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Introduction about health inequality
Health inequality runs throughout life, from before birth through into old age. It exists between social classes, different areas of the country, between men and women, and between people from different ethnic backgrounds. But the story of health inequality is clear: the poorer you are, the more likely you are to be ill and to die younger. That is true for almost every health problem.
Health inequalities in the East of England. Although this region is one of the wealthiest in the country with few deprived local authorities, there is considerable variation in health within PCTs or local authorities. The PCT profiles presented here are based on Middle Super Output Area (MSOA) data and compare major health indicators within the PCTs and compare PCTs with each other.
The UK Presidency of the EC held between July and December 2005 featured health inequalities as one of two health themes. Two interim reports on the state of health inequalities in the EU were commissioned and published during the Presidency. A summit conference Tackling Health Inequalities – Governing for Health, was held on 17/18 October and emphasised the importance of action to deliver change through effective policies and governance, drawing on models of policy and good practise across member state governments.
With the eastern enlargement of the EU, more attention is being drawn to the fact that the citizens of the less wealthy Central and Eastern European countries have poorer health and shorter life expectancy than those in Western Europe. In addition to the east-west gap in health, differences in health between socioeconomic groups have increased in many countries as socio-economic determinants such as education, employment, and lifestyle affect health.
Health inequalities are unacceptable. They start early in life and persist not only into old age but subsequent generations. Tackling health inequalities is a top priority for this Government, and it is focused on narrowing the health gap between disadvantaged groups, communities and the rest of the country and on improving health overall.
Concerted action to reduce the health gap permeates our programs within the Department of Health and is supported across Government. The Health Inequalities Unit (HIU) is a small team in the Department of Health with a cross-government focus. The work of the unit is shaped by a Public Service Agreement (PSA) target to reduce inequalities in health outcomes by 10 per cent by 2010, as measured by infant mortality and life expectancy at birth.
In 1997, a scientific review of health inequalities in England was undertaken by an independent inquiry into health inequalities chaired by Sir Donald Acheson, a former CMO. This inquiry also looked at possible policies to address these inequalities. It found that the health gap had grown significantly since the 1970s and reported that in the early 1970s, death rates among men of working age were almost twice as high for unskilled groups as they were for professional groups, by the early 1990s, death rates were almost three times higher among unskilled groups.
The national health inequalities strategy for England is set out in the Programme for Action (2003), covering around a third of the population, not just socially excluded groups. It outlines a twin-track approach with a national target to reduce health inequalities by 10% as measured by infant mortality and life expectancy at birth by 2010. The aim is to improve the health of people in disadvantaged groups and areas faster than the rest of the population. This includes reversing the ‘inverse care law’ where those with the greatest health needs have the least access to services.
This requires action on a broad front and is reflected in the strategy themes
- supporting families, mothers and children.
- Engaging communities and individuals.
- They are preventing illness and providing effective treatment and care.
- She was addressing the underlying determinants of health.
Since 2004, a health inequalities dimension has featured in other health targets, including the targets for heart disease and cancer. It encourages action in disadvantaged groups and areas necessary to meet other health targets. This approach is already showing results – the death rates from both diseases are falling fast, but the health gap between different social groups is falling faster – by 24.7 per cent in heart disease and 9.4 per cent in cancer in absolute terms over six years.
The national health inequalities strategy for England is recognised and well established. Delivering change to meet the 2010 target is the next step. This will require
- a stronger focus on achieving the target among key players
- being clear about what action is necessary and what interventions work, clarifying needs, evaluating initiatives and monitoring delivery
- mobilising NHS and local government so that health inequalities issues are embedded in local service delivery, and build partnerships
- developing the spearhead group of deprived areas (covering 28% of the population) as a focus for new initiatives – this group is key to improving the health of disadvantaged groups and areas faster than other areas.
- continuing to work across government – and with cross-government programmes for long-term, sustainable reduction in health inequalities.
