Health problems demonstrably vary with class, race, gender, and residence, all critical factors that our market-based health delivery system cannot effectively address. In market economies, where health and health services are, at the end of the day, related to income, the aggregate power of the national economy is not the central issue. As a result, despite having one of the most productive economies in the world, the United States suffers, by many different measures, from a marked maldistribution of health-care provision. Why? Because we frown on any rational planning to correct the injustices of the market, lest it inhibit profits. As a result, the fact that the U.S. spends far more on health care than any other country in the world is only a vain and arrogant boast, when it does not translate into affordable, equitable access to high quality medical care, because we prefer to regard health-care as a commodity than as a right. That will make an interesting inscription on our collective headstone.

In Britain, where I lived for 12 years (1980-1992), on the other hand, the availability of health services is universal and equal, because of a national health system –the NHS– that was instituted at the end of the Second World War. Generally supported by all political parties, the British system has usually been falsely described here as a “socialized” one, in order to deter our market-oriented public from fully grasping its merits. Yet, even Margaret Thatcher was famously quoted as saying that the NHS was safe in her hands, because popular opinion gave her no other choice.

The Origins of the NHS
The National Health Service in Great Britain is a remarkable example, within an advanced industrial capitalist economy, of a universal health-care system. It is far from perfect, not least because, from the start, it contained some fundamental contradictions that always limited its potential to dampen the adverse health effects of socio-economic differences. It was a system committed to an egalitarian ideal in a society that was still deeply structured along class lines. “Yet,” as Galileo would have said, “it moves.”

A part of the spirit of the modern NHS, Conservative Party reforms notwithstanding, owes much to the fact that the West has a long history of what we would today call “public health.” This is about much more than medicine. During the French Revolution, Condorcet, the mathematician and biographer of Voltaire, expressed the view that government should ensure that people were not “exposed to misery, to humiliation, to oppression,” that it should guarantee “that all members of society should have an assured subsistence each season, each year, and wherever they live…” Needless to say, that idea was rapidly repudiated as soon as Napoleon was safely exiled on St. Helena. But, such ideas surfaced periodically, in Britain during the Victorian era, for example, when Sir John Simon, first medical officer of health to the City of London (1848–55) and to the central government (1855–76), tried to set up a unified national medical service. But, in general, these were isolated moments that had limited effect, during a period when the political and social elite tended to regard disease as a function of immoral behavior.

The earliest germ of the idea of the NHS can probably be traced to the time of the Boer War (1899-1902), when many British working-class men were found to be too unhealthy to be accepted into the Army. This set off alarm-bells, at a time when the advance of the Empire was a major source of prosperity for the English elite and ill-health was seen as a factor in the rise of working-class militancy. Not long after, taking a leaf out of the book of Germany’s Chancellor Bismarck, the Liberal Prime Minister, David Lloyd George, introduced some corrective measures, to inhibit the rise of socialism with preemptive social policies.

Medicine for Profit is the American Way?
The French-born, Swiss-trained medical historian, Henry Sigerist, suggested that one of the principal reasons that this didn’t happen in the United States was that we had no comparably active labor movement to put significant pressure on government. We have waited, instead, for the fitful evolution of progressive forces within the mainstream “property parties,” the Democrats and the Republicans, as G. William Domhoff has aptly called them, to come around and that has taken a very long time; and, even, then, the commitment tends to be half-hearted. For the most part, progressive social reform in the United States is regarded as politically subversive. As a result, we have tended to entrust improvements in health to technology and to a fairly narrow biomedical paradigm that has focused more on combating pathogens and disease vectors than on addressing the broader social or economic determinants of ill-health.

This has had some positive consequences, but, in general, it has allowed medicine in the U.S. to become big business and has made most doctors ardent defenders of the status quo. As a result, it was the American Medical Association, exploiting the prevailing anti-Communist sentiment of the post-war era, that helped defeat President Truman’s effort to institute a national health insurance program. According to James Sundquist, in Politics and Policy: The Eisenhower, Kennedy, and Johnson Years. (Brookings Institution Press, 1968), the AMA shamefully “organized what became by far the most expensive lobbying campaign in history, aimed at ’socialized medicine’ and the Democratic politicians who supported the Truman plan.”

In the U.S., some degree of state involvement in health care provision didn’t come until 1965, when Congress passed Medicare and Medicaid. But, the former was only applicable to those 65 and over (10% of the U.S. population in 1965 and still just 13%, 30 years later), and it opened yet another door for private health insurance agencies. It is now just another feature of a costly (in human terms as well as financially) intricate medical-industrial complex, made up of academic hospital centers, the AMA, private insurers, drug companies, etc., which collectively aim to ensure that U.S. medicine is very profitable.

Its aim is certainly not to optimize the delivery of quality health-care. To make that our priority will mean removing it, unequivocally, from the marketplace.

Posted on June 30th, 2009

Eric B. Ross is a U.S.-trained anthropologist, who taught for 16 years at the Institute of Social Studies (The Hague), where he specialized in the political economy of agrarian change, health policy and equitable development and was Chair of the Institute's MA in Development Studies. He currently is Visiting Professor of Anthropology and of International Development Studies at The George Washington University in Washington, D.C. Among his books are Death, Sex and Fertility and The Malthus Factor: Poverty, Politics and Population in Capitalist Development. He is editor of The Porcupine.

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