by Susan Rosenthal
Consider the following statements:
“Easy access to health care has created a society of consumers with an insatiable demand for medical services.“1
“All individuals, all mental health care systems, and all nations face the ubiquitous problem of scarcity. The demands of society are infinite, but its capacity to meet those demands is finite.”2
Such statements are presented as self-evident and repeated like mantras. The myth of scarce resources is repeated so often that it has been accepted as true. Everyone knows that unreasonable demand has created a social crisis. Rising government debt is considered proof of too much spending on social programs, despite years of cutting corporate tax contributions.
The myth of scarcity has one purpose, to justify rationing social programs. There is no evidence that society does not have, and never could have, sufficient resources to meet human needs. On the contrary, the resources spent on war alone could provide everyone in the world with top-notch medical care. Let’s examine the facts.
The manufacture of scarcity
There is no real scarcity in the world; quite the opposite. Productivity continues to rise much faster than the population.
The GDP, or Gross Domestic Product, represents the value of all the goods and services produced in one year. Between 1970 and 1990, the population of Canada grew 25 percent while the GDP expanded 647 percent. Over the same two decades, the population of Britain rose 3.2 percent, while the GDP swelled 964 percent. In the United States, over the same period, the population increased 20 percent while the GDP climbed 440 percent.3
One might think that such massive increases in wealth in proportion to the population would result in a generous rise in the standard of living, including universal access to medical care. This has not happened. Under capitalism, wealth is socially produced but privately owned, so only a privileged elite benefit from rising productivity.
According to Forbes magazine,
“The rich just keep getting richer. And there are more of them.”
The combined wealth of the richest 200 people in the world is close to one trillion dollars. This sum is greater than the combined wealth of the bottom half of the world’s population. In only four years (1994 to 1998), the average wealth of the world’s 200 richest billionaires more than doubled. In the United States, the most affluent more than tripled their wealth during the same period. In Africa and the Middle East, the elite saw their assets grow 165 percent; in Latin America, 106 percent.4
The private ownership of social resources holds back the development of humanity, depriving the majority of the benefits of science, technology and increased productivity. The best example is the United States, a nation that dominates the globe and, therefore, serves as a model to the rest of the world.
Class inequality is greater in the U.S. than in any advanced industrial nation. Despite continued economic growth, the gap between the have-lots and the have-nots continues to widen. In 1973, corporate CEOs in the U.S. made 35 times the average worker’s wage. By 1997, they were making 209 times the average wage. Despite the expansion of the nation’s wealth, average real wages are 19 percent lower than they were in 1973, which means they are back to the level they were in 1958. As real wages have fallen, the poverty rate has risen from 11.1 percent in the mid-1970s to 14.5 percent in the mid 1990s.5
An artificial scarcity has been manufactured for American workers, who are sinking into debt. In 1996, household debt totaled 89 percent of annual disposable income compared with only 67 percent in 1980.6 As consumer debt rises, those with money to lend are further enriched at the expense of those in need.
The technological revolution was supposed to provide everyone with increased leisure time. However, like the rise in wealth, the rise in leisure went only to the leisured classes.
Over the past 27 years, the amount of time Americans spend on the job has risen steadily, so that the working year is now one month longer than it was fifty years ago. Americans report their leisure time has declined by one-third since the early 1970s. Workers are spending less time sleeping and eating and have less time for their children. Overwork exists alongside persistent unemployment. Twenty percent of workers are unable to secure as many hours as they need to make ends meet.7
In Canada, the gap between rich and poor is also increasing. In 1973 the richest ten percent of families with children made 21 times more than the poorest ten percent. In 1996 the richest families made 314 times more than the poorest. Between 1973 and 1996 the proportion of mid-income earners (with children) earning between $24,500 and $65,000 dropped from 60 percent of the population to 44 percent. Sixty percent of Canadian families with children are currently earning less than they did in 1981, even though 2/3 of mothers with children under age three are working compared with only 1/3 a generation ago.8
Canada workers are also putting in longer hours. Every week, 19 percent of Canadian workers contribute an average of nine extra hours of overtime each. In any given week, 11 percent work unpaid overtime. Thirty-two percent of unionized and 42 percent of non-unionized workers report working on weekends.9
Despite working longer hours, take-home pay has fallen. The average Canadian family needs 76.8 weeks of paid employment a year just to cover basic expenses. The lowest third of earners need 83.6 weeks. In almost a quarter of dual income families, the woman’s earnings make up half or more of the combined income.
