Medicine under capitalism
Politicians will be after your vote again soon, so they’ll be promising to save “your” NHS. Is it yours? Where did the NHS come from? And can politicians really save it?
With the general election looming, representatives of the various pro-capitalist parties will be grubbing about for your vote. The NHS is always a political battleground, and the major political parties often focus their campaigns on the issue because they think it is a potential vote winner. All politicians – whether Liberal, Tory, Labour or the Socialist Alliance candidates – agree, it seems. The NHS is in a dreadful state, and something must be done. What they propose must be done varies – spend more, move over to private healthcare, cut red tape, etc – but the unspoken assumption is that the NHS is a good thing in and of itself.
The NHS and public health are understandably and rightly matters of major public concern. They are the subject of public debate – to the extent that such a thing exists – precisely because they are of such vital importance to our present and future wellbeing. But this debate on the future of the NHS entirely focuses on how scarce resources should be allocated. It is accepted that the NHS and the practice of modern medicine is a “good”, but that, unfortunately, there is not enough of it to go round. Which leads to another assumption: that whatever the concrete problem, it is possible to resolve it within the contexts of the system, via parliamentary “democracy” and/or pressure group politics. All that needs to be done is for some trade union, for example, to “call on the Government” – to demand that the Government do something. But what could they do, and for whom?
No one doubts that the NHS has, for some time now, been in a state of crisis. This is not because of the failure of politicians. It is not the case that individuals are sabotaging what would otherwise be an all-right system. The crisis in the NHS is a reflection of the growing recognition that the increasing costs of medicine are not producing a commensurate increase in labour productivity – what the medical journals euphemistically refer to as “cost effectiveness”.
Contrary to popular belief, the NHS is not dedicated to satisfying the human need for health care, or the eradication of disease. Medical practice and research in capitalist society is strongly influenced by its role in maintaining a healthy labour force, and in socialising and controlling people in a class-divided society. The NHS keeps us fit for work so we can produce profits for our bosses. It is an integrative mechanism that helps hold class-divided society together.
The need of individual bosses to make as much profit as they can from us has to give way, to a certain extent, to the long-term needs of capitalist society as a whole. This is the basis for the idea that the state and the NHS are forces for “socialism”: legislation that protects workers from too much overwork and stress, provides education and basic health care, etc, came to be identified with “socialism”, rather than with the needs of developing capitalist society. (This view is defended to this day by the leftwing of capitalism, such as leftwing labourites, trotskyists, etc.)
In order to cut through this sterile debate, it is necessary to take a historical view. One cannot understand the NHS, or make sense of the waffle of politicians, by looking at a snapshot of it at one point in time, but by looking at how it came into being, the social context within which it operates, in whose interests it operates, and so on. Hospitals don’t fall from the sky.
In defence of capitalism?
From about 1870 onwards, there was a huge increase in the standard of life of most workers. Mortality rates fell, largely due to improvements in public health – such as clean water, effective sewage disposal and sanitation – and working class living standards improved. The widespread use of more complex machines over this period made possible an intensification of the labour process – workers were made to work harder – but on the other hand, this required a fitter and therefore more reliable work force. During the 20th century, mortality rates continued to fall. Capitalist development led to an increase in life expectancy for the whole population. It is facts like these that provide powerful support for the idea of the rationality and benevolence of capitalist society.
But at the same time, capitalism had to restructure if it was to survive. In the first decade of the 20th century, the Labour Party and the trade unions were vociferous in demanding social reforms. This increased level of working class organisation formed the background to the social legislation enacted by Lloyd George’s liberal government in the period from 1906 onwards. These reforms were not a gift from a benevolent state, nor were they merely a ploy to buy off working class discontent. They were an important element in the attempt to restructure British capitalism. It was starting to become clear that the quality of human labour was a crucial factor in capitalist development, and that capitalists must therefore invest in it just as they invested in the maintenance of machines.
