In 1998, the British Labor government issued two important reports that underscored its view that, according to the British Medical Journal, “the root causes of ill health are mostly social, economic, and environmental and require policies that target help at those who are worst off.” There is little reason, when you think about it, when you make the effort to dig beneath the platitudes and hype, to imagine that the situation is any different in the United States. But, this has rarely entered the year-long health care reform debate. Politicians and intellectuals alike skirt around the disquieting edges of the problem when they talk about the affordability of insurance, about the people who sink under the weight of catastrophic illness, who lose their homes or their loved ones because they cannot pay for shelter, food and medical care at the same time. But, in the United States, it is regarded as unseemly and even unpatriotic to speak frankly of poverty, let alone about how it is one of the principal determinants of ill health and medical need.

We want to believe, in our hearts, that ill health is fundamentally a function of individual will, that, if we can just solve a purely functional problem of how to connect people to doctors and then leave it up to them, all will be well. Of course, we do need to ensure the optimal functionality of our health care system. But, we need, in the first instance, to make it a system, which means endowing it with a clear, coherent and comprehensive purpose: to ensure that everyone, regardless of social status or income, has access to quality health care. (Notice, by the way, that I don’t say “affordable health care.” When you create a universal system, as in Britain, you shouldn’t need to say “affordable,” as a way of ensuring universal availability. That’s just how it works: everyone can see a doctor, can obtain necessary treatment from a physician, a specialist or a hospital, without cost to the individual even being a consideration. Affordability only needs to be considered in terms of how the country as a whole pays for the system –in the same way that it considers how it will pay for the national defense.)

But, no national health system, however exquisitely it functions, can be a part of a larger capitalist economy without having to deal, on a regular basis, with the chronic consequences of poverty, which will contribute disproportionately to the total costs of the system until social policy addresses them, above and beyond the question of access to medical practitioners. It makes no sense, morally or financially, to address the human costs of cardio-vascular disease brought about by poor diets if people cannot afford to eat well; or to address the long-term costs of diseases produced by work-place hazards, if we make no effort to ensure health and safety standards where people work. A real national health system will strive to overcome the health disadvantages that result from poor housing, low wages and poor education. It will run the gamut from providing first-rate peri-natal care for all women to enforcing occupational risk assessment for all workers to ensuring effective and respectful management of chronic illness for all the elderly. Neither personal initiative nor corporate interest can do this. It requires a comprehensive societal approach to medicine that goes far beyond what is reducible to the issue of individual health insurance and that can realistically only come from an integrated system of local, state and national political strategies.

But, it means that, by the time the debate began last year over how to provide health insurance, it was already, as the British government acknowledged a dozen years ago, out of step with reality.