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.
Class society makes you ill
“I ask myself how, as a physician, I find myself up to my ears with the problems of society,” writes Michael Marmot. It is a question that committed doctors have been asking for several generations as they try to explain and cope with the way that illness is moulded by society. Evidence for the social gradient is astonishingly widespread. It affects us all. It is not just about the contrast between the rich and poor but is so “fine grained” that if we graph illness against some indicator of relative position we see that as relative position improves so does health. Wilkinson calculated that 50 to 75% of the differences in average life expectancy in rich countries are now determined by differences bound up in the distribution of income and related factors. Table 3 shows how this is reflected in the pattern of key illnesses in the UK.
Why should this be? Material need cannot be ignored. Income poverty is not the basis for a good life, and societies with the greatest levels of inequality will also have the largest numbers of poor people. But it is relative poverty and position that matter most. So what is going on? The biomedical answer seems to be that vulnerability and susceptibility to illness and death are related to the degree of adversity in our lives. Some exercise is good for you but relentless physical demands in circumstances over which you have no control drain the body. Similarly, some stress is good for you but relentless worrying about job, home, family, etc not only drains you emotionally but feeds back into physical and mental ill health:
“The relationship among the nervous system, the endocrine system, and the immune system is emerging as the pathway that can help our understanding of the changes in health which are associated with changing social and economic conditions.”
In other words, although illness arises from bodily processes it is really a product of social organisation. And – this is crucial – because health follows the social gradient it is not just about improving the conditions of the poorest. In health terms it is in our collective and individual interest to tackle the problem more systematically. As Marmot puts it:
“Much of the discussion about social inequities in health has focused on the health disadvantage of the lower class. This is analogous to seeing social problems as particular to a disadvantaged minority, rather than a problem for society as a whole.”
Table 3: The UK disease pattern by social group 1991-3, standardised rates per 100,000 for men aged 20-64.
Source: Acheson, 1997.
|Lung cancer||Coronary heart disease||Stroke||Accidents, poisonings violence||Suicide|
Marmot’s argument here is partly a reformulation of RH Tawney’s famous comment that “what thoughtful rich people call the problem of poverty, thoughtful poor people call with equal justice the problem of riches” but it is more. The steeper the social gradient, not only the bigger the health gap between those at the top and those at the bottom, but also the lower the average position of all. “The countries with the longest life expectancy are not the wealthiest but those with the smallest spread of income and the smallest proportion of the population in relative poverty.” There is therefore a problem with thinking that because I am near the top in UK terms (and the level of inequality in the UK is one of the highest) I will live longer than someone at the bottom or in the middle. This is true. But it is also true that you would live longer still if society were more equal. It was realised in the 1990s that “the mortality rate for the lowest social class in Sweden [with less inequality] is less than that for the top social class in the United Kingdom”.
The narrow biomedical mechanism that produces this has three elements. The first is the psycho-social impact of pressure on bodily processes. This is socially determined. The second is our health behaviour and how we respond in terms of what we eat, whether we smoke and drink, take exercise, etc. This too is socially determined. The third is how supportive our family, friends and social networks are. This is also socially determined. Only then does the fourth issue, healthcare, become a central issue and, when it does, it too is socially determined.
If we look at our lifestyles as a whole, their patterns reflect either the accumulation of advantage or disadvantage. The story starts in the womb with fetal development, it is manifest in the early years, at primary and secondary school. It is then compounded by what type of job we get and how precarious our employment is, and so on. But why can this not be explained by people at the top choosing wisely and those at the bottom choosing badly?
The really interesting aspect of the social approach to health is how careful the analysis is of what conditions our behaviour. The cleverness of the Whitehall Studies of UK civil servants is a good example. The researchers took a large group in which the members appeared to be similar and apparently had some more positive elements in their work conditions. They then designed a study of how work, position, life, social situation, etc interacted and combined. This analysis allowed them to nail the myth that top managers are prone to more heart attacks because of “pressure”. They are not and we now know why. With responsibility comes status, power, control, means to relieve stress (membership of the gym, a night at the opera, a holiday villa) often arranged by your secretary and so on. As you move lower down, people’s lives become more bound up with lower status, less control and the need to battle and juggle a host of other commitments. It is the harassed worker on the shopfloor or in the office who is more at risk of a heart attack and, beneath them, the cleaner doing two jobs on the minimum wage. This also explains negative health behaviours and why these should give rise to different incidences of disease when the same immediate causal factors, eg smoking, appear to be present.