At least 25 percent of the Canadian labor force works some form of shift-work, and this percentage is growing with the demand for 24-hour production. Shift-workers suffer more insomnia, fatigue, gastrointestinal difficulties, cardiovascular symptoms and disrupted family and social lives.10
Healthy profits, sick people
While North American workers produce huge amounts of wealth for their employers, they suffer from a pathogenic concoction of overwork, rising debt and family stress aggravated by diminishing access to health and social services.11
Research shows that the health of populations declines as one moves from the wealthiest to the poorest strata.12 The rise in class inequality, combined with the downward pressure on workers’ living standards, is contributing to an overall deterioration in population health.
At some point in any given year, about 52 million adults in the U.S. (more than 1 in 4) show symptoms of mental illness.13 Between 1995 and 1996, the number of American children aged 6 to 12 who were prescribed fluoxetine (Prozac) quadrupled, from 51,000 to 203,000. Sertraline (Zoloft) prescriptions for children saw a similar jump.14 15
Employee stress-related disorders cost Canadian businesses $12 billion a year. Forty-seven percent of Canadians report feeling “really fatigued” at least once a week, 39 percent feel “really stressed” on a weekly basis, and 11 percent feel “really depressed.” The sources of stress and depression were listed as “financial problems, work-related issues, stress, family/relationships and health-related issues.”16 In Canada, the adolescent suicide rate is four times higher than it was in the 1960s.17
In every nation, rising pressures at work, the sense of powerlessness to change anything, the disintegration of the social safety net and the unfairness of class inequality find expression in chronic illness, drug addiction, domestic violence, murder and suicide. In a world overflowing with material abundance, such deprivation, misery and ill-health should not be tolerated.
Their greed or our need?
According to the Organization for Economic Co-operation and Development (OECD), the amount of social resources spent on health
“does not reflect the highest level of benefits obtainable within the socially determined level of resource boundaries. It is rather the result of successive negotiations about how much nations consider reasonable to allocate to medical care…”18
As living standards rise, people demand more access to medical services because they expect to partake in the benefits of medical science and technology. This natural pressure to generalize the benefits of social progress is obstructed by the private ownership of social wealth and the fierce competition between capitalists for a larger share of it, both of which are responsible for the economic convulsions of the past 25 years.
Since the 1970s, the world economy has suffered significantly lower rates of profit.19 The interaction of the falling rate of profit with the boom-and-slump business cycle has produced three world recessions: in 1974, 1980 and 1990. The current Asian financial crisis, the collapse of the Russian economy and the crisis in Latin America may signal the beginning of the next and possibly the worst recession ever. According to the Economist,
“With remarkable speed, Asia’s financial mess has come to seem the biggest threat to America’s economic expansion. Given that economists have underestimated the severity of Asia’s crisis so far, the recessions there (and hence the effect, through trade, on America) may well be bigger than many expect.”20
Economic crises damage the health of working people, while depriving them of access to remedial services. Employers respond to the falling rate of profit by closing factories, laying off workers, speeding up work for those who remain, lengthening the work day, and cutting wages and benefits. At the same time, corporations get tax cuts that increase government debt, leaving seemingly insufficient revenue to fund social programs. Governments blame the debt on social spending, cut social programs (supposedly to relieve the debt) and then hand even more money to the business class.
In fact, medical spending, as a proportion of GDP, has remained stable in most countries, with the exception of the United States where extravagant profit-taking inflates the cost of health care.21 The argument that government spending on social services is excessive and that privatization will increase “cost-effectiveness” is used to de-fund and privatize social services. As Harold Eist, past-president of the American Psychiatric Association, observed,
“There is no free market in health care and there never has been. The poor do not get equal care - if they get any care - and this has been especially true of the poor suffering from mental illness and who are struggling with high levels of unemployment and every known form of discrimination.”22
To boost profits, employers and governments attack the living standards of workers on every front. But there is a physical limit to how much people can work and there is also a limit to how much deprivation and injustice they will tolerate. While many believe that governments must be convinced to change their policies, historically, only strikes, revolts and threatened revolutions have raised living standards and won funding for social programs.23
The assault on medicare
When society is divided into classes, such that those who labor to create the wealth are not the ones who control it, there must arise a State to enforce this unequal state of affairs, and to propagate ideas that will justify this arrangement.
