Last Thursday U.S. Medicare officials followed the lead of a number of U.S.corporations and announced a plan to pay bonuses for better care. A few months back a group of major corporations including General Electric, Ford and others launched a pilot program in Cincinnati,Lexington and Boston, to pay doctors bonuses of up to 10% if they prove they are taking better care of cardiovascular and diabetes patients.
Does this mean capitalism cares? Hardly.
But it does illustrate how the profit motive is often incompatible with public health.
TheU.S.spends by far the most money on health care of any country in the world. Around 14% of gross domestic product (GDP) goes to health care. The next closest country spends just over 10 percent. Not only do Americans allocate a larger percentage of GDP to health care, they spend more in absolute dollars. Americans pay $4,637 on average for health coverage while Canadians, the fourth biggest spenders, shell out $2,200 (US). According to the Globe and Mail, “[Canadian] governments spent 7 per cent of GDP on health in 2001, while American governments spent 6.7 per cent (April 21)”. Basically, Canadian and American governments spend the same amount on health even though in Canada unlike the U.S.the state provides universal health coverage.
Nevertheless, American life expectancy is only the 17th highest in the world. More importantly a World Health Organization study that counted years of good health showed that the U.S.ranked even lower by that measure. “The United States rated 24th under the system, or an average of 70.0 years of healthy life for babies born in 1999.” Christopher Murray, a director from WHO summarized the findings; “Basically, you die earlier and spend more time disabled if you’re an American rather than a member of most other advanced countries.” (www.who.com)
That relatively pitiful health can be attributed to the overwhelming influence of the drive for profit in the U.S.health system and in American society in general. No other industrialized nation has a health system where the capitalist profit motive plays a more significant role.
The inability of extreme capitalism to see any values other than exchange values, any entitlements other than property title, is perhaps most obvious in opposition to publicly funded health care in the U.S. As a result up to 60 million Americans lack basic health coverage ever year (NY Times).
Moreover, capitalism is antagonistic to public health promotion. The system prefers to treat illness rather than prevent it. Yet, preventive health promotion is substantially more effective than curative care. According to Laurie Garrett in the Betrayal of Trust, “86 percent of increased life expectancy was due to decreases in infectious diseases. The same can be said for theUnited States, where less than 4 percent of the total improvement in life expectancy since the 1700s can be credited to twentieth century advances in medical care.”
In other words, no matter how the corporate media inundates us with wondrous tales of the latest medical technology, nothing is anywhere near as important as preventive health promotion.
However, preventive care measures, such as good sewage and water systems, draining swamps near cities, education, regulated food handling, proper occupational health and safety or universal vaccinations bring little in terms of profit. These sorts of measures are almost always best provided socially.
So, like much of curative medicine, the plan to give doctors incentives for better care, might offer short-term improvements, but will be unsuccessful at seriously improving and extending people’s lives.
The payment system for doctors is already set up in a manner that leads to spiraling costs with no necessary correlation to improved public health. Almost all doctors in the U.S.and 90% inCanada are paid on a fee-for-service basis. (In other jobs this is called piecework). Under this system, doctors are private entrepreneurs who have a financial self-interest in treating rather than preventing ill health. Instead of giving doctors bonuses for better treatment, the current payment system, based upon the number of patients treated, should be abolished.
In a rational system financial incentives would be based upon public health promotion.
Even in Canada, a country that ostensibly has a “socialized” healthcare system, curative medicine reigns supreme. Basically, government-financed medical insurance pays the fees for a curative medical system controlled by physicians. (Canadian doctors have strongly resisted attempts to change the payment system.)Canada’s public health care system acts only as a counterweight to the entrepreneurial focus on cures over prevention.
Canada’s “socialized” medicine, through more centralized and rational planning, does put an increased emphasis on public health. In most provinces vaccinations are provided in a more accessible and rational manner. Public health units are decently equipped. Quality public education is also more widely available than in the U.S.because a publicly funded system does have a financial incentive to do what really works. The Canadian system has not, however, reoriented either the medical profession, pharmaceutical industry or the rest of the bio-med industrial complex to focus on prevention instead of private profit.