How Marxists evaluate capitalist society
In Marxian economic discourse, the capitalist mode of production (i.e. CMP) refers to the socio-economic base of capitalist society, which began to grow rapidly in Western Europe from the end of the eighteenth century and later extended to most of the world. It is characterized by the predominant private ownership of the means of production, distribution and exchange in a mainly market economy. The owners of capital are the dominant capitalist class (bourgeoisie). The working class (proletariat) who do not own capital must live by selling their labour-power in exchange for a wage.
The CMP may exist within societies with differing state systems (e.g. liberal democracy, fascism) and different social structures.
Although Marx thought of himself as a scientist whose primary tasks were to explain the workings of the capitalist economy (his economic theory) and to explain the dynamics of class societies generally (his theory of history), it is reasonably clear that he also believed that capitalism was a bad thing, however historically necessary it might be. Furthermore, he clearly believed that the problems with capitalist society are deeply rooted in the sense that only a radical transformation of capitalism (i.e., its replacement by socialism) could eliminate or significantly reduce these problems. For these reasons, Marx can be thought of as offering a radical critique of capitalist society. The purpose of this book is to explicate and critically evaluate this critique.
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Marx never explicitly summarised his definition of capitalism, beyond some suggestive comments in manuscripts which he did not publish himself. This has led to controversies among Marxists about how to evaluate the “capitalist” nature of society in particular countries. Professionalism is based on Marxist ideas. The capitalist agency theory postulates that all professionals are political suspects and trained servants of the capitalist elite.
Doctors represent part of the ruling class and contribute to capital accumulation by treating symptoms of capitalist society such as alienation and diseases generated as a result of capitalist exploitation. Criticisms of this approach are plenty: this approach cannot explain the difference in status and power among different professional groups. Further, it does not take historical evidence into account at all. Again referring to surgeons, they are used to have the social status of barbers in the 19th-century English society (Starr, 1982). Barbers were certainly no noblemen.
Health economics would seem to be a perfect topic for heterodox dissent, and yet, surprisingly enough, radical economists and Marxists have not on the whole been attracted to health economics. Still, health economics is a field that must make the average neoclassical economics squirm because it challenges his or her standard assumptions at every turn.
Perhaps that is precisely what makes it so interesting to study.
Dependency theorists argue that these inequalities are enforced by transnational corporations (TNCs). They suggest that these large companies, such as Big Pharma, are attempting to make profits where they should perhaps be making concessions. They would also argue that the World Trade Organisation works for the benefit of the rich. These Marxists believe that health problems were introduced with Colonialism when the indigenous were enslaved and exploited on plantations.
This loss of culture and independence aroused anomie leading to alcoholism and suicide. The introduction of mono cash crops also restricted the diet of the poor, which has led to malnutrition and food shortages. The colonialists also brought diseases such as chickenpox which the indigenous were unable to withstand. Dependency Theorists would go on to argue that this exploitation continues to exist through neo-colonialism. Guder Frank (1971), a Dependency theorist, states that the core nations have exploited the peripheral. Subsequently, they have accumulated wealth whilst the peripheral countries are destitute. Thus they are increasingly dependent upon the developed world.
Marxist theorists are critical of the Western imperialist health care model imposed upon the Third World as part of the process to modernise. The model is ill-suited for society as it is too highly technological and expensive, relying on imports from the West. For example, the aforementioned Hospital set up by the Gates Foundation has not been used widely by the local people who feel intimidated by the extravagant building. It could be argued that the money could be invested to have more benefit for the people if less was spent on show and appearance.
Additionally, the Western model of health care is focused on treating different illnesses; for example, in the West, hospitals may involve the treatment of cancer or heart disease as opposed to malnutrition or diarrhoeal diseases. This means that the model is largely curative rather than preventative. In the case of Aids, for example, money would perhaps be better spent on education and sex protection to help contain the epidemic, rather than on drugs for those who are infected.
The health care facilities often have an urban bias, leading to inequalities within the countries. There are few clinics in rural areas; therefore, those people suffer. Health care is also often expensive, thus benefiting only the elite. Skilled staff are in short supply, with an average of 1 Doctor for every 17,000 compared to 1 per 520 in the West. They are also expensive; therefore, many are sent abroad to train. Often they can earn more by staying in these countries and so do not return to their home country. However, the Dependency theory can be criticised for being too disparaging of the Western model, for although there are problems, the intervention of the West has brought benefits for the people.