It is commonly believed that the State is a neutral body that mediates between the classes. In reality, the function of the State is to enrich the already rich and to impoverish the already poor, as the current crisis of health care reveals so clearly.
According to Dr. Robert Evans, director of population health for the Canadian Institute of Advanced Research at the University of British Columbia,
“there are powerful redistributive motives behind parts of the health care reform agenda in all countries” and “competition and market mechanisms generally are particularly suited to both facilitating and concealing the process of redistribution.”24
In Canada, seven billion dollars have been chopped from the federal health budget by the current government. Further cuts by the provinces have devastated a once exemplary medical system.
Providing epidural pain relief to women in labor is no longer considered an essential service, and is unavailable in several hospitals across the country.25 Seniors are denied new treatments for osteoporosis, Alzheimer’s Disease and Parkinson’s Disease.26 Tens of thousands of nursing jobs have been lost, so that fewer nurses are expected to care for much sicker patients. Between 1992 and 1996, the average length of hospital stay was cut by 16 percent for medical and surgical patients and by 26 percent for obstetrical patients.27
Since 1995, the province of Ontario cut another $800 million from a hospital system which now has $4 in assets for every $5 in liabilities. The hospital funding crisis is so acute that resources are being diverted from patient care to fund raising.
Recently, the Ontario government gave one Toronto hospital permission to sell $300 million in bonds to raise money for badly-needed renovations. The government is not guaranteeing these bonds, so the hospital must use the money it receives to provide patient care as collateral. The cost to the hospital of servicing this bond (interest and administration) is estimated at $21 million, which means that the hospital must put its future payments for patient care in hock to the bond traders.28 This is a disastrous funding strategy for hospitals already burdened with long wait-lists for care.29
In 1995, 60 percent of Canadians expressed satisfaction with the health care system. Just two years later that figure plummeted to 30 percent.30 Canadian physicians are also frustrated. In a 1998 survey, 62 percent of Canadian doctors complained of workloads that were too heavy, and 55 percent reported that their family and personal life were suffering.31 Fifty-three percent of family physicians had patients with problems accessing medical care in their communities, and 30 percent reported local physician shortages.32
Hardly a day goes by without some medical horror story in the media, yet the government denies that patient care is suffering because of the cuts. We are told that patients expect too much, nurses are lazy and doctors are greedy. Politicians and bureaucrats repeat their allegiance to the Canada Health Act (which guarantees equal access to health care), but withhold the necessary funds needed to make this a reality. While health workers exhaust themselves trying to provide quality care with insufficient resources, governments are offering Canada’s $75 billion medical system to their business friends.33
Dancing with the devil?
The disintegration of Canadian medicare would not be possible without the co-operation of medical professionals. Well-meaning physicians have become partners in the brutal (and brutalizing) process of rationing medical services, in the mistaken belief that, if health spending must be reduced, physicians can best advise on how to make cuts without compromising the quality of care.
In 1997, the Ontario Medical Association (OMA) signed an agreement with the government of Ontario to help control the “rate of utilization growth and demand for medical services.”34 To that end, the OMA and the Ministry of Health formed a joint body, the Physician Services Commission (PSC), with a goal of cutting $120 million from the 1998 health budget. The PSC also launched a research project to reduce the public use of the medical system by finding ways to “modify” patient behaviors that are “inefficient.”35
Doctors are expected to police the use of the health system. In Ontario, oversized glossy posters displayed in physicians’ waiting rooms warn that, “Every Dollar Lost To Health Fraud Is A Dollar Taken From a Patient Who Needs It”
“Every year health fraud costs us millions of dollars. People who defraud the system are taking your tax dollars. Even worse, they’re taking dollars needed to provide vital medical services for patients who need them most. You can help put a stop to this. If you know or even suspect someone is defrauding your Ontario Health Insurance Plan, call the fraud line listed below. Together, we can stop the assault on our health system and make sure people get the care they need, when they need it.”
