The Political Economy of Social Inequalities

Consequences for Health and Quality of Life

Vincente Navarro

• Publisher: Routledge
• Year: 2020
• eBook ISBN: 9781351863902
• Topic: Medicine
• Subtopic: Mental Health in Psychology

In the last two decades of the 20th century, we witnessed a dramatic growth in social inequalities within and among countries. This has had a most negative impact on the health and quality of life of large sectors of the populations in the developed and underdeveloped world. This volume analyzes the reasons for this increase in inequalities and its consequences for the well-being of populations. Scholars from a variety of disciplines and countries analyze the different dimensions of this topic.

PART 1 Review of the Research

CHAPTER 1 A HISTORICAL REVIEW (1965—1997) OF STUDIES ON CLASS, HEALTH, AND QUALITY OF LIFE: A PERSONAL ACCOUNT

Vicente Navarro

The invitation I received from the organizers of the session expressed their wish that I speak about my life’s work on the relationships between class and health within the continuously evolving political context of the past 35 years. I also notice that in the promotion of the session, “An Evening with . . .," the organizers referred to the growing interest within the academic community in studying the relationship between class and health. This interest seems to have motivated the invitation for a person who has been working on this topic for 35 years to share his experience with the younger generations—those who may like to discover a sense of history and experience—helping to correct the omission of a historical perspective for which U.S. scholarship has frequently been criticized. I will try to establish a linkage and continuity between the past, the present, and the future, sharing with you my experiences, thoughts, and impressions of where we have been, where we are, and where we might like to be.

But first, let me start—as you requested—with a brief biographical note which explains my commitment to the subject. That commitment is not merely academic. It is rooted in a strong experience in my very early youth, when I fought in the Catalan and Spanish antifascist underground, a fight—a good fight—which millions fought for freedom, democracy, solidarity, and social justice, all pointers toward the political objective of achieving, someday, a classless society. Millions—including some of my family and close friends—have fought and died or been killed in the 20th century to achieve this goal. Those years of struggle had an enormous impact on my life and motivated a life-long commitment to the study of class relations in order to transcend them, to allow the development of human society’s potential for achieving the level of health and quality of life desired by all people.

I had to leave Spain in 1962 for political reasons; this political exile led me first to Sweden then to the United Kingdom. In those parts of Europe I met many interesting people, but two in particular were to have a huge importance in my life. One was Karl Evang, the Chief Health Officer of Norway at that time, and the other was John Brotherston, a professor at the Usher Institute of Edinburgh University and later the Chief Health Officer of Scotland. While my intellectual life was clearly shaped by studying in Spain under Manuel Sacristan—the Gramsci of Spain—my professional life in the health area was most influenced at that time by Evang and Brotherston. It was they who, with Stampar from Yugoslavia, wrote the famous definition of health in the 1948 World Health Organization Constitution. This, as you will recall, defined health as more than the absence of disease, and declared as the objective of our public health project not just the somatic and psychological but also the social well-being of the individual and of the collectivity. It saw health, therefore, as rooted not only in biological but in social conditions. This was an enormous break with the traditional understanding of health and medicine, putting both in their proper context: the social structure and social relations in our societies.

Very few people have realized that this definition of health—now one of the most frequently cited definitions in medical texts—grew directly out of the pact achieved by the victorious antifascist forces after World War II (and let’s not forget that this war was primarily an antifascist war). It was a pact made in response to the high level of expectations created by the end of the war. The enormous sacrifices made by the popular classes during that war had been made with the hope of achieving a better future. The three major forces behind the pact were the New Dealers in the United States, the social democratic governments in Western Europe, and the Soviet Union in Eastern Europe. The political instruments of the working classes and their labor movements in alliance with the middle classes were the main forces behind that pact, establishing the bases for setting out the public’s responsibilities for providing social transfers and services that greatly improved the health and quality of life of the majority of people. In Europe, both East and West, the labor movement was rooted in Marxism as the theoretical frame for understanding and changing class relations in those societies. On this side of the Atlantic the Weberian tradition was stronger, although forces rooted in Marxism played an important role in the establishment of the New Deal—also a result of an alliance of the working class with the middle class and southern farmers.