It was against this background that plans for a state-organised medical service were formulated during the interwar period, culminating in the publication of the Beveridge Report in 1942. This was received enthusiastically by almost everyone, from people calling themselves socialists and communists, to the Archbishop of Canterbury, to some of the leading capitalists of the day. One group that wasn’t so impressed was the Socialist Party. We published a pamphlet at the time entitled Beveridge Reorganises Poverty (a photocopy of this is available by contacting our Head Office), which made, rather brilliantly, many of the points I will make again here. As the pamphlet makes clear, Beveridge gave expression to a broad section of hardheaded opinion in the ruling class of his period. Beveridge was for social reform, so long as the existing structure of society remained fundamentally the same. As Harold Macmillan later put it:
“After 1931 many of us felt that the disease was more deep rooted. It had become evident that the structure of capitalist society in its old form had broken down, not only in Britain, but all over Europe and even in the United States. The whole system had to be reassessed. Perhaps it could not survive at all; it certainly could not survive without radical change … Something like a revolutionary situation had developed, not only at home, but overseas.”
Increased state intervention came to be seen as crucial in the struggle to save capitalism – it was not the struggle for socialism, but its opposite. It was part of the postwar settlement between capital and labour.
To summarise the basic argument in Marxist terms, medical care is important for the reproduction of the forces and relations of production. The reproduction of labour power is provided for through the payment of wages – which enables us to feed, clothe and house ourselves at a historically and culturally specific level – but also through the state, which has, to an extent, taken responsibility for the collective reproduction of labour power by providing education, social security, and other welfare services. The development of the NHS was in part a recognition that a shift away from unskilled manual work to other forms of employment would require a healthier workforce and a more stable and qualitatively superior one. To put it more plainly, the NHS helps keep us fit for work so that we are forced to keep on selling the only thing of real value we own – our creative abilities – to our employers.
To recognise this is not to dismiss modern medicine as completely irrelevant or useless. Large-scale sanitation in the developed world, vaccines, and even the NHS itself, must be seen as gains for the working class in some aspects. It is, rather, to see through the “each according to needs” socialist rhetoric surrounding the NHS. The whole process of the foundation of the NHS was a contradictory one, serving the interests of capital and, as a byproduct, that of the workers.
The NHS also serves different sections of the capitalist class. This is to say that the medical field is itself a large and growing arena for the accumulation of capital, the most obvious example of which is the hugely profitable pharmaceutical industry, and the potentially hugely profitable emerging biotechnology industries. (Since the publication of the human genome project, speculative capital has been pouring into biotech industries, even though no one yet knows if anything will come of it.) The pharmaceutical industry justifies its huge profits by reference to the cost of the research and development it carries out, but it tends to remain silent on the amount it spends on advertising. Most of the information about drugs that doctors rely on comes, directly or indirectly, from the drug industry itself.
So what do we suggest? Although we cannot specify in advance a utopian blueprint for a socialist health policy, we can state that in socialism profit would no longer be the criterion for making decisions about production. Very different goods could then be manufactured, possibly using alternative technologies, with work organised in different ways, so as to reduce the possibility of ill health arising in the first place. And although it would be absurd to say that all disease would be abolished, we can assume that a real concern for the health of the population would be reflected in planning and decision making. Such a society is not a pipedream, but the logical outcome of the working class taking control of their own struggles against the current system, and redirecting their energies into an explicit attack on it.
The demand for a healthier society is in effect a revolutionary demand, since health-damaging aspects of production cannot be removed in response to political reform. This is because it is an inherent feature of capitalism that the interests of capital accumulation ultimately determine social and economic priorities.
But at the election, that is not the sort of message that you can expect to hear. Plenty of blather about spending on the NHS. Plenty of promises. The Socialist Party, however, doesn’t make promises. Instead, it can give a guarantee. Voting for a capitalist party, whether Labour, Tory, Liberal, or Socialist Alliance, will make no difference to your quality of life. Only your own actions – the “self-activity of the working class” – can change the world.