The reader is urged to “Help Stop Health Fraud,” and a toll-free number is provided.
Who are the villains defrauding the health system? Are they the pharmaceutical companies whose inflated prices have made drugs the costliest component of the medical system? Are they the politicians who have extended patent protection for pharmaceutical companies to keep cheaper generic drugs off the market? Are they the growing army of bureaucrats who are employed to ensure that no one receives health care to which they might not be entitled? Or are they the very rich, who are the primary beneficiaries of the very generous tax breaks being paid out of former healthcare dollars?
Because the poster is intended for use in physician waiting rooms, one can only assume that the culprits are “undeserving” patients. Perhaps they are illegal immigrants, or poor American cousins who slip over the border to get medical care that would be unaffordable at home. The enemy could be anyone: my neighbor, my workmate or even myself. Do I really need to see the doctor for that ailment? Am I misusing the system? The message is that health care is a privilege, not a right, undeserving patients are plunging the medical system into crisis, and only by policing ourselves and each other can we serve the greater good.
Government pressure to cut costs has an insidious, corrupting effect. Dr. Michael Kramer, pediatrician and Distinguished Scientist of the Medical Research Council of Canada, has recommended that it would “provide a much greater return on Health Canada’s investment” to fund more research into the causes of pre-term births than to “waste money” funding government programs that provide milk, eggs and orange juice to poor pregnant women.36 As if we could not afford do both!
Some physicians have rejected the myth of scarcity and fought the cuts to medical services. In four Canadian provinces, doctors have used job action and other militant approaches to demand more money for health care.37 Sadly, their inability to reverse the cuts has left many demoralized and susceptible to believing that if the cuts cannot be stopped, they should at least be wisely administered.
Assembly-line medicine
A section of the medical profession is cooperating with government to transform medicine into a dehumanized, assembly-line process. This process, which is advanced in the United States, allows a few physicians to join the ranks of highly-paid medical bureaucrats and profiteers, while most of the rest are pushed into managed-care factories, providing assembly-line medicine in piece-work fashion.
Consider the Australian Medical Relative Value Study (a joint project between the Australian Medical Association and the Australian government) and the Resources-Based Relative Value Schedule (RBRVS) Commission of Ontario (a joint project of the Ontario Medical Association and the Ontario government) which is patterned after its Australian counterpart.
“The development of a RBRVS is a complex undertaking that ranks and rates insured physician services according to the resource inputs required to perform those services.” Physician work is broken into “four service-specific resources…time, mental effort, physical effort and stress. Mental effort, physical effort and stress collectively are referred to as intensity factors. The two specialty-specific resources are practice costs and opportunity costs, and these differ from one specialty to another.” A “pilot project will determine whether evaluation/management skills should be considered separately from knowledge and judgement in the determination of mental effort. Similarly, the pilot study will determine whether intensity factors will be evaluated explicitly and separately in a composite method or implicitly in a global method of evaluating intensity.”38
Disguised in professional language, RBRVS is an application of industrial “time-and-motion” study to the practice of medicine. Dissecting the work into its component parts, pricing those parts and then hiring a variety of people to complete fragments of tasks is a de-skilling and dehumanizing process that has proved highly profitable in industry.39
In Canada, some have suggested that further privatization of medicare can be avoided by imposing a “health benefits tax” to be paid by individuals “according to the health benefits they receive.”40 However, the whole point of medicare is to tax universally to service universally. The more individuals have to pay, the more inequality creeps into the system and the more the health of the population suffers.41
The industrialization and privatization of health services present all health workers with a choice. Do we help government dismantle and privatize health care, or do we oppose the rationing of social services and demand more money for health care? We cannot straddle both sides of this fence.
Modern Malthusians
The State protects the “right” of the rich to privately own the social wealth and propagates the ideas that justify this arrangement.
