Book Review from the October 1983 issue of the Socialist Standard
The Political Economy of Health (Lesley Doyal with Imogen Pennell), Pluto Press, 1979 (h/b £10, p/b £4.95)
This interesting and well referenced book provides an analysis of health in Britain, public health, medicine and the development of British capitalism; the role of capitalism in determining health patterns in underdeveloped countries and the effects of colonialism on the health of indigenous populations; sexism within the National Health Service. The basic assumptions that health and illness are predominantly biologically determined, that medicine is a value free science and that scientific medicine provides the only viable means for mediating between people and disease are all questioned.
The conflicts between health needs and capitalist pursuit of profit are well illustrated: where improvements have occurred it is usually because of political expediency or because it is profitable to do so. The public health reforms initiated by the 1848 Public Health Act which reduced deaths from cholera by improving sanitary facilities were motivated by fear of the spread of epidemics to the rich, the escalating cost of poor relief to families made destitute by disease and the risk of Chartist agitation against the wretched conditions endured by the working class.
There are statements that socialists disagree with: " . . . we can assume that under socialism profit would no longer be the criterion for making decisions about production or consumption. Very different goods could then be manufactured. possibly using alternative technologies, with labour organised in less damaging ways, and income more equally distributed”. Although the first part of the statement is sound there will be no money in a socialist society and, therefore, no income to distribute.
The 'Inverse Care Law’ described by Julian Tudor Hart is incompletely quoted on page 197. "In areas with most sickness and death, general practitioners have more work, larger lists, less hospital support and inherit more clinically ineffective traditions of consultation than in the healthiest areas; and hospital doctors shoulder heavier case loads with less staff and equipment, most obsolete buildings, and suffer recurrent crises in the availability of beds and replacement of staff. These trends can be summed up as the inverse care law: that the availability of good medical care tends to vary inversely with the need of the population served". The omitted crucial final sentence is "This operates more completely where medical care is most exposed to market forces and less so where it is reduced”.
The book shows how colonial exploitation caused malnutrition by enforced changes in traditional methods of agriculture, exacerbated by the cultivation of “cash crops" such as tobacco or coffee. Diseases such as yellow fever, leprosy, hookworm and yaws were carried from West Africa to the Americas as a result of the slave trade.
The exploitation of women as health consumers and employees is argued. However, one feels that the authors are on less certain ground when they state: "It is difficult to articulate the medical model of women in any systematic way. It is not spelled out in textbooks, and must be constructed from an examination of the nature and content of medical education and medical practice”.
The influence of medical staff in the status-oriented and sexist National Health Service is examined with its emphasis on high technology and curative medicine at the expense of resources allocated to long-stay hospitals and preventive medicine. Private medical schemes are organised by employers as incentives and rewards for managerial staff during periods of wage restraint. As the authors state: “the continued existence of private practice makes it possible for overall standards in the NHS to be reduced without affecting the health care of the decision makers themselves".
Although socialists will find points of disagreement in this book the authors have produced a readable, well researched book rich in valuable reference material. The Political Economy of Health should be read by all socialists engaged in health care and may well become a standard reference work by which future books on health care are judged.