Lost in Translation
Steffie Woolhandler and David Himmelstein
In the 1920s, a major current of Soviet health planning contemplated the withering away of curative medicine. Many believed that as socialism evolved into communism--eliminating inequality, poverty, alienation, and oppression--prevention, in the broadest sense, would obviate the need for doctors and hospitals.
This Soviet view was an extreme, caricatured version of a long, more holistic socialist tradition. Rudolph Virchow (the founder of modern pathology) and Friedrich Engels analyzed the social determinants of disease in Silesia and the British working class, respectively. Early in his career, Salvador Allende (then minister of health in a Popular Front government) described the social origin of disease and suffering in his book La Realidad Medico-Social Chilena, and concluded that only broad structural change in Chilean society could adequately address health problems.
The Marxist tradition has delineated a socialized biology; patterns of health, disease, even physiology that are shaped in interaction with a specific social environment. As Richard Levins has pointed out, there is a "late twentieth century capitalist" pancreas, not in the sense of a particularly wealthy organ, but rather an organ stressed to the point of diabetes by a variety of socially determined factors: patterns of diet dictated by agribusiness; living and school environments antagonistic to exercise; work situations that constrain meal schedules and physical activity; and a profit-driven health care system that fails to embrace prevention.
Recent work on inequalities in health, which forms the empirical foundation for Daniels, Kennedy, and Kawachis piece, is a statistical restatement and verification of this tradition: Virchow and Engels prose descriptions are being translated into the modern scientific language of epidemiology. Such translation is a great service; it presents alien and suspect ideas in acceptable academic format. Concern over social and health inequality has become a legitimate focus for academic work, encouraging altruism among colleagues and students, and providing ammunition for progressive reformers. Press attention has followed, and with it, pressure on policy makers to ameliorate inequality.
But in the translation from socialism to epidemiology something has also been lost. In analyzing typhus, Virchow found the social seeds of disease, and prescribed (and participated in) efforts to overthrow a social system in which "thousands always must die in misery so that a few hundred may live well." Allendes prescription for the ill health due to social inequality was a united front to uproot capitalism and imperialism in Chile.
Daniels, Kennedy, and Kawachi describe the phenomenology of inequality and injustice, but leave its origins and perpetrators obscured. Hence their prescriptions call for a change in policy, but not in power. They would redistribute wealth, but dont renounce the reign of the market or the inviolability of property rights that are the mother and father of inequality.
Failing to identify the perpetrators of poverty and inequality can also lead to confusion over policy choices. Daniels, Kennedy, and Kawachi imply that resources might profitably be shifted from a profligate health care system into programs to upgrade the standard of living for the poor. In Canada, the Health Minister published a more explicit statement of a similar view. Yet when health care was cut, the resources were transferred to the rich, not to the poor.
The people and institutions (the corporate elite or ruling class) that benefit from the unequal provision of health care also benefit from the unequal distribution of wealth, education, and power. When these powerful groups are weakened--through popular mobilization, inequality shrinks and health care improves. Thus, the Great Society social programs of the 1960s substantially shrank inequalities in income, education, wealth, and housing--and coincided with the passage of Medicare and Medicaid. In Sweden, recent cuts in health spending have coincided with a more general attack on the welfare state.
Finally, we would raise three minor quibbles with Daniels, Kennedy, and Kawachi. First, health care is so expensive in the United States that for sick people, inadequate insurance often means poverty. Indeed, ill-health is the leading cause of personal bankruptcy. Second, we are uncomfortable with their implication that health is the key metric for measuring a society. Does Japanese longevity make Japan a model society? Third, analyses focused on inequality should not obscure the horrific absolute deprivation in our society. In 1995, 11.6 million Americans went hungry, 4.4 million had their gas or electricity turned off, and one million were evicted from their homes.
These criticisms should not detract from the great service that Daniels, Kennedy and Kawachi have performed in this paper and elsewhere. They have been effective leaders in academia in the fight for equality and justice.