The first serious threat to the class division of society was raised during the French Revolution, when working people raised the cry for liberty, equality and brotherhood. To counter the spread of revolution to Britain, the Reverend Thomas Robert Malthus published his Essay on the Principle of Population in 1798. Malthus denied
“the possible existence of a society, all the members of which should live in ease, happiness, and comparative leisure; and feel no anxiety about providing the means of subsistence for themselves and their families.”42
Malthus insisted that population always grows faster than the ability of the land to produce food. Therefore, poverty and misery are based on “natural law,” which cannot be challenged. Frederick Engels described Malthus’ theory in this way:
“that the earth is perennially overpopulated, whence poverty, misery, distress, and immorality must prevail; that it is the lot, the eternal destiny of mankind, to exist in too great numbers, and therefore in diverse classes, of which some are rich, educated, and moral, and others more or less poor, distressed ignorant, and immoral. Hence it follows in practice, and Malthus himself drew this conclusion, that charities and poor-rates are, properly speaking, nonsense, since they serve only to maintain, and stimulate the increase of, the surplus population…that, in other words, the whole problem is not how to support the surplus population, but how to restrain it as far as possible. Malthus declares in plain English that the right to live, a right previously asserted in favour of every man in the world, is nonsense. This is now the pet theory of all genuine English bourgeois, and very naturally, since it is the most specious excuse for them.”43
Since the 18th century, Malthus’ theories have been used to defend social inequality. All social ills, from poverty and disease to famine and environmental degradation, have been mistakenly attributed to the problem of too many people wanting too much.44
Malthus was wrong. The development of science and technology has made agricultural land so productive that farmers in rich nations are paid not to grow crops while mountains of stored food are destroyed or left to rot every year. The problem is not too many hungry bellies. The problem is that food is sold for profit, and too many people can’t afford to buy it.
When it comes to health care, there are not more people than can be properly cared for, but there are more people than can be cared for profitably. Malthusians deny that social progress should mean rising living standards for everyone. Their aim is to advance capitalism, by sacrificing human needs to business goals. This unpalatable truth cannot be publicly acknowledged. To do so would be to admit that what is good for business is bad for human beings. The myth of scarcity was invented to circumvent this problem.
Modern Malthusians fill the mainstream media with cries of scarcity. Instead of praising the aging population as a medical and social success, they blame improved longevity for straining the system to the breaking point. Rather than welcome technological advances, they worry that more people will live longer and therefore use more health and social services. Discussions of what is medically effective are submerged by arguments about money. The myth of “never-ending crisis” is a deception practiced by all nations to promote public acceptance of rationing.45
The grapes of wrath
The myth of scarcity is needed to reconcile the obscenity of growing wealth alongside growing poverty. According to the World Health Organization, around 300 million people live in 16 countries where life expectancy actually decreased between 1975 and 1995. Fifty percent of deaths of children under age five are associated with malnutrition. At least two million child deaths a year could be prevented by existing vaccines and most of the rest could be prevented by access to clean water and other basic necessities. Nearly 1.3 billion people live in absolute poverty, and more than 15 million adults aged 20 to 64 die every year from preventable causes.46
The myth of scarcity insists that such suffering cannot be prevented, because there is not enough to go around. This argument hardens our hearts, erodes our humanity, negates centuries of human progress and reinstates the law of the jungle, where only the strong can hope to survive. We are expected to accept the unacceptable: beggars in the streets of the world’s most prosperous cities; an abundance of food, while millions starve; treatments for disease that the poor cannot afford; one part of the population being overworked, while the other part is desperate for work; surplus wealth growing alongside, and at the expense of, destitute populations. As American author John Steinbeck wrote in 1939,
“There is a crime here that goes beyond denunciation. There is a sorrow here that weeping cannot symbolize. There is a failure here that topples all our success…and… in the eyes of the people there is a failure; and in the eyes of the hungry there is a growing wrath. In the souls of the people the grapes of wrath are filling and growing heavy, growing heavy for the vintage.”47
The goal of modern Malthusians is to ensure that the grapes of wrath are never harvested, to justify the dominance of the few and the misery of the many, to obscure what would otherwise be obvious: that ordinary people create all of society’s wealth and deserve their share of it.
The elite who rule society can never accept this account of the matter. If they did, they would have to abandon their system of private ownership and competition; they would have to acknowledge the inhumanity of depriving millions to enrich a few. Since they cannot deny reality, they promote the myth of scarcity.48
To advance medical care as a right, not a privilege, we must be clear on three points. First, there is no scarcity and no need to cut funding for health and other social services. Second, medicine should not be a business but a social service that is fully funded so that it can be available to all. Finally, we must organize with other workers to demand that society’s abundant resources be used to meet human need, not corporate greed.