The Marxist viewpoint forces one to look at the inequalities in a different light and highlights problems and inconsistencies with the theory of Modernization theory.
Marxism explain inequalities
There are many separate strands of reasoning within its explanatory rubric which can be more or less ordered according to the extent to which the primary causal significance is assigned directly or indirectly to the role of economic deprivation. Amongst explanations that focus on the direct influence of poverty or economic deprivation in the production of variation in rates of mortality is Marx’s radical critique. This theory of political economy provides a theory of history linked to an explanatory account of the contemporary form and inevitability of economic exploitation.
Those associated with such a radical approach see health or the physical welfare of workers as a key-dependent variable determined by the system of production, which also gives a particular character to the culture and the ideology of society. Not all follow Marx, and those who do risk interpreting modern problems in a way which he would not necessarily have approved. Crudely expressed in its original form, the argument was as follows.
Capitalism is, in essence, a system of economic organisation which depends on the exploitation of human labour. The accumulation of profit, the guiding principle not only of the economic system but of the whole form of capitalist social organisation, is the storing up in the tangible form of the human effort and resources expended by individual workers over and above what they either require or have been allowed, to maintain their bodies in a fit and healthy condition.
Marx did not use the modern concept of health in his analysis and was primarily concerned with the material welfare of human beings. This is reflected in his theory of “immiseration”, which assumes a minimum subsistence level which capitalist social organisation systematically violates through its greed for profit. In the process of immiseration, the worker experiences economic deprivation on an ever-increasing scale until finally he is left with insufficient resources to maintain bodily health.
Placed in its historical context, Marx’s analysis can be seen, at least in part, as a counter critique to Malthusian theory, which saw the relationship between death, disease and poverty as a natural phenomenon: the demographic safety valve of the fixed relationship between population size and the natural level of material wealth in the world. Marx’s antidote to this “naturalistic” theory of social inequality stressed the potential elasticity of material produced under the capitalist mode of production, while at the same time drawing attention to its dependency on an unequal distribution of resources as well as its inherent tendency to promote material inequality in health as well as property between human beings.
Most modern proponents of Marxist theory do not interpret the process of material exploitation in terms of human bodily resources and tend to measure surplus value in terms of wealth or property, the factors into which human labour is transposed. With the benefit of a century’s hindsight, the validity of much of this nineteenth-century theory of the relationship between health and material inequality has been accepted today, especially for the earlier phase of competitive industrial capitalism (G F Stedman-Jones 1971; Thompson, 1976). Exploitation, poverty and disease have virtually become synonymous for describing conditions of life in the urban slums of Victorian and Edwardian cities, as they are today for the shanty towns of the underdeveloped world.
A relationship between material deprivation and certain causes of disease and death is now well-established, but then so is the capacity of the capitalist mode of production to expand the level of human productivity and to raise the living standards of working people. Economic growth of the kind most readily associated with the European style of industrialisation has in itself been credited with the decline in mortality from infectious disease during the nineteenth and twentieth centuries.
Today death rates for all age groups in Britain are a fraction of what they were a century ago, and many of the virulent infectious diseases have largely disappeared, and the “killer” diseases of modern society – accidents, cancer and heart disease – seem less obviously linked to poverty. Against this background, the language of economic exploitation no longer seems to provide the appropriate epithet for describing “Life and Labour” in the last quarter of the twentieth century.
Through trade union organisation and wages council machinery, it is now argued that labour is paid its price and, since health tends to be conceptualised in optimum terms as a fixed condition of material welfare which, if anything, is put at risk by affluent living standards, it is assumed by many that economic class on its own is no longer the powerful determinant of health that it once was.
- L. Goldmann, “Le Marxisme Est-il une Sociologie?” in Recherches Dialectiques (Paris: Gallimard) 1955.
- K. Marx, “Arbeitslohn,” 1847, Kleine ökonomische Schriften (Berlin: -Dietz Verlag) 1955.
- K. Marx, Capital, pp. 557-558.
- Tackling Health Inequalities – A Status Report on the Programme for Action, 2005.