of Capitalist Health Care. New York: Free Press.Google Scholar
- Waitzkin, H. 2011. Medicine and Public Health at the End of Empire. Abingdon: Routledge.Google Scholar
- Waitzkin, H., and The Working Group on Health Beyond Capitalism. 2018. Health Care Under the Knife: Moving Beyond Capitalism for Our Health. New York: Monthly Review Press.Google Scholar
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