References
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2. A. Maynard, “Are mental health services efficient?” International Journal of Mental Health, Vol. 22, No. 3, 1993, p.3.
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8. E. Carey, “Rich get richer as wage gap widens”, Toronto Star, October 22, 1998, p.1.
9. Ibid
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21.S.M. Rosenthal, “Market madness and mental illness: The crisis in mental health care,” International Journal of Mental Health, Vol. 27, No. 1, 1998, p.5.
22. H. McConnell, “U.S. psychiatrist calls for vigilance against politicians,” The Medical Post, November 11, 1997, p55.
23. Ibid
24. “Going for gold: The redistributive agenda behind market-based health care reform,” Health Policy Research Unit Discussion Paper Series, Centre for Health Services and Policy Research, University of British Columbia, January 1996.
25. “Epidurals should be available to all women,” Medical Post, November 11, 1997, p. 42.
26. “Ontario denies new drugs to seniors,” The Toronto Star, August 12, 1998, p. A9.
27. C. Noesgaard, “The cost of caring,” Registered Nurse, January/February 1998, p. 4.
28. Editorial, “Hospital bond shows erosion of health system,” The Toronto Star, September 20, 1998, p. F2.
29. B. Laghi, “Edmonton hospitals cancel most elective surgery,” The Globe and Mail, February 27, 1998, p A4.
30. C. Gray, “The brutal politics of health care,” CMAJ, Vol. 158, No. 7, April 7, 1998, p. 922.
31.P. Sullivan, & L. Buske, “Results from CMA’s huge 1998 physician survey point to a dispirited profession,” CMAJ, Vol. 159, No. 5, September 8, 1998, p. 525.
32. “The Janus project,” Canadian Family Physician, Vol. 44, August 1998, p.1745.
33. R. Cairney, “New private facility woos public dollars in Calgary,” CMAJ, Vol. 159, No. 5, September 8, 1998, p. 551.
34. W. Orovan, “Toward challenge and opportunity,” OMA Fax Network, Vol. 3, No. 17, May 1998, p.3.
35. M. Borsellino, “Ontario to ‘modify’ patient behaviour to cut costs,” The Medical Post, April 14, 1998. p.1.
36. M.S. Kramer, “Maternal nutrition, pregnancy outcome and public health policy,” CMAJ, Vol.159, No.6, September 22, 1998, p.663.
37. B. Sibbald, “In your face: A new wave of militant doctors lashes out,” CMAJ, Vol. 158, No. 11, June 2, 1998, p. 1505.
38. J. Wade, “The development of a resource-based relative value schedule”, http://www.rbrvs.on.ca/articles/index.html., accessed September 12, 1998.
39. H. Braverman, Labour and Monopoly Capital: The Degradation of Work in the Twentieth Century, New York: Monthly Review Press, 1974.
40. M. Gordon, J. Mintz, D. Chen, “Funding Canada’s health care system: a tax-based alternative to privatization,” CMAJ, vol. 159, no. 5, September 8, 1998, p. 493-6.
41. D. Blane, E. Brunner, & R. Wilkinson (eds.), Health and Social Organization: Towards a Health Policy for the 20th Century, London: Routledge, 1996.
42. T.R. Malthus, Essay on the Principle of Population as it affects the Future Improvement of Society, London: McMillan & Co.,1798.
43. F. Engels, The Condition of the Working Class in England, CD ROM, Classics in Politics: Marx and Engels, London: ElecBook, 1998.
44. A. Chase, The Legacy of Malthus: The Social Costs of the New Scientific Racism, New York: Alfred A. Knopf, 1977.
45. “Health economics: Selling the big sleep,” The Medical Post, August 5, 1997, p. 63.
46. Fifty facts from the World Health Report 1998, http://www.who.int/whr/1998/factse.htm., accessed August, 1998.
47. J. Steinbeck, The Grapes of Wrath, New York: Penguin, 1980, p. 385.
48. F. Engels, Outlines of a critique of political economy (1844), in R. Meek, Marx and Engels on Malthus, London: Lawrence & Wishart, 1953, p. 58.
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