Mike Haynes is a professor of economics at the University of Wolverhampton in the United Kingdom. His article, Capitalism, class, health and medicine, was published in 2009 by International Socialism and is republished with permission.
Medical myths and madness continued
A genuine national health system would seek to minimise the causes of ill health in society at large and to maximise the coverage, comprehensiveness and efficiency of healthcare when it was needed. The focus on “bringing the market in” does just the opposite. It helps to maximise the stresses that produce poor health and it fatally compromises the ability of any healthcare system to rationally deal with the resulting patterns of ill health. In the 1990s attention in the UK was for a time focused on Dr Harold Shipman who turned out to be a doctor who was also a serial killer, dispatching his older patients. But the real story of the last decades is that the biggest serial killer in the health system is the market, and in the dock alongside Shipman should have been all those who pushed it and the consequent break up of the NHS. Sadly, if this sounds like rhetoric, it is supported by a grotesque trail of evidence, and not least in the statistics of lives lost and the stories of grieving relatives, of how healthcare is failing in market driven systems.
In the UK the NHS that was built up after World War II had serious faults and these were not helped by systematic underfunding. But it was based on a developing sense of comprehensiveness, universality and equity, and in comparative terms it was one of the most, if not the most, efficient healthcare systems in the world. Its dismantling through the development of first internal, and then external, markets – the creation of what Allyson Pollock calls the NHS PLC has broken this and begun to reproduce some of the worst irrationalities of private healthcare systems and their scandals. Worse, although this process began under the Tories, if anything it proceeded faster under New Labour.
It is true that over time more money has been pushed into health but the market-based health reforms have also created more routes by which this money could be devoted to non-health outcomes and into private pockets. Part of the systematic underfunding of the NHS in the past has been reflected in low pay in its lower levels, and nobody could object to this being improved. But additional resources have also been sucked to the top and out of the system by the market privatisation process, building better offices for the likes of global accountancy and consultancy firms such as KPMG or PriceWaterhouseCoopers, rather than providing more hospital beds. Health is big business. In Europe the health service consumes around 8 to 10% of output. In the US it is nearer to 15%. Add in all other forms of healthcare and we are nearer to 10 to 20%. This is such a huge amount that the pressure is to grab as much as possible for privatised control and private profit. Any number of examples could be given but it will be sufficient to sketch the perverse consequences in terms of the pharmaceutical industry. It is not the case, as is sometimes argued, that “big pharma” has no interest in cures. Of course it does. The problem is the way it operates under capitalism systematically compromises a rational allocation of resources to meet human need.
First note the scale and interlocking character of this industry – not just the huge drug companies but also biotech, the food supplement manufacturers, the vitamin producers, even homeopathy, far from being “alternative”, are big business. Few in number, these companies are diversified global giants in their own right but they are far from averse to underhand linkages. The biggest corporate criminal fine in history was of $1.5 billion levied by the US government against the “vitamin cartel” for price fixing. But it is easy to see the attraction of fleecing the market. Medical drug sales alone in the UK work out at £200 per person annually or over 1% of national income – a huge amount. In the US the figure is nearer 2% of national income.
Getting as much of this income as possible means big profits. This helps to explain the fact that the pharmaceutical industry spends only around 14% of income on research and development but 30% plus on marketing and administration. It also helps to explain the startling fact that 10% of the world’s health burden gets 90% of the research and development. Money follows the patients and the systems with spending power. Ninety percent of the human health burden gets a mere 10% of R&D, and even more grotesquely this is probably less than the amount now spent to provide better drugs for pets in rich countries. Plus all this research is now becoming less effective. In the middle decades of the previous century there were major medical advances in drugs, techniques and treatments but in recent decades the rate of real improvement has declined. That means that companies now have to push copycat, “me too”, drugs that barely differ from one another, or encourage us to believe in new diseases for which they can then sell us old cures. In this battle patents are crucial. Eighty percent of drug expenditure is on patented drugs in advanced countries. Patents keep prices high and allow profits to be squeezed even if the drug could be lifesaving for those who cannot afford it. These same pressures then lead on to the systematic undermining of ethical standards in research as companies pressure researchers into exaggerating the efficacy of their copycat drug over someone else’s.
But the pressure of these big companies is also highly political. They are a formidable lobby, spending billions, and leaning on governments and international organisations. They practise a revolving door system whereby politicians, regulators and top health service people are regularly invited to join them and effectively rewarded for their past compromises. They subvert the health debate. Systematic bribery is practised in the health trade with all sorts of inducements to prescribe one product over another. Front organisations are set up. Some patient groups have stupidly allowed themselves to be compromised by accepting drug company money and becoming advocates demanding costly drugs whose real benefits are doubtful. And if all else fails, these companies follow the trail pioneered by the tobacco industry of sowing doubt where there should be none and intimidating their critics.
