As global capitalism slowly withers, a non-exploitative health care system has entered the realm of the possible.
“Capitalist health care, as well as the adverse health outcomes that capitalism generates, will not improve substantially until we change the global capitalist system.”
In this series, we ask acclaimed authors to answer five questions about their book. This week’s featured author is Howard Waitzkin. Waitzkin is Distinguished Professor Emeritus of Sociology at the University of New Mexico and Adjunct Professor of Internal Medicine at the University of Illinois. His book is Health Care Under the Knife: Moving Beyond Capitalism for Our Health. The book was written in collaboration with the Working Group on Health Beyond Capitalism.
Roberto Sirvent: How can your book help BAR readers understand the current political and social climate?
Howard Waitzkin: “Of all the forms of inequality, injustice in health is the most shocking and inhuman.” Martin Luther King said these words in 1966, after more than half a century of failed efforts to achieve a national health program in the United States that provides universal access to services. About half a century later, a reform occurred – Obamacare – that reduced the number of uninsured by about 40 percent, markedly increased the costs of care for many who previously held health insurance, shifted responsibility for health care costs increasingly to patients and away from insurance companies (leading to greater “underinsurance”), and provided huge additional tax-generated public subsidies for the private insurance industry. Skeptics have questioned whether the “failure” of repealing Obamacare and the apparently half-hearted attempt to enact a Trumpcare that retains key elements of Obamacare constituted another act of political theater and manipulation of political symbolism so typical in the age of Trump.
“Capitalism is “imploding” due to its own inherent contradictions.”
The capitalist system in which capitalist health care is situated has become more fragile, with deepening stagnation, recurrent crises of increasing severity, unemployment and underemployment, and inequality. As Samir Amin and many others have noted, capitalism is “imploding” due to its own inherent contradictions. Meanwhile, capitalism is creating ecological threats to the survival of humanity and other species. In contrast, social movements worldwide are pressing for sustainable models of economic production and human services based on solidarity rather than commodification and profit.
In this context, we need a deeper understanding of the changing structural conditions that link capitalism, health care, and health. This book grew from a recognition that such linkages deserve closer study and that this analytic work will assist in real-world struggles for change.
What do you hope activists and community organizers will take away from reading your book?
We hope that activists and community organizers will come away from the book with a clear understanding that capitalist health care, as well as the adverse health outcomes that capitalism generates, will not improve substantially until we change the global capitalist system of which capitalist health care is one important component. We see four main priorities for action in the United States and in other countries still affected by the neoliberal, corporatized, and commodified model of health care during the era of Trump: 1) a sustained, broad-based movement for a single payer national health program that assures universal access to care and drastically reduces the role of corporations and private profit; 2) an activated labor movement that this time includes a well organized sub-movement of health professionals such as physicians, whose deteriorated social class position and proletarianized conditions of medical practice have made them ripe for activism and change; 3) much more emphasis on local and regional organizing at the level of communal organizations, as envisioned by István Mészáros and attempted in multiple countries as a central component in the revolutionary process of moving “beyond capital”; and 4) carefully confronting the role of political parties, recognizing the importance of a labor or otherwise left-wing party in every country that has constructed a national health program, and understanding that the importance of party building goes far beyond electoral campaigns to more fundamental social transformation.
All these priorities emphasize the urgency of creating bridges that link health activism with social movements that focus on social class oppression including poverty and inequality, racism, sexism, environmental degradation, militarism and imperialism, and the dominant ideologies that lead women and men to accept pathological social conditions as normal. Through this work, we aim to inform future struggles for the transformation of capitalist societies, as well as the progressive reconstruction of health services and public health systems in the post-capitalist world.
We know readers will learn a lot from your book, but what do you hope readers will un-learn? In other words, is there a particular ideology you’re hoping to dismantle?