Curative medicine, though often beneficial in the short term, can actually be detrimental to health. For instance, the Chicago Tribune calculated 103,000 deaths in 2000 from hospital-grown infections, 75% were preventable, mostly from better cleaning techniques by doctors and nurses. (www.researchprotection.org)
Similarly, 80% of all the recent Severe Acute Respiratory Syndrome (SARS) victims in Toronto caught the illness at the hospital (Globe and Mail April 12).
SARS in fact highlights the importance of proper public health promotion. In Vancouver, British Columbia, where there is more contact with China then in Toronto, the number of SARS cases was substantially lower. The main reason is that last February public health officials in B.C. sent memos to hospitals warning them to be aware of atypical pneumonia. Immediately thereafter emergency room physicians were on the lookout for this type of pneumonia (later known as SARS). People with these symptoms were moved from the general hospital population to avoid possible infection. In Ontario, where government cutbacks to Medicare have been more severe, it appears no memo was sent.
Ultimately, a cure for SARS will probably be found. Nevertheless, public health promotion through preemptively quarantining individuals is substantially more effective than any cure at combating the disease.
Another example that highlights the comparative advantage of proper health promotion is child immunization in the province of B.C.compared to Ontario. In Ontario, doctors for financial reasons lobbied and gained control over the immunization process while in B.C. public health departments in each health region administer vaccinations for the entire population. The fragmentation of the system under the control of private-practice doctors means that there is less of a systematic effort to immunize. As a result, in Ontario, many more children enter Grade 1 without immunization.
The role of drug companies in promoting curative medicine is clear. They lobby for the unrestricted ability to promote their products, no matter the health effects. Over the past few years spending on pharmaceutical advertising has skyrocketed. American pharmaceutical companies and media corporations lobbied for the right to advertise direct-to-consumer, which has sizably increased demand for drugs. Similarly, according to the Economist, “the number of drug reps inAmerica alone has almost tripled since 1995, to some 90,000 last year, even though the number of doctors has barely budged.” (Feb 15)
Pharmaceutical companies lobby doctors to prescribe drugs, but frequently downplay the negative health effects. Often doctors, who are paid based upon the number of clients they see, prescribe drugs as a way of saving time. It is quicker to give a prescription than to take a proper, thorough health history. The cycle perpetuates itself whereby doctors increasingly lose the ability to see beyond short-term cures. Similarly, because the system is based upon curative medicine, doctors are not sufficiently trained with regards to health promotion.
Physicians can even satisfy requirements for annual educational updates by attending talks put on by the pharmaceutical industry. According to the Wall Street Journal, “the dinner and talk counted as two hours of credit toward their [doctors] annual requirements for continuing medical education, or CME.” (Dec 4, 2002)
The rise in drug marketing over the past years has led to massive increases in pharmaceutical sales. “In 2000 alone, Americans filled three billion prescriptions, double the number in 1990 (N.Y. Times March 2)”
Not only are doctors filling more prescriptions but in some cases they are also profiting personally. The March 31 N.Y. Times reported that many doctors are profiting from selling Ephedra, a weight-loss drug. The death of pro baseball pitcher Steve Bechler highlights the dangers of the drug. Not surprisingly, however, “according to medical ethicists, studies consistently show that when doctors have a financial stake in a product or service, their patients use it more. (N.Y. Times March 31)”
Aside from excessive visits to the doctor and pill popping, capitalist medicine also drives the production of fancy medical technologies that do little in the way of improving health and are only accessible to the rich.
A recent measure by the U.S. Congress exemplifies the interconnection between public health and the larger capitalist system. Last year, Congress put aside $125 million to fund the first year of the Center for Disease Control’s marketing campaign to reduce obesity amongst 9-13 year olds, which is a good step forward in public health promotion. The amount of money allocated, however, is a pittance compared to the amount of money fast food companies spend marketing. According to the Wall Street Journal, “by comparison, the five leading fast-food chains spent $1.5 billion promoting their products last year.” (July 18, 2002) This doesnÃt even take into account the majority of harmful food and drink products being advertised.