From 1948 to 1965, however, many changes occurred. In the United States, a rapid growth in families’ disposable income (at a rate of 2.5 percent per year) and a growing perception of well-being helped to establish the “American dream”—a perception responding to the reality that parents would see their children become better off than they had been. This produced a new understanding—an understanding reproduced by the mainstream media always ready to propagate the views of the dominant forces—that the United States was a middle-class society, with the majority of Americans in the middle.

This was the scene when I landed in the United States in 1965, joining the two million immigrants arriving in the country that year. (I soon realized, incidentally, that having a heavy Spanish accent and a Spanish surname could be a source of negative distinction and suspicion.) I arrived in August of that year, invited by Professor Kerr White to join him at The Johns Hopkins University.

Professor Odin Anderson from Michigan was then the major theoretical voice in the analysis of medicine. In his major opus (Health Care: Can There Be Equity? The United States, Sweden, and England, 1972), he concluded his analysis of the United States with a homage to the middle class and to the American dream:

The middle class was and still is the source of entrepreneurial, technical, and managerial skills, which exploited natural resources, developed the economy, and thus . . . created a social surplus that spilled over into other endeavors such as the arts, education, health services and warring for national honor and expansion.

In this theoretical scenario there were no dominant or dominated classes, or even dominant groups or elites. Terms such as working class were printed in quotation marks to signal the reader that they were suspect terms, used by ideologues who should be excluded from the forum of serious scholarship. It may be difficult for current researchers to believe that, in those times, terms such as class, working class (not to mention class struggle), and just plain capitalism were dismissed as ideological. No serious scholar, aware of the penalty that it would carry, would dare to use these terms. I have in my files several letters from editors of academic journals requesting that I should not use the term working class because it was excessively ideological, and encouraging me to replace it with the less valueladen term socioeconomic status. (They did not seem to realize that such a change was more than a mere semantic modification.) One particularly interesting note, from the then editor of Social Science and Medicine (the major journal of medical sociology at that time), recommended “dismissing such inelegant and ideological expressions as working class.” I know of another scholar, Professor Ray Elling, who received a similar note from the same editor. (The same journal, incidentally, later published a leading article that was an extremely abrasive review of my work.) Nor did the dissenting voices speak of classes, but rather of interest groups. They interpreted the situation in medicine as resulting from the medical profession’s dominance in the practice and institutions of medicine. Their major intellectual reference was Professor Eliot Freidson, the foremost theoretician in the professional dominance school. The radical version of that interpretation of the house of medicine appeared in Health PAC’s American Health Empire, written by Barbara and John Ehrenreich, who saw the medical establishment as primarily responsible for the sorry state of affairs in medicine.

There was, however, a group of scholars who did not share this vision of the United States. They were the disciples of Henry Sigerist—a figure whose fame and official recognition, incidentally, have always intrigued me. My experience in the United States—particularly in the 60s and 70s—was that, in an intellectual environment that was profoundly ideological, the use of a class discourse was cause for abuse and discrimination. Because of that experience, I have always been perplexed—and, indeed, envious—that an intellectual whose discourse was a class discourse, with frequent references to class power relations affecting the nature of medicine, was actively and enthusiastically supported by the Rockefeller Foundation (a major voice of the U.S. establishment), had his picture on the cover of Time magazine, and had a regular radio show on CBS. Sigerist’s America was indeed very different from the America I had experienced! The difference between his America and mine was McCarthyism, a class response to the popular expectations raised by the end of World War II. Its objective was to purge from society those voices that supported and wanted to expand these expectations, the realization of which would have reduced the privileges of the U.S. establishment. This explains why, by the mid-60s, the nature of what is “acceptable” and “supportable” in the United States had changed quite dramatically. And it explains why Henry Sigerist left the United States and why his disciples, repressed most brutally by McCarthyism, had to hide their language and discourse. Actually, I will always remember that, shortly after my arrival in the United States, I received a visit from two disciples of Sigerist, Professors Milton Roemer and Leslie Falk (later to become dear friends of mine), who cautioned me about being so open and transparent in my analysis of U.S. society and its medicine; they warned me that such openness would attract rejection and even hostility. Having suffered fascism directly (under a dictatorship in Franco’s Spain) I did not pay much attention to their warning. I soon learned, however, that intellectual fascism, McCarthyism, was alive and well in the United States and that its destructive powers could be even worse than the fascism I had experienced in Spain. Many times in my 32 years in the United States I have thought of Milton and Leslie’s warning. It proved remarkably accurate.

