SusanRosenthal.com – Solidarity is the Best Medicine

by Susan Rosenthal

Book Review: Blane, Brunner & Wilkinson. (Eds), 1996, Health and Social Organization: Towards a Health Policy for the 21^st Century. London: Routledge.

Health and Social Organization shatters “common sense” myths about health. At the same time it promotes another myth, that social policy is shaped by science, when it is actually shaped by the needs of the capitalist system.

The stated purpose of this book is

“to provide policy-makers and the public at large with a scientific understanding of the social, economic and cultural determinants of a nation’s health status.”

The first chapter examines more than 50 years of public health policy in Britain, Canada, the United States and other nations. This history shows that the post-war expansion of the welfare state was accompanied by a narrowing of the difference between mortality rates at the top and bottom of the social hierarchy.

Numerous studies have linked improved health and life expectancy with expanded social services and a rising standard of living. Nevertheless, the focus of health policy began to shift in the 1950s, as efforts to reduce social inequality were replaced by efforts to modify individual behavior. The overall message was politically conservative,

“As a recipe for health, the dos and don’ts of personal behaviour have a strong resonance with traditional morality: against drinking and smoking, in favour of sexual fidelity, and against sloth and gluttony.”

During the 1970s, several studies attempted to measure the benefits of changing health-damaging behaviors. The results were disappointing. The 361,662-strong Multiple Risk Factor Intervention Trial in the United States found that sustained behavioral change was difficult to achieve, even among highly-motivated, high-risk individuals. Nevertheless, individuals continued to be held responsible for their health.

The social protest movements of the 1960s renewed interest in the influence of social factors on health, along with the recognition of poverty in the midst of post-war affluence. While social programs reduced the scale of absolute poverty, the harmful effects of relative poverty remained.

The class gradient

In Britain, the first Whitehall study, which began in the late 1960s, found that both mortality risk and the prevalence of health-damaging behaviors increased from the top to the bottom grades of the civil service hierarchy and were not accounted for by differences in smoking, blood pressure, obesity or exercise. Both the first and second Whitehall studies discovered that those near the top of the gradient (where there is no poverty) have worse health than those at the top, and the gradient continues all the way down.

Throughout the 1970s, research into the health-damaging effects of class inequality flourished. Widening occupational differences in mortality were documented in Britain and in France. These differences could not be accounted for by individual behaviors or specifically occupational hazards. In the United States, the bulk of the health differences between Black and Whites Americans was found to be rooted in social and economic factors.

In Chapter 2, Leonard Syme discusses coronary artery disease, which has been studied extensively for over 50 years. Researchers agree that cigarette smoking, high blood pressure and high cholesterol are risk factors for this disease, and other factors have been implicated, including obesity, physical inactivity, diabetes, blood fat levels and clotting factors, stress and various hormones. However, when all of these risk factors are considered together, they account for only 40 percent of all coronary artery disease. What is causing the remaining 60 percent?

In Chapter 5, Alvin Tarlov argues that the factors that most influence the health gradient, for virtually all diseases, are: having control over your work, having work that stimulates your creativity, having freedom from economic insecurity, having more education and a higher standard of living, being appreciated for your contributions and having social support.

Tarlov disagrees with those who promote a genetic basis for sickness, arguing that “genes as a determinant of health account for 1-5 percent of the total disease burden of man.” Access to medical care is also a minor factor. Tarlov concludes,

“The chronic, persistent, inescapable dissonance between what a person would like to do or become and what seems accomplishable triggers biological signals that are antecedent of chronic disease development.”

In Chapter 3, Mildred Baxter cites a 1994 study that found that differences in survival from breast cancer were based more on socioeconomic deprivation than on the type or malignancy of the tumor. She calculates that if class differences were eliminated, more lives would be saved than the number expected to be saved from a national breast cancer screening program. In the west of Scotland, an estimated 336 lives per year could be saved by breast screening programs, compared with 475 lives that would be saved by eliminating social deprivation. Baxter concludes that medicine is

“unable to alter socioeconomic disadvantage, and equally unable, on the whole and despite an increasing involvement in health promotion, to change lifestyles. Thus it is little wonder that medicine may resign itself to treating whatever comes before it, defining socioeconomic differences as outside its sphere of influence.”