More importantly, the advertisements failed to mention the impact nutrition has on obesity and health. According to a professor quoted in the Wall Street Journal the reason “the CDC is avoiding the issue of poor eating habits [is] because it doesn’t want to offend the powerful food industry.”
Similarly, to seriously reduce obesity we need to reduce car culture. This is also politically sensitive since the automobile industry is a major economic and political player. Last year, Canadians spent a whopping $112.8 billion ($75 billion US) on car maintenance and purchases. (La Presse April 10)
Capitalist food interests do not want discussion of how their food is harmful to human health. Similarly, the auto industry doesn’t want cities to reorient themselves to become more conducive to walking. Nevertheless, to successfully improve public health, society would certainly need to look into these aspects of our sedentary life.
Furthermore, public health promotion has to confront other entrenched capitalist interests. For example, how does work affect people’s health? How much and under what circumstances are people working? As a result of the weakening of the organized U.S. working class, Americans are now working 200 hours more than they did in the early 1970s. (In Europe people are working less. The average Norwegian works 29 percent less than the average American or 14 weeks per year.) According to the N.Y. Times, “the harmful effects of working more hours are being felt in many areas of society. Stress is a leading cause of heart disease and weakened immune system.” (April 12)
The structure of the workplace also affects people’s health. Evidence shows that health-care employees (nurses, orderlies etc…), for instance, have significantly reduced back injury rates in workplaces where they have significant job control. Where workers have more control they tend to design their jobs in a more humane fashion. In addition, a growing body of evidence shows that workers who don’t feel in control have higher levels of job stress, which makes their bodies more susceptible to ill health.
Outside the workplace, the social inequality effects of less-fettered capitalism have negative public health effects. Academics have concluded that “there are good reasons to believe that policies that promote greater inequality such as budgets that slash top tax rates Ã³ cause higher rates of sickness and mortality.” (Financial Times Dec. 8, 2002) The FT further explains; “if you look for difference between countries, the relationship between income and health largely disintegrates. Rich Americans, for instance, are healthier on average than poor Americans, as measured by life expectancy. But, although the U.S. is a much richer country than, say, Greece, Americans on average have a lower life expectance than Greeks. More income, it seems, gives you a health advantage with respect to your fellow citizens, but not with respect to people living in other countries. We lack the data on the relative health of the richest tiers in different countries, but it would not be surprising if even the wealthiest Americans paid a personal price for their nationÃs inequality.”
The reasons put forward are that “once a floor standard of living is attained, people tend to be healthier when three conditions hold: they are valued and respected by others; they feel in controÃ in their work and home lives; and they enjoy a dense network of social contacts. Economically unequal societies tend to do poorly in all three respects: they tend to be characterized by big status differences, by big differences in peopleÃs sense of control and by low levels of civic participation.” Health is intimately connected to peopleÃs psychological state. And inequality appears to harm peopleÃs psychological state.
Outside of the industrialized world the negative impact of capitalism towards peopleÃs health is even clearer. In Africa or Latin America, the lack of proper drinking water or sewage leads to the premature death of millions. For this reason, there are many famous examples of doctors from non-industrialised nations who after realising the futility of attempting to cure, decided to struggle against capitalism instead Che Guevara and Salvador Allende were two of the best known.
Moreover, there is a serious global inequality of health resources. Public health officials use the term the 10/90 gap. In effect, the wealthiest 10% of the world receives 90% of all health research spending, while the poorest 90% only receives 10%. According to the profit motive 90% of humanity is of little value.
In the end, the capitalist profit motive is antagonistic to public health. So long as medical care is based on fee-for service and on private profits, cures will always be favored over prevention. Public health promotion necessitates long-term social planning whereas capitalism is driven by short-term private profit.
Economic democracy on the other hand, a mix of community and workplace ownership as well as political democracy, would help to improve public health. If the economy were democratic, people would most likely choose their health before profit as opposed to under capitalism where wealth-holding minorities can choose private profit over public health.
yves engler is amontrealbased activist currently working on a book about student activism at Concordia university. He can be reached at [email protected]