This dominant anticlass scenario, then, was the theoretical terrain on which I landed in 1965. Repression, however, generates resistance, and this is the history of the study of class and health from 1965 to 1997. Such intellectual and academic resistance in the 60s and 70s was made possible by changes in the political context of the times. The conservatism of the 50s and early 60s was shaken up by the tumult of the 60s, a decade that became known for its social agitation. Intellectual creativity does not occur in moments of conformity but in moments of questioning.

While the historiography of the 60s has focused on the students’ protests (which indeed were central in the United States and elsewhere in launching many of the key movements of that decade, such as the anti-Vietnam War movement and the May events in France), the reality is that many forces and classes, including the working classes, played a major role in many countries, including our own. During the May events in France and the hot autumn in Italy, workingclass mobilizations paralyzed those countries. Even Sweden saw its mines closed down. And in the United States, besides the impressive anti-Vietnam War mobilization and the splendid civil rights movements, we also saw labor strikes that affected the energy and transport sectors, forcing President Nixon to call out federal troops to put down miners’ strikes in North Carolina and Virginia. A common denominator in all of these working-class movements in western nations was their concern for health and quality of life issues rather than just wage or compensatory demands. As the Italian workers who took over the Fiat factories put it so eloquently in a slogan held in front of a factory: “We want to work in factories in which we can sing while working.” Thus work itself should be a source of joy and creativity, not just a means to achieving creativity through the world of consumption. Similarly in the United States, the most class-conscious workers, the coal miners, started a strike—one of the largest in U.S. history— about the nature of work, health, and well-being. They were questioning the power relations in the world of production, challenging the class relations dominant in the United States. These power relations were also being threatened by elements of the civil rights movement, which soon realized that the dividing line in the United States is not only race but class. None other than Martin Luther King, one of the most admired persons in the United States, stated that many of the issues in which the civil rights movement was involved were actually class issues. And a few weeks before he was killed, he indicated that “we are engaged in the class struggle, the critical struggle in the U.S.” (quoted in D. J. Garrow, The FBI and Martin Luther King, pp. 213-215, Penguin Books, 1981).

The Development of Resistance: The Class Approach in the Analysis of Health and Medicine

In that environment of resistance, several events occurred that greatly affected the area of studies on class and health. One was the establishment of the International Journal of Health Services (IJHS). Three individuals played a critical role in this event. Professors Karl Evang and John Brotherston (both very critical of the extreme conservatism of U.S. academic life at that time) had encouraged me to establish a forum for the presentation of critical views suppressed in the mainstream academic journals. Professor Kerr White, however, played the most crucial role. A Canadian liberal in the Bertrand Russell tradition, and a man of maverick convictions who detested conventional wisdom and practices, he gave his full support to the establishment of a journal committed to opening up academia to all positions, provided they were presented with the rigor required in a scholarly journal. Without Kerr, John, and Karl, such a journal could not have been established. They asked me, a junior, nontenured assistant professor, to create such a forum.

Most analytical and critical works that would later have major impacts in the areas covered by the journal—health and social policy, political economy and sociology, history and philosophy, and ethics and law—started in the pages of the IJHS, including the research findings and theoretical discussions on the relationship between class and health. Many well-known scholars started their intellectual work in the pages of the IJHS, and I am pleased to note that the works of two other speakers celebrated this evening—Professors Elizabeth Fee and Nancy Krieger—were first published in the IJHS. Even today, well-established authors send some of their contributions to the IJHS knowing that other journals would not dare to publish them. Not uncharacteristically (as happens with most forums in the United States that are critical of mainstream thought), the journal is better known outside than inside the United States.

