Issues in the Political Economy of Health Care

John B. McKinlay

• Publisher: Routledge
• Year: 2022
• Print ISBN:
  9781032257488
• eBook ISBN:
  9781000578911
• Topic: Medicine
• Subtopic: Health Care Delivery

Originally published in 1984, this book attempted to fill a gap by providing a broad-ranging structural analysis of the health care sector and the political and economic forces which influence its shape and contents, both in the western world and developing countries. The contributors examine the relationships of capitalism to health care, in terms of its influence on the physical environment, the incidence of social diseases and the prevailing (20th Century) view of what constitutes health itself; and in terms of the consequences of the new medical industrial complex it has created, such as the declining provision of health care for the poor and disadvantaged and the growing power of the pharmaceutical industry.

Part One The social production of health and illness

One Capitalism, health, and illness

Joe Eyer

Capitalism is a kind of class society that came into being sometime in the late Middle Ages of Europe, and has extended to dominate the whole world today. Since the nineteenth century, capitalist ways of organizing labor and extracting economic surplus have had ever greater consequences for the patterns of human health and disease. These impacts have been so great that it is fair to say that capitalism is unique in human health history. The watershed of changes in health and disease with capitalism is larger and more fundamental than even those associated with the origins of agriculture and class society itself, seven to ten thousand years ago.

At the core of the capitalist social process is the transformation of people from rural agricultural villagers living in kinship-based, settled, traditional communities into migratory, largely urban wage workers without fundamental community ties. This deprivation of social support systems and exposure to new hazards and stresses are important in the rise of peculiarly capitalist modern diseases. The transformation of peasants into wage workers critically depends on vastly increasing agricultural output, and thus food surplus, to feed a productive urban working class. The greatly expanded supply of food through a revolution in agriculture is the cause of the major health gains under capitalism. With an economic surplus from both agriculture and industry several orders of magnitude larger than that at the disposal of any previous human society, capitalism has been able to grow at the expense of these other social forms to dominate the people and resources of the world today.

This process of transformation, growth, and expansion causes the specific health changes highly characteristic of capitalism. In this chapter we will review these changes: the great lengthening of life expectancy from birth; the rise of new diseases in adulthood, especially for males; the redrawing of the whole picture of health by class through the creation of the working class and especially a large, highly disrupted lowest social class; the dramatic creation of surplus population; and the emergence of a new pattern of short-term death rate fluctuation synchronized with business cycles. So characteristic are these changes that one can almost diagnose “capitalism” once they are all in evidence.

Health achievements of capitalism

Looked at in the broadest possible way, capitalism has had two historically unprecedented major health achievements. First, the world population alive today is much larger than any previous form of society could support. Second, this manifold expansion of population has been achieved by improvement in health and decline in death rates to levels lower than those enjoyed even by the elites of the past.

Late ice-age hunter-gatherers had an average life expectancy from birth of about thirty-eight years. With the rise of agriculture-based class society, life expectancy probably declined to thirty to thirty-five years, with a great expansion of population. In cities of slave civilizations life expectancies as short as twenty or twenty-five years were common. After six thousand years of agricultural class societies, world population had grown to about 500 million by the end of the European Middle Ages. In Europe at that time, rural life expectancy was again about thirty-five, with that in cities lower (Glass and Eversley 1965; Acsadi and Nemeskeri 1970; Angel 1975).

Under capitalism the human population has expanded almost tenfold since the sixteenth century, to 4.7 billion today. Most of this expansion has occurred since the nineteenth century and is associated with the extension of average life expectancy at birth to over seventy years in advanced countries and to forty, fifty, or sixty even in the poorest areas of the periphery, in Africa and South Asia (Waldron and Ricklefs 1973; United Nations Dept of International Economic and Social Affairs 1982).

Nutritional improvement has been fundamental to this death rate decline, especially in advanced countries. In experimental field trials, it is clear that improved nutrition, particularly for protein, has a much larger impact on sickness and mortality than other public health or medical measures (Scrimshaw, Guzman, and Gordon 1967; Scrimshaw et al. 1968; Scrimshaw, Taylor, and Gordon 1968; Scrimshaw et al. 1969). Historically, the major infectious diseases declined long before specific medical countermeasures became available (McKeown and Record 1962, 1975; McKeown, Brown, and Record 1972; McKeown 1976a, 1976b, 1978; McKinlay and McKinlay 1977). Beyond better nutrition, many other factors have been significant in the decline of the death rate (World Health Organisation 1974; Powles 1976). Basic literacy is necessary to the functioning of an industrial society. Scientific methods of birth limitation are key for the decline of female adult mortality. Mass public health and sanitation measures have restricted or eliminated disease vectors and improved food storage and handling. Immunization has been developed against many infectious organisms, and antibiotics for treatment and prophylaxis.

A highly developed, expensive, labor and capital intensive medical care system is not, however, necessary to the great reduction in death rates. Now most countries experience most of the possible death rate decline before they develop a large medical system, and many very poor countries have achieved almost the whole of this decline simply by better distribution of existing food, mass public health campaigns, and immunization, without even mass use of antibiotics. In international cross-sections, the addition of hospital beds per capita or doctors per capita beyond this very basal level results in little change in gross health statistics (Waldron and Ricklefs 1973). Parts of highly developed medicine may indeed increase the death rate. For example, when doctors went on strike in Los Angeles County in 1976, limiting elective surgery for the most part, the death rate fell by about 15 per cent and rose well above its previous level when the doctors resumed practice, before returning to normal. This means at least one out of every six deaths in Los Angeles is due to the overdevelopment of medicine (Roemer and Schwartz 1979; James 1979).