During the 1980s, the economy boomed, but not for all, as the income gap widened between the high-paid and the low-paid. Increasing class inequality has been accompanied by increasing health inequality, higher death rates for the lower strata, and the re-emergence of tuberculosis in the poorest sections of the population. Despite its National Health Service, Britain still showed up to four-fold differences in mortality rates between the social classes.

We don’t need more evidence

Having shown that excess mortality accompanies class inequality, one would expect the authors to launch into a discussion of how to eliminate class divisions. Alas, no. Throughout the remainder of the book various esteemed authors argue for more evidence to prove what we already know.

In Chapter 15, Eric Brunner suggests,

“The case for remedial action to reduce the burden of preventable ill health can be strengthened if the biological pathways connecting low social status with specific diseases are understood.”

In reality, no amount of evidence can solve the central problem. To improve population health, we must reduce class inequality. However, class inequality is required for the continued accumulation of capital.

Policy-makers want to reduce sickness and medical costs without eliminating the class structure that generates them. In the one chapter devoted to work and health, Michael Marmot and Amanda Feeney suggest how this might be done.

“A major reason for exploring the links between social status and ill health is the search for ways to break the chain linking them. Work is potentially an important link in the chain binding social status to ill health that can potentially be modified without necessarily changing the fundamental nature of social stratification.”

Unfortunately for reform-minded researchers, one cannot preserve alienation, exploitation and oppression, while eliminating its deleterious effect on human health. (Although efforts to do so could provide a comfortable career in academia.)

As Brunner observes, social phenomena require social explanations. And social problems require social solutions. However, funds are diminishing for research in social health and for social measures to improve health. Improving living and working conditions eats into profits. On the other hand, the alteration of individual human chemistry, physiology, psychology and behavior is profitable for those who specialize in adapting human beings to unhealthy social conditions.

The general argument of this book, that national investment in human health pays economic dividends in the long run, is true in the abstract. However, the nature of capitalist competition means that long-term interests are regularly sacrificed for short-term gain. A good example was the Y2K crisis.

The prospect of global computer meltdown with its accompanying disruption of all computer-dependent systems (including nuclear launching systems) was disregarded for the sake of the immediate competitive edge granted by sacrificing the first two digits of the year. Because the consequences of this decision lay in the future, and there was no immediate financial gain for anyone who corrected it, the problem was deferred with no regard for the consequences.

A pathogenic system

It’s fashionable to insist that social reform can be profitable. In reality, there is no direct relation between increased investment in human health and increased economic growth. In a rational society there might be, but not under capitalism. Most nations are reducing their investment in health, education and social welfare in order to fund corporate subsidies. Such policies increase class inequality and worsen population health.

In times of economic crisis, declines in living standards and uncertainty about the future create a pathogenic combination. Between 1989 and 1993, death rates rose dramatically in Eastern Europe. When capitalism goes into crisis, death, disease and starvation follow as the system struggles to regenerate itself at the expense of ordinary people.

The accumulation of capital will continue to deepen class and health inequality until workers fight for a larger proportion of the wealth they produce. However, the working class exists for the authors of this book only as object, never as subject. In their view, social policy-makers determine the existence and degree of social inequality. The working class sickens and dies, but never resists, demands or transforms society.

Having excluded the working class as the agent of social change, the authors can offer only moral arguments to policy-makers who are committed to an immoral system. In unquestioning acceptance of capitalism’s prime directive – accumulate, accumulate – Fraser Mustard argues that,

“the dominant task will be how to sustain stable social environments (social capital) with diminished resources.”

Since this book was published, we have seen an unprecedented dismantling of public health, education and welfare systems despite continued economic growth. Resources have diminished only for the working class. They have multiplied for the rich.

All the research linking the nurturing of pre-school children with improved intellectual and behavioral performance has been thrown out the window as working-class children are deprived of quality daycare, early education, nutritious food, affordable housing, employed parents and access to social services. In the face of such lean and mean policies, we don’t need more research, we need to fight back.

In 1844, Frederick Engels wrote The Condition of The Working Class in England, in which he documented the unnecessary death and disease generated by capitalism. Engels argued that the most effective way to prevent disease and premature death is to abolish class divisions. Since then, researchers have accumulated another 155 years of evidence to prove the pathogenesis of class inequality.

Despite the value of the information it presents and the political questions that it raises, Health and Social Organization lacks the political clarity of Engels’ ground-breaking work. As a guided tour through the field of social health, Health and Social Organization is a valuable resource. Unlike Engels’ work, it offers no way forward.

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