In a capitalist society there is. inevitably, a conflict between the health needs of the working population and the pursuit of profit. Workers are viewed predominantly as economic units to be exploited for their labour power. The cut-throat nature of capitalist competition obliges manufacturers to keep production costs as low as possible to maintain profits and avoid being undercut by rivals and forced out of business.
Conflicts occur because the unchecked efforts of manufacturers to produce goods as cheaply as possible lead to the impoverishment of the workers by the payment of low wages, longer working hours, hazardous working conditions, exploitation of child labour, environmental pollution, and stress from alienating, repetitive, boring work on factory production lines. But a considerable amount of ill-health is caused by the interplay of factors resulting from the exploitation of labour. Accidents are caused by fatigue and hazardous working conditions. occupational disorders are common; gross exploitation leads to poverty, bad housing and malnutrition. However, the provision of health care represents a cost against production to be avoided if possible. The workers try, with partial success, to mitigate exploitation through trade unions and parliamentary reforms by pressing for better working conditions, higher rates of pay and the provision of health and social services.
In the early days of the industrial revolution the large-scale migration of labour from rural to urban areas provided a plentiful supply of unskilled labour. Consequently, there was no incentive for the capitalists to conserve the workers' health. By the 1830s the misery endured by the working class led to labour agitation which found expression in syndicalism and Chartism and posed a threat to the stability of the state. At the same time cholera epidemics threatened the rich as well as the poor and led to the reform of sanitary facilities initiated by the 1848 Public Health Act. By contrast tuberculosis, a disease of poverty, which did not seriously threaten the affluent in large numbers, continued to be a major cause of death for the poor for nearly a century longer.
Iliffe (1983) has examined the political motives underlying the 1911 National Health Insurance Act. with its attempt to placate labour agitation and undermine the influence of the emergent Labour Party; provide a fitter fighting force for the impending war with Germany, and make the workers believe that substantial social change afterwards would make the war worth fighting. The position of workers as economic units under capitalism was exemplified by the exclusion of women and children from even the limited provisions of the Act.
The modern welfare state was drawn up by William Beveridge in 1942 with apparently more humane and far-reaching provisions for health care than previous legislation. Many absurd claims have been made that the creation of the welfare state was "revolutionary" or "socialism in action", but Kincaid (1973) states:
In his plan Beveridge gave expression to a broad section of hardheaded opinion in the ruling class of his period. He was for social reform. so long as the existing structure of society remained fundamentally the same. In fact he was for social reform precisely because it would allow the existing order to continue essentially unchanged. It is not as a visionary that Beveridge deserves to be remembered. Rather his particular distinction lay in an ability to translate the general objectives of ruling class reformism into detailed and technically workable proposals.
The National Health Service of 1948 introduced a comprehensive system of health care "free at the point of use” for the first time. This principle has been undermined from the beginning and now, at a time of industrial recession, the very foundations of the welfare system are under attack. This is because there is now a surplus of labour and capital does not need to conserve the workers' health. Indeed, in terms of profitability — the motivation which drives capitalism — it is uneconomic to spend money on the health care of "non-producers" such as the unemployed or the elderly.
The class bias of mortality rates is often not fully appreciated for it is believed that illness strikes at random, that modern illnesses are diseases of affluence, and that progress is being made towards a better life (Mitchell. 1984). The facts show otherwise, for as Mitchell states:
The National Morbidity Survey reveals a clear pattern among long-term and recurrent illnesses. Chronic bronchitis is a major cause of time off work and a persistent and disabling condition. Women with husbands in unskilled jobs go to see the doctor with it three times more often than women married to men in professional jobs. Among their husbands there is a four-fold difference. With bad backs, bones and joints, the picture is similar. Women in social class one go to see the doctor with arthritis half as frequently as women in social class five Doctors see men in unskilled jobs with slipped discs, back pain and sciatica three times more often than men in professional jobs. Ulcers, another so-called "businessman's disease", drive men at the bottom of society to the doctors twice as frequently as men at the top. Top men die of ulcers four times less frequently than men in unskilled jobs. Other common conditions for which there is the same kind of class pattern include varicose veins, phlebitis, chronic digestive problems, epilepsy and diabetes.
For middle-aged men in social class five the death rate has actually risen in the last thirty years compared with a fall in social class one (Black Report. 1982).
Although the "welfare state" was created to patch up the problems caused by poverty without damaging the wealth and privileges of the few it does, nevertheless, alleviate some of the misery and insecurity of the system and was not gained without considerable. if misguided, struggle on the part of the workers. But like all reforms it has been only partially successful and has shown how vulnerable to attack it can be. In the last two decades hospitals have closed all over Britain. By contrast, private insurance schemes increased by 25 per cent between 1971 and 1979 (Iliffe. 1980). For the poor, the old. the disabled, the chronic sick, mentally ill and mentally handicapped a move to insurance based medical services has frightening implications because of difficulty obtaining insurance as they lack profitable investment prospects. Iliffe has described how the closure of mental hospitals without adequate alternative provision causes mentally ill people to drift into the "homeless, workless population that sleeps in cardboard boxes and derelict buildings, rummages through litter bins and provides police, courts and prisons with an unpunishable stratum of hopeless recidivists".
Private residential homes for the elderly have flourished in an attempt to profit from the lack of adequate public services and have been encouraged by the present government. However, Philipson (1985) has provided examples from several different countries to show that when profit is the dominating force the standards of care leave much to be desired. The privatisation of catering. laundry and domestic services threatens the job security of many hospital employees; breaks the strength of the trade unions; forces down wages to subsistence levels. All of these moves are more difficult to resist at a time of unemployment which damages the bargaining power of the unions.
Good health is best maintained by avoiding poverty, dirty, dangerous work, poor housing and polluted environments. The National Health Service, valuable though it is in times of illness, cannot remedy these problems.
The National Health Service represents the best and the worst aspects of reformism. It has undoubtedly ameliorated some of the more health damaging effects of capitalism without tackling the misery of the system itself. High technology medicine continues to flourish at the expense of psychiatric, geriatric and community care. But if private medicine replaces the National Health Service the poor will not be able to afford such treatment as heart transplants or micro-surgery. And if only insurance schemes are available then workers will pay to be at the back of the queue and it will cost even more to move to the front.
Iliffe. S. (1980) "Private medicine and the Tory government". Medicine in Society 6(1) 12-15.
Iliffe. S. (1983) The NHS. A Picture of Health? Lawrence and Wishart. London, pp 17-19.
Kincaid. J. C. (1973) Poverty and Equality in Britain. Penguin. Harmondsworth. pp 45-46.
Mitchell. J. (1984) What Is To Be Done About Illness And Health? Crisis in the Eighties. Penguin. Harmondsworth.
Philipson. C. (1985) "Private care or no care at all? — a socialist dilemma" Medicine in Society 10 (4) 21-23.
Townsend. P. and Davidson. N. (1982) Inequalities in Health: The Black Report. Penguin. Harmondsworth. p 51.