This is not a pretty picture. But it is made worse by the way that the drive towards more markets and privatisation in health service provision further sideline real solutions. This is perhaps best seen as an attempt to enable the private sector to plunder the state by means of legalised corruption – the private finance initiative disaster in the UK is the best example. Of course the ideological preference for markets reflects something more than the veniality of the pocket but it is important to stress how much material interest there is in profiting from health privatisation.
What cements this is the managerialisation of state health provision. In Britain this now permeates all levels of the NHS, coopting medical staff, but the most obvious indicator is the rise in the number of people who are specifically employed as “managers and senior managers”. In 1998 there were 22 000 of them; by 2008 there were 40 000. This has led to a fall in the number of staff per “manager” from 48:1 to 34:1. And presiding over them all, the NHS board at the very top had eight people in 2004-2005 and cost £1.2 million. By 2008 it had 24 and cost £3.5 million. And alongside these are a huge army of management and IT consultants so that the NHS alone vies with UK manufacturing each year for the title of the fourth largest funder of UK consultancy firms. While this may make little sense in its own terms, it is a necessary step in enabling a more systematic distortion of healthcare, leading towards the creation of a “medico-industrial complex”.
But the most disturbing issue is the extent to which healthcare itself can become a source of ill health – indirectly through the diversion of resources and directly through the systematic failure to offer patients the cures that they expect and, on occasion, even giving them new illnesses.
In the previous century enormous progress was finally made in developing medicine that had some hope of curing some patients. But the limitations of medicine are still more serious than is often imagined. Not the least of these is that treatment can have unintended consequences. Cases of adverse drug reaction are well known and these often received huge publicity. But there are bigger issues. Even in the best systems, all hospitals, anywhere in the world, are unsafe places. You can make them better or worse but the problems will never be removed completely, so the best approach is to reduce the numbers needing their services. In the UK, for example, the National Audit Office estimates that as many as one in 12 to one in 10 patients will experience an adverse incident. These can range from negative reactions to treatment to mistakes, care and neglect problems and, most serious of all in terms of large numbers, cross-infection. This can lead to illness, disability and death. Unnecessary deaths in NHS hospitals have been as high as 34 000 a year but the government report which gave this figure added that “in reality the NHS simply does not know”.
Most attention has been focused on “superbugs”, such as MRSA and clostridium difficile, to which the weak and elderly are especially vulnerable. The rise of this type of infection appears to be in part a consequence of new antibiotic-resistant strains. But more immediate causes appear to be at work. One is ward cleanliness – what those in the trade call “the mop and matron” problem, looking back to an age when matrons reputedly directly supervised nurse and ancillary staff performance. The second is rates of bed occupancy that are the highest in the advanced world. The third is insufficient appreciation of the danger of cross-infection by medical staff and visitors and therefore their lack of care in contact. The first and second issues are unambiguously related to the NHS profit/target driven culture. And if the three issues were properly addressed in the short term, they could cut cross-infection and death but the threat would still be there. Although better hospital design adds a further long-term element, it seems that we will have to live for the foreseeable future with a greater degree of cross-infection risk. On top of this we can then add poor case management. Again this can unambiguously be related to the profit/target culture, as was revealed in the notorious case in Staffordshire where managers manipulated patients to hit targets, leading to an estimated 400 to 1 200 unnecessary deaths. But as critics pointed out, Staffordshire is only the tip of the iceberg and the practices here, albeit perhaps pursued more systematically, are apparent across the NHS.
The case for radical change
In how radical a direction do these arguments really push us? Since inequality varies between countries it cannot be the case that there is no space within capitalism to improve things. Reducing the levels of inequality in the US and the UK to those in Sweden is clearly compatible with the continued existence of capitalism since Sweden is a capitalist country. Moreover this would dramatically improve the lives of people in the US and the UK. This is the obvious case for reform and this is the immediate punch of the inequality argument and the argument of those who appeal to the self interest of governments in facilitating change. But this is too easy, for even in Sweden the gaps and the inequalities, although less, are real.