We hope that readers un-learn the dominant ideologies that linkneoliberalism, health care, and health. These links initially emerged from policies advocated by economists in the military sector during the Vietnam War, which were first imported into health reform debates during the Nixon administration. International financial institutions, especially the World Bank, promoted a boilerplate for neoliberal health care reforms, which focused mainly on privatization of services previously based in the public sector and on shifting public sector trust funds to private for-profit insurance corporations. This model became the basis for Colombia’s health reform of 1994, Hillary Clinton’s unsuccessful proposal for the United States during the same year, Mitt Romney’s health plan that he spearheaded in Massachusetts during 2006, and eventually Obamacare in 2010. We clarify the ideological underpinnings of the neoliberal model and show that the model has failed to improve access or to control costs, although it has succeeded in enhancing the profitability of an increasingly financialized private insurance industry.
“The model has failed to improve access or to control costs.”
Closely linked to neoliberalism, economic austerity policies have led to drastic cutbacks in health services and public health infrastructure in many countries; these policies also have affected health outcomes adversely through increased unemployment, food insecurity, unreliable water supplies, and reduced educational opportunities. We document the devastating impacts of austerity policies in Europe. Focusing especially on Greece, Spain, and England, as well as several countries of Latin America, and we analyze four dimensions of austerity: 1) constriction of the public sector health system, 2) retreat from universalism, 3) increased cost sharing, and 4) health system privatization. Struggles against neoliberal austerity policies open a path toward post-capitalist alternative systems. Such efforts also show that the achievement of universalism in health care systems, as occurred previously in Europe, remains vulnerable to rollbacks as political and economic elites fight to preserve or to restore their own dominance.
Who are the intellectual heroes that inspire your work?
Three heroes of social medicine took risks by courageously focusing on the social causes of illness in their lives and work. Friedrich Engels, who collaborated with Karl Marx during the mid-1800s, wrote a book which became the first comprehensive study in social medicine: The Condition of the Working Class in England in 1844. Based on his efforts with workers and their families in the industrial city of Manchester, Engels offered a detailed account of occupational and environmental diseases that anticipated research on these problems during the next 170 years. His analyses remain no less gripping and relevant now than they did then. Influenced by Engels, Rudolf Virchow in Germany developed the field of cellular pathology, for which he still receives wide recognition in the United States and other countries. Because of his focus on the social conditions that cause epidemics and on the social responsibilities of health professionals, Virchow also gained recognition around the world as the “father of social medicine”; this important component of his work has received little attention in the United States. And Salvador Allende in Chile, himself directly influenced by social medicine through a pathology professor, Max Westenhoffer, who was Virchow’s student, became a leader of social medicine in Latin America during the 1930s. As an elected senator, Allende founded the first national health program in the Americas. Then, as president of Chile in the early 1970s, until he died in a military coup supported by the United States, Allende orchestrated a series of influential social medicine initiatives that became models throughout Latin America and the rest of the world.
In what way does your book help us imagine new worlds?
The book’s last part focuses on the road ahead – the contours of change that we foresee and the concrete actions that can contribute to a progressive transformation of capitalist health care and capitalist society. To envision transitions toward a better world, we need to grapple with efforts in other countries that already have been moving along such a road. We analyze a series of popular struggles in which we have participated during the past decade as researchers and activists. These accounts focus on resistance against the privatization of health services in El Salvador and of water in Bolivia, as well as an ongoing struggle to expand public sector health services in Mexico. These scenarios portray an image of diminishing tolerance among the world’s peoples for the imperial public health policies of the global North and a forceful demand for public health systems grounded in solidarity rather than profit. These cases also show how struggles concerning health can expand popular participation inpolicy decisions previously controlled by political and economic elites.
About the United States, we offer a critique of Obamacare, explaining and demystifying managed care organizations, the consolidation and integration of health systems, and increasing share of costs for patients. We summarize the key elements of the revised single payer proposal, including its provisions about coverage, financing, and transition from the current corporatized and financialized arrangements, and comment on shifts in needed strategy during the era of Trump. As global capitalism slowly withers, a non-exploitative health care system has entered the realm of the possible. The road that leads to that place, for all its challenges, must become the road that travels “beyond capital.”
Roberto Sirvent is Professor of Political and Social Ethics at Hope International University in Fullerton, CA. He also serves as the Outreach and Mentoring Coordinator for the Political Theology Network. He is co-author, with fellow BAR contributor Danny Haiphong, of the new book, American Exceptionalism and American Innocence: A People’s History of Fake News—From the Revolutionary War to the War on Terror.
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