The East Coast Discussion Group, Later HMO

Contrary to the prevalent individualistic understanding of life, I believe that all intellectual (as well as manual) work is the result of a collective rather than individual endeavor. The enormous intellectual creativity of the 60s and 70s in the studies of class and health was the result of a highly productive exchange among a group of researchers who met regularly (every three weeks), rotating the place of gathering (between Baltimore, Washington, and New York), to discuss theoretical, conceptual, and methodological issues in the study of class, health, and quality of life. Several of us, frustrated with the profound conservatism of U.S. academic life, started the intellectual network that we called the East Coast Discussion Group (ECDG). Howard Berliner, Rob Burlage, Barbara Burney, John Crawford, Robert Crawford, Joe Eyer, Elizabeth Fee, Sally Guttmacher, Jane Halpern, Kim Hopper, Sander Kelman, David and Rhonda Kotelchuck, Joane Lukomnik, Vicente Navarro, Hila Richardson, Len Rodberg, Jack Salmon, Evan Stark, Meredith Turshen, and Grace Ziem were the founders of that group, which later expanded to the west coast with Howard Waitzkin, Thomas Bodenheimer, Richard Brown, and others, many present in the audience today. Our intellectual roots lay in many critical traditions and our concern was the study of exploitation and domination, in their different dimensions—although the group’s ever-developing theoretical frame evolved toward viewing the forces of exploitation and their effects on health primarily through the lens of class analysis. This is why we later renamed the group the Health Marxist Organization, or HMO—witnessing ten years later the takeover of these initials by the business establishment to mean health maintenance organization. I regret we did not copyright these initials!

The intellectual productivity of this group was extraordinary. Started by just a few of us, the ECDG (later HMO) soon became a fairly large network. We were creatures of the 60s, and as such we were intense, anarchic in our focus, constraintless (abrasive on occasion) in our positions and practices, and unrestrained in the expression of our emotions and commitments. Many articles and books came out of that intellectual project, products that, for the most part, first appeared in the International Journal of Health Services, one of the very few academic journals in the United States that was receptive to this type of critical scholarship. Another such journal was the American Journal of Public Health, which also published works by several members of the HMO, including my article “The Underdevelopment of Health of Working America” (Vol. 66,1976).

It may be of interest to explain the response triggered by the HMO in the United States in the 60s and 70s. The mainstream academic media ignored the group’s critical intellectual production. Even by as late as 1982, neither the American Sociological Association nor the U.S.-dominated International Sociological Association had acknowledged the existence of the group’s production. The periodical State of the Art in Medical Sociology in 1974, 1978, and even in 1982, for example, did not cite any of our works.

More frequently, however, the response was one of overt hostility. Social Science and Medicine (whose editor had advised me to avoid the term working class as too ideological) published, as I mentioned earlier, a leading article that was an abusive and abrasive insult to one of us (Vicente Navarro). That article defined Navarro’s Marxism as a “disease,” concluding that human liberation called for the elimination of that disease (Social Science and Medicine, Vol. 19, 1984. For a reply to that attack, see Vol. 20, 1985). I have to assume that the author meant intellectual rather than physical elimination. This abusive article precipitated the resignation from that journal’s executive board of Professor Howard Waitzkin, at that time of the University of California. Unfortunately, some of our colleagues from other countries were ready to fill that vacancy, mindless of the need for a cross-border solidarity among critical scholars.

Many of the works produced by the HMO were distributed in a type of underground culture. Students’ demands for these works became a stimulus for our production. Slowly but surely the position ...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Introduction
• PART I Review of the Research
• PART II Causes for the Growth of Inequalities and Their Impact on Health and Quality of Life
• PART III Critique of International Agencies: WHO, PAHO, World Bank, IMF, UNICEF, and UNDP
• PART IV Neoliberalism and Social and Health Policy
• PART V Debate on Pathways of Social Inequalities and Health
• PART VI Analysis of Proposed Solutions: The Importance of the Political Context
• Contributors
• Acknowledgments
• Index