But some readers may be puzzling about a theoretical problem in the link between social class and the health gradient. Those who insist that we live in a class society have to defend themselves not only against those who deny the reality of class but also those who want to define it simply in terms of hierarchy. It is here that we run up against the fundamental weakness of the argument about social gradients in health. It is clear that they exist, but what causes them? What is the “cause of the cause”? To solve this problem we have to look behind the gradients and explore what determines the different incomes, jobs and degree of control that people have over their lives. This means that the central thing has to be class analysis and showing how any gradient is structured by ownership and control and not least, in capitalism, by ownership and control of the means of production.
Here several related concepts are absolutely central – alienation, exploitation, class and class conflict. Inequalities are a consequence of how these interact and it is from this that social gradients and gradients of ill health flow. Marmot makes occasional gestures towards this but they are weak and inconsistent. The same is true of Wilkinson even though he has a more systematic grasp of the social side. To insist on the importance of this is not just about adding an additional layer of possibly superfluous explanation. It makes the argument stronger in terms of its logic and explanatory power, and it gives it a clearer political thrust because it also forces us to consistently address the political economy of both health causation and the limits of reform within the system.
Alienation, for example, is fundamental to explaining both our loss of control of social processes and the way that they are turned against us, and our resulting inability to relate to one another as proper human beings. Exploitation gives us the possibility of understanding how and why the rewards go to the few who make so little contribution to our real wealth. And class and class conflict help us to understand the resulting texture of social relationships and their antagonisms.
We can make these arguments work in a more precise fashion too. As organisations have become more powerful the argument arises about who has effective disposition of capital and labour within them. The key social argument here is that the more your position gives you control over capital and labour, control over yourself, your work, the work and lives of others, the lower the levels of ill health. The more your life is controlled by others the less the level of health. The social gradient is not simply about “who has what” but the capacity to command people and resources – the very issue that is at the centre of class analysis.
But to take this analysis further we need people whose expertise is the analysis of capitalism’s social structures to link up with the people whose expertise is in health and illness. One of the most creative ways of making the connection was set out nearly three decades ago by Eric Olin Wright. Wright took on the argument that class was disappearing in modern society because of the alleged explosion of groups in the middle. These groups appeared to stand between capital and labour; they had what he called “contradictory class locations”. He then devised a way of mapping these contradictions, focusing crucially on how much control of capital and labour they had. It becomes obvious in his analysis that these intermediate groups often have little and are therefore closer to labour than capital. This reflects what many of us understand intuitively: the badge may say manager but we all know that in reality it means some low-grade supervisory responsibilities that do not preclude trade union membership and even militancy.
Using these ideas to map how capitalism really operates and divides us has an obvious attraction for those seeking to more systematically underpin the analysis of health gradients, and some researchers have already looked in this direction. But here’s the problem. Almost immediately Wright had set out this argument, he retreated under the pressure of the anti-class theorists. This has meant that it has fallen to others to defend this extension of class analysis as a way to understand capitalism. But it has also acted as a disincentive to use the argument to tighten the theoretical and empirical links between class and health.
Medical myths and medical madness
But this argument raises other political issues and not least for the medical establishment. Prevention, as everyone knows, is better than cure. “The most sophisticated and effective healthcare in the world cannot produce results as good as simply remaining healthy in the first place.” But “creating healthy societies and individuals largely results from action outside the health sector”. Healthcare can never remove the gradients in causation, only deal with some of the consequences.
