Wednesday, May 5, 2021

The cost of lives (1985)

From the May 1985 issue of the Socialist Standard

The relentless pursuit of profit under capitalism produces a wealth of contradictions: coal mines are closed while old people die of cold, food production is curtailed despite widespread starvation, hospitals are closed and ill health in the general population increases in spite of advances in high technology medicine. The provision of health care is distorted by the competing forces within capitalism as social needs are, if catered for at all, secondary and coincidental to the overriding requirement of profitability.

The interests within the health care system are: the workers trying to obtain improved medical services "free at the point of use"; the government trying to "privatise" medicine and reduce state provision of health care, the insurance companies who are gaining increasing numbers of subscribers to private insurance schemes as the National Health Service deteriorates; the companies who supply drugs, equipment, provisions. construction and services and are parasitical on the health service; private medicine with fees for consultation and surgery.

Although bringing health care under state provision with the development of the National Health Service appeared to represent a gain for the working class it is, in fact, a victory for ruling class expediency and has developed, and continues to be shaped, according to the needs of capital. There is no doubt that new discoveries, technological improvements and modern drugs have eased the misery of many serious diseases. However, it would be wrong to assume that the use of sophisticated techniques automatically confers benefits on patients. Illich (Limits to Medicine, 1976) claims that coronary care units are no more effective than normal medical wards but require three times as much equipment and five times the number of staff to run them. Garner (The NHS: Your Money or Your Life, 1979) cites research which supports this claim and points out that patients nursed in coronary care units have a higher mortality rate than those nursed at home.

Ineffective or even harmful treatments may continue to be used because they are profitable or allow control, prestige and power by vested professional interests. The misleading publicity (or advertising) which accompanies technological medicine and discouragement of information and knowledge outside professional circles may lead to a "demand" for dubious medical treatments by the general public who mistakenly believe that miracle cures have been found without being aware of potentially dangerous complications or side-effects. The damage that commercialised medicine can cause has been pointed out by Eyer:
  . . . when doctors went on strike in Los Angeles County in 1976. limiting elective surgery for the most part, the death rate fell by about 15 per cent and rose well above its previous level when the doctors resumed practice. before returning to normal. This means at least one out of every six deaths in Los Angeles is due to the overdevelopment of medicine.
(J. B. McKinlay (Ed.): Issues in the Political Economy of Health Care, 1984.) 
Although excessive medical and surgical intervention is a feature of private health care, under-provision of facilities is common when its supply is less profitable. Professor Stewart Cameron of Guy's Hospital. London claims that 2,000 sufferers from renal failure may be dying unnecessarily each year in Britain because of insufficient renal dialysis machines (Medicine in Society, 1984).

The considerable variation in the provision of health care facilities has been summed up by Julian Tudor Hart (Lancet, 1, 405. 1971) as the Inverse Care Law. in which he states: ". . . the availability of good medical care tends to vary inversely with the need of the population served. This operates more completely where medical care is most exposed to market forces and less so where it is reduced." Wales typifies the Inverse Care Law with some 10.000 deaths from coronary artery disease each year and 25,000 men of working age suffering from angina, but with a dearth of cardiologists compared with regions in England (Medicine in Society, 1982). This contrasts markedly with private medicine as the fashionable London clinics accepted patients from the continent for coronary by-pass surgery until it was realised that patients receiving drug treatments made similar progress. It is true that a minority of people with coronary heart disease benefit from by-pass surgery providing they are properly assessed and identified. Also the much simpler and safer procedure of supplying cardiac pacemakers could save lives in Wales if they had the resources.

Heart transplants make dramatic news but there is little evidence that, on average, they prolong life expectancy. The deaths of heart transplant patients get very little reporting by the media, distorting the benefits, or lack of them, of technological changes. Nevertheless, in spite of all the evidence that technological advances need to be approached much more cautiously and with considerably more evaluation, there seems to be more specialisation and technological expansion than ever before. Garner has pointed out that doctors in the United States carried out twice as many operations on a group of Federal employees when paid a fee-for-service than doctors paid a flat salary by another insurance scheme. Similarly, the number of hysterectomies performed in Saskatchewan increased by 72 per cent after the introduction of national health insurance which reimbursed the doctor. Apart from the obvious profit motive, the restriction of skills to a professional elite concentrates power, prestige and more money into fewer hands. Mitchell (What is to be Done About Illness and Health?, 1984) claims: "We tend to assume that historically paid physicians opposed the herbalists and lay healers because their methods were ineffective or dangerous. Yet there is considerable evidence that it was because these methods did work that they were threatened".

Widgery (Health in Danger, 1979) has questioned the "medical prestige mongering" of advanced medicine: "In Buenos Aires doctors are playing about with cardiac surgical units costing tens of thousands of dollars while new-born babies die in the precincts of the hospital for lack of decent milk". He also questioned some of the cardiac resuscitation procedures:
 . . . while every effort can and should be devoted to monitoring and reviving patients in units equipped for intensive care, the kind of indiscriminate, ineffective invasion we carried out, which we wholeheartedly conceived as solely for the patient's good, was in fact depriving the dying of the last shred of dignity in order to give us a little practice and a little false prestige. None of this is to argue that we should abandon or relent our development of medical science, but we need to sharpen its focus, take more seriously its implications and applications. We need to ask honestly, every time whether its net result enhances the doctor's prestige or the patient's well-being, for these are by no means the same thing.
Under capitalism medical care assumes its most profitable form and there is usually more money to be made from curing a complaint than preventing it. In under-developed countries the resources consumed by curative medicine in the prestige hospitals of the major cities have been at the expense of preventive services in the rural areas. ("The Politics of Health in Tanzania", Development and Change 4 (1) 39. 1972) has put the contradiction of high technology medicine co-existing with poor primary services in Tanzania in perspective:
  . . . a man has hookworm anaemia (common in Tanzania). He has been ill for years; eventually he has to stop work altogether. He is admitted to hospital. He needs laboratory tests, skilled medical and nursing attention, drug treatment and a blood transfusion. After a time he improves, and he eventually goes back to work. At home, he catches hookworm again; the whole process is repeated. If his village had used pit latrines none of this would have happened.
Poverty remains the main cause of a considerable amount of ill health. Millions of children die each year from malnutrition and infection in the Third World. Even in the more affluent countries workers have higher mortality rates than the rich as a result of working in stressful, polluted, alienating environments and living in poor housing conditions. And within countries such as Britain relative poverty is still quite widespread. Thus a socially deprived area such as Rochdale has an infant mortality rate 2½ times greater than the national average.

In advanced, industrialised countries preventive services also have a low priority because they are less profitable. Yet governments are anxious to shift the burden of costs away from the state and back to the consumer. As Crawford states:
  The emphasis on individual responsibility for health mystifies the social production of disease and undermines demands for rights and entitlements to medical care. Beneath the rhetoric about the costs of medical care and the obligation of the individual to remain healthy lies a political programme to shift the burden of costs back to labour and consumers and to paralyse regulatory efforts undertaken to control environmental and occupational hazards. (J. B. McKinlay. op. cit.)
As it is uneconomical to safeguard workers' health during unemployment because a reserve army of labour is available, drastic cuts have been made in the health and social services. But substantial increases in military expenditure, aid to private industry, the police force, and tax advantages for the wealthy reflect capitalism's priorities.
Carl Pinel

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