Corresponding to the dramatic decline in infectious diseases due to all these measures, infant and child mortality have been dramatically reduced, people grow up to a foot taller, mature sexually earlier, and in adulthood no longer suffer from the chronic impairment of parasitic or recurrent infectious disease. As a result, humans now have demonstrably greater mental and physical potential (Waldron and Ricklefs 1973).

But the full extent of this potential has not been realized under capitalism (Waitzkin 1981). To appreciate this, we can contrast two widespread patterns of mortality by age in the recent death rate decline. If improvement in nutrition and public health measures occurs without much urbanization - as in Sweden from the eighteenth through the mid-nineteenth centuries, Ceylon after World War II, and China 1950-65 - death rates are reduced all across the ages from infancy through at least age eighty years by roughly the same proportions (Preston 1970, 1976). The fact that death rates in older ages decline with equal rapidity as those in younger ages is important. It means it is possible to reduce selection pressure on the population in infancy - from 20 per cent losses in the first year to less than 5 per cent losses - without a proliferation of “genetic defectives” into the adult population, who previously would have died in infancy but now suffer elevated death risk in adulthood. Contrary to the still usual medical assumption, the reduction of death rates in infancy and childhood is not accompanied by a necessary tendency for people to die sooner in adulthood and old age (Eyer and Sterling 1977).

The second major pattern of death rate decline occurs in countries which undergo large-scale capitalist social transformation and health improvement in parallel. This pattern shows great reductions in death rates for children, then in infancy and childbearing ages for females, but much slower declines, if at all, for adult males and older people generally. For males over fifty in most developed countries, there has been no increase in life expectancy despite the allocation of the majority of highly developed health care resources to this age group. Especially for men, death rates may even rise at labor market entry ages (fifteen to thirty) compared to precapitalist levels, and there is a very marked tendency for such a rise to move through the age pattern of death rates as the first group showing it ages, as if it were exposed to a health risk in young adulthood which continues to develop and increase in effect with age in those still alive. As a result, male death rates at ages fifty to seventy in most advanced capitalist countries are notably higher than comparable death rates for less transformed countries where nutrition, immunization, and basic public health measures have been applied (Eyer and Sterling 1977).

The improvement of nutrition, immunization, and mass public health measures make possible a deep reduction of infectious and parasitic diseases from the beginning to the end of the lifespan, with corresponding death rate reductions even to the oldest ages. This potential has only been partly realized in the advanced capitalist countries because noninfectious diseases have risen in adult ages with capitalist social transformation. These diseases include cardiovascular diseases, cancers, cirrhosis of the liver, diabetes, obstructive lung disease, automobile and industrial accidents, suicide, ulcers, and many smaller causes of death. Behind the rise of these diseases stands the rise of their major risk factors: hypertension, smoking, type A behavior, obesity, elevated blood fats and cholesterol, excess alcohol consumption. These risk factors in turn are directly linked to the stressful nature of the capitalist social process. Important contributions to the rise of modern diseases also come from occupational and environmental hazards characteristic of capitalism (Eyer 1980; Sterling and Eyer 1981). Were these diseases to be eliminated, average life expectancy from birth could be extended into the nineties.

Capitalism causes the rise of modern diseases

The basic social process of capitalism is itself the source of increased stress. The very same social changes which increased agricultural productivity and made possible a large nonagricultural labor force are also the fundamental causes of the health risks that increase with capitalism. These changes can be summarized as the uprooting of people from stable communities and the subjection of life to the constantly changing demands of the market for labor.

There is approximately a twofold increase in death risk associated with each of these: long distance emigration from a settled traditional rural area, family breakdown, long-term unemployment, and long hours at demanding jobs over which the worker has little control. All of these sources of stress rise dramatically as capitalist social transformation gets under way and continue at high levels with further capitalist development. In addition, they show the same age pattern as the health risks that rise with capitalism: rising dramatically in young adulthood (the maximal age of migration and family breakdown) and continuing at high levels through middle age (high pressure, alienated work, and long-term unemployment) (Eyer and Sterling 1977; Eyer 1977b).

These stressful social changes, and many others, lie behind the rise of risk factors for modern diseases. Cardiovascular diseases dominate modern excess mortality, and the most common and powerful risk factor for cardiovascular disease in Framingham and other large prospective studies is elevated blood pressure. Hypertension is involved in over 80 per cent of all cardiovascular deaths in the Framingham study, and is at least twice as strong a predictor of death as smoking or blood cholesterol levels (Kannel and Sorlie 1975).

Waldron and her coworkers have compiled and analyzed all of the international cross-cultural studies of blood pressure. Cross-cultural sampling of blood pressure in different kinds of societies shows that undisrupted hunter-gatherers, ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Original Title Page
• Original Copyright Page
• Table of Contents
• List of contributors
• Introduction
• Part One The social production of health and illness
• Part Two Capital interests and the role of the state
• Part Three Selected issues
• Part Four The penetration of the developing world by the transnational medical industrial complex
• Name index
• Subject index