This type of argument is difficult to make. We are rightly appalled by inadequacies in healthcare but we tend to take for granted the inequalities in health causation. It is awful that when Julie had her heart attack in her 50s she had to wait 30 minutes for an ambulance; then there was the four-hour wait in accident & emergency and the dirty wards on which she eventually died. But the prior question is why she had a heart attack in her 50s and why Jane, who worked as a cleaner in the same office, had one a couple of years later and died before help could get there?
We need to take any argument about the role of medicine in health in two stages. The first is to stress the absolute importance of what is called primary prevention and not to fall into the trap of thinking that we can leave the causes of illness alone and focus on better treatment. Primary prevention saves lives but primary prevention may not involve medical measures in the narrow sense at all. Only three out of the 39 proposals made by the 1997 Acheson Report of the Inquiry into Inequalities in Health related directly to health service provision. If the problem is a choice between a worse treatment and a better one, we should obviously demand the better one. But the issue should not be about whether we can afford treatments but whether we can afford people to be ill. It is often said that medical costs will always rise. This is an absurd argument in itself because it ignores the way in which the drive for profit is behind the cost rises that exist. But even if it were true, reducing the numbers of ill people in the first place would reduce the cost problems. The less people that you have to treat, the more you can afford to spend on making those who have the genuine misfortune (and not the socially determined one) to fall ill. The real problem then is to alter the fundamentals of the generation of illness caused by class society.
Primary prevention is therefore politically challenging. There has always been a minority tendency in the medical establishment that links health improvement to real social reform, and within this group a smaller one still who continue to insist that so long as capitalism and class society exist we will remain trapped in unequal lives and unequal deaths. But many health professionals also see the immediate attraction of the medical fix. And so do we as patients once we get trapped in ill health. Even the members of the team that produced the original Black Report were split on this issue. According to Sir Douglas Black:
“We were all agreed that education and preventative measures, specifically directed towards the socially deprived, were necessary. But the sociological members of the group … considered that the consequent expenditure should be obtained by diversion from acute services. On the other hand the medical members … felt that the acute services played a vital role in the prevention of chronic disability and could not be further cut back without serious effects on emergency care, on the training of doctors for both hospital work and for family practice and on the length of waiting lists. We spent a long time, without real success trying to resolve this matter.”
This fudge is not enough. Consider the problem of mental ill health. Its burden continues to rise in the advanced world. There is a big question over whether the medical fix actually works. But suppose the evidence was clearer that it did. It would still not be enough for three reasons. First, “it is inconceivable that enough professionals could be trained and employed to treat the many millions of casualties of our psychologically toxic social environment one at a time”. Second, if the problem is the toxic environment then once people are returned to it their symptoms are likely to recur. Third, this approach does nothing to stop new cases appearing. But the same logic applies to other areas. Britain, for example, is acknowledged to have one of the poorest records in the advanced world for longer-term survival after major incidents like cancer and heart attacks. You can now guess that there may be two explanations for this. One is medical – the weaknesses of early identification, treatment and follow up. The other is inequality. If inequality increases your chances of getting a life threatening disease, then however good the medical fix the pressure will be on again once you return to the environment that helped to cause the illness in the first place.
At this point, however, many take fright. It seems easier to imagine that the way forward is to work on medical solutions to ill health and demand more resources for these. But this takes us to the second issue of whether a health system run for profit can ever rationally answer human need. The answer is an unequivocal no. The first simple rule of healthcare is Tudor Hart’s “inverse care law”, which says that “the availability of good medical care tends to vary inversely with the need for the population served [and this] operates more completely where medical care is most exposed to market forces”. A national health system has to be based on principles of comprehensiveness, universality and equitability. “Supply and demand”, internal and external markets, subvert these principles and undermine the capacity of rational health planning. They even undermine the very sources of information which would make such planning possible. The result is variation in the coverage of basic services. With this comes a huge loss in real efficiency.
A second simple rule of healthcare then emerges: the more the logic of capitalism determines the supply of healthcare, the higher the costs, the larger the management layer, and the greater the diversion of resources away from treatment and care and into private hands. With this level of irrationality in the system we can then move to a third simple rule of healthcare: the more the logic of capitalism determines the supply of healthcare, the more the healthcare system itself may become a threat to social health.