In economic terms Sweden is actually a very unequal society. We can measure inequality before and after transfer spending. Transfers are taxes that are paid and then redirected as welfare, social and health spending. A country such as Sweden combines a high pre-tax inequality with a low one after tax and transfers. It allows the basic inequalities of capitalism but offers a “compensating mechanism”. In the rich countries levels of social expenditure run at just over 20% of total output. In Sweden they are about 30% of output. The result is evident in the comparative poverty statistics. According to one set, before transfers the poverty rate in the UK was 28.8%, higher than even the US at 23%. Sweden was almost as high as the UK at 28.3%. Welfare spending of all kinds transformed this situation. The US poverty rate fell to 18.6%, the UK to 16.4% but the Swedish to just 3.3%. In comparative terms this is an enormous difference. But the big point in terms of the health argument is that the Swedish system is still built around very significant core inequalities and therefore the social processes that generate unequal health. What Sweden is much better at is using welfare and social policies to limit some of the consequences but not, crucially, eliminating them, as workers in Sweden know to their cost.
We know, for example, that the massive rise in unemployment will damage people’s health through its financial and psychological effects. The impact will be worse in a country like the UK where benefits are low, means tested and stigmatising compared to a country such as Sweden where the welfare state is more comprehensive and generous in funding and attitudes. But all the care in the world can only take second place as a solution to not losing your job in the first place and knowing that you can rely on having decent work and a decent life. The best solution to the problem of unemployment leading to ill health is therefore a system which does not put your health at risk by putting your job at risk in the first place.
In addition, we must not make the mistake of assuming that progress in the longer term will always be positive. Although there have been widespread increases in life expectancy during the past two to three decades, a significant minority of countries have gone backwards. Since the 1990s, 16 countries have experienced sharp falls in life expectancy – mostly in Africa but also in the states of the former Soviet bloc. This has been catastrophic for the countries concerned and it is no exaggeration to say that lives shortened and lost run into many millions.
And the recent pressures across the globe, including in countries such as Sweden, have been towards weakening both people’s economic positions and the systems available to deal with the consequences. The extent of real labour market “flexibility” and of precarious work is a matter of dispute, and we should be the last people to exaggerate it. Fear can weaken people’s resolve to defend what they have and a strongly organised labour force is likely to be a healthier one. But we cannot ignore the pressures to undermine past achievements and the attrition that is still ongoing. This is the lesson in the UK of two decades of Labour and Tory commitment to the market, whatever its health costs. State policies to bolster the strength of capital, however they are presented, are not simply based on intellectual errors and misunderstandings. They reflect the intrinsic need of the state to support capitalism. And this is taken to a whole new level during a crisis.
Crisis, by reducing economic activity, cuts some causes of death such as accidents at work and on the road, but it increases others as the pressure of the crisis is felt. The focus on profit now leads to mass unemployment, and governments panic over how much to spend and how much to cut. The pressure of crisis undermines the possibility of making an appeal to enlightened self-interest. The bosses who jump ship or practise crisis management by slash and burn are hardly likely to slow down in the face of appeals about the human misery that will follow. If you are closing a plant at a day or even a few hours notice, the issue of a “fair” redundancy process and the availability of counselling for redundant or surviving workers is unlikely to be a priority. Nor should we imagine that because there has been a catastrophic failure of global capitalism this will in itself prompt a systematic rethinking. Without a fight it will not even necessarily undermine the influence of those who brought about the crisis. It should never be forgotten that the economic crisis of 1929 did not lead to a radical change in establishment ideas. The people running the system in the 1930s were the same as those in charge in the 1920s, or their subordinates or worse. This helps explain why the greatest crisis that capitalism produced was what WH Auden dismissed as “a low dishonest decade”. Without a radical alternative we risk the same scenario for ourselves.
This points to the need to understand that the balance of class forces is not only crucial to patterns of ill health and death but also to the solution. We know from history, for example, that war and revolution can radically change patterns of health, illness and health service delivery, and often in a remarkably short time. Problems which are deep rooted do not disappear overnight but they can be confronted in new ways. For instance, in the UK in World War II, despite the conflict, civilian health improved as radical changes had a dramatic short-term effect and health delivery was shifted towards a new basis. Elsewhere more rapid political change has had the same effect. It acts this way because it challenges the whole basis on which society is run and resources are allocated, and in so doing leads to a more fundamental questioning of the mechanisms that produce ill health and are supposed to lead to its solution. Not least, it leads to people being able to see themselves less as isolated, alienated and exploited victims than as part of a more collective solution.
The real solution then has to be a radical one and it has to raise the nature of capitalism as a system. But this cannot be achieved by shouting from the sidelines. A battle against the inequalities of the system and the crisis has to be fought at all levels: to sustain and improve conditions in the workplace; to oppose redundancies; to resist budget cuts; to fight against housing repossessions. Those who will be most useful, resilient and successful will be those who understand that not only are such campaigns important in their own right but make best sense if they link up and become part of an argument for a general change. This can then lay the basis of a decent society that will also be a healthy one – one in which social inequality will no longer give rise to unequal lives and unequal deaths.