|A three-year investigation by the World Health Organisation (WHO) into the ‘social determinants’ of health has concluded that social factors are to blame for huge variations in health and life expectancy around the world.
Tellingly, the report focuses not just on the difference in life expectancy between different countries, but also on the difference between people living a few miles apart within the same country.
For example, the report has found that the average life expectancy in wealthy Hampstead is 11 years longer than it is in the inner-city ward of St Pancras, despite the fact that both are within the London borough of Camden, and are separated by a mere 3 miles.
Meanwhile, the average boy living in the leafy commuter village of Lenzie, just 6 miles northeast of Glasgow, will live a massive 28 years longer than a boy born in the city’s run-down suburb of Calton, who will be lucky to make it past the age of 54.
Other, narrower, studies in recent times have also revealed the widening gap in health and life expectancy between Britain’s best- and worst-off communities. Infant mortality rates are significantly higher among the most disadvantaged, while breast cancer survival rates are lower and recurrence rates higher, for instance.
These differences are clearly too significant to be written off as simply genetic or biological. The panel of experts assembled by the WHO to make up its Commission on the Social Determinants of Health found that, in almost all countries, poor socioeconomic circumstances equated to poor health. In short, concludes their report, “social injustice is killing on a world scale”.
Of course, this will not come as a surprise to Marxists, who have long held that it is capitalist conditions, not any inherent stupidity or ignorance, that lead the poorest in our society to live the least healthy lives.
Poverty and despair - a truly toxic combination
In an interview for BBC News Online, a GP working in the aforementioned Glasgow Calton, Dr Robert Jamieson, enumerated the factors that left his patients in such poor health. Top of his list of killers in the area were heart disease, diabetes, asthma, bronchitis, drug and alcohol abuse and violent crime. He also cited depression as a major problem and a contributing factor in exacerbating other conditions.
On the subject of poverty, Dr Jamieson was adamant that this is the real cause of the vast majority of health problems in Calton, citing the unemployment, low income and dire housing conditions endemic in the area.
Meanwhile, the WHO commission’s chairman, Sir Michael Marmion, told Radio 4’s Today programme that without action to change people’s physical circumstances, injustice and inequality will only increase.
He said that the widening health inequality gap in Britain is part of a pattern emerging throughout the world. “There are examples of countries where health inequalities have narrowed but, in too many cases, we have seen a widening.
“But that means the magnitude of health inequalities are not fixed - if the gap can widen, it can get narrower.” (Our emphasis)
Sir Michael went on to say that, although there has been an overall improvement in people’s health in the UK over the last eight years, this had been disproportionately weighted in favour of the better-off sections of society.
“The key message of our report is that the circumstances in which people are born, grow, live, work and age are the fundamental drivers of health and health inequity.”
Answering the interviewer’s predictable jibe about poor people taking ‘personal responsibility’ for the way they ‘choose’ to live, Sir Michael said: “People need the opportunity, the possibility, to take control of their own lives – but the conditions need to be right to allow them to do that.”
The WHO’s report highlights education, affordable housing, management of access to unhealthy foods and social security protection as key. It also says that governments should take action to ensure a living wage for workers, as well as to create working conditions that reduce work-related stress and ensure a healthy work-life balance.
So what is to be done? How is this equitable world that guarantees a minimum standard of living, decent housing and good food for every person to be arrived at?
The report highlights three main principles of action by which a world might be created in which health inequity is abolished and people are given a real chance to live the length and quality of lifve available to them biologically:
“1. Improve the conditions of daily life – the circumstances in which people are born, grow, live, work, and age.
“2. Tackle the inequitable distribution of power, money, and resources – the structural drivers of the conditions of daily life – globally, nationally, and locally.
“3. Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health.”
In particular, the report’s authors correctly pinpoint a need to start early and create equity for children at the beginning of their lives, stating that “It is better for the individual child, and for society – in rich and poor countries alike – to provide a positive start, rather than having to resort to remedial action later on.”
These points are valuable; however, the authors of the WHO’s report, hemmed in as they are by the logic of the capitalist system, cannot quite bridge the gap between aspiration and reality.
How we are to transform the world as it is into the one that is required for ‘health equity’ is a question that cannot be addressed by the report head on. At various points, however, hints are given.
At one point, the authors note with approval that south Korea has guaranteed a minimum living standard for all its people, including provision for food, clothing, housing, education and health care in return for participation in public works, training schemes, etc. What we are not told is that this has been granted under the two-pronged mass pressure and struggles of the south Korean proletariat on the one hand, which has always been extremely militant, and that of the north Korean proletariat on the other, whose socialist system, created unprecedented levels of education, housing, health care and cultural provision for working people, even in the difficult economic circumstances of the last two decades.
Elsewhere, we are informed that trade-union activism is vital in protecting workers’ pay and conditions, or fighting for better ones, in what amounts to a tacit admission that, left to itself, the logic of free-market fundamentalism will only push workers further into poverty.
And, indeed, information is given that shows Britain to have the highest relative poverty rates for single parents and the elderly in the imperialist world, marginally higher even than those of the US. The report cites a study carried out in England among over 65s that found that the minimum cost of living to ensure a healthy life for pensioners is £131.00 per week (April 2007 prices), half as much again as the state pension for a single person (£87.30) or the means-tested (and therefore frequently unclaimed) pension credit guarantee (£119.05).
These are the rewards for a working class that has allowed its trade-union and labour movement to be hijacked by class-collaborating Labour-affiliated leaderships.
Ultimately, the report’s conclusions are based on a misplaced faith in the benevolence of the capitalist class, which is being asked to distribute its wealth more fairly. Inevitably, the report ignores the elephant in the room, ie, the domination of the means of production by a tiny ruling elite, which is forced by the laws of capitalist competition to continually increase its exploitation of the working class and peasantry.
However, despite the inability of the report’s authors to see past the limits of capitalism, and their consequent resort to hand-wringing and requests to the capitalists to be kinder and more caring towards the masses of the world, to divide their resources more equitably etc, this report’s conclusions are dangerous talk, for they place the blame for the poverty of the masses fairly and squarely on the shoulders of the ruling class, just at a time when they are more desperate than ever to create the illusion that workers’ problems are self-created (ie, because they are idiots), or that they are the result of a ‘strain on the country’s resources’ (ie, because there are too many immigrants).
Socialist and progressive countries show the way forward
While Sir Michael and his colleagues at the WHO wait in vain for the capitalist system to start putting the interests of the masses of workers above the desperate and unceasing quest of capitalist corporations for maximum profits, some of the positive stories hidden away in the text of the report give a clue as to the real solution to the insoluble contradiction between the demands of the market and the needs of the people.
In a section entitled ‘Ensuring equity from the start’, the report details how Cuba starts early on educating its children.
“Cuba’s Educa a Tu Hijo [Educate your child] programme is generally thought to be an important factor in Cuba’s educational achievements at the primary school level (Unicef, 2001). The programme, introduced in 1985, is a non-formal, non-institutional, community-based, family-centred ECD service under the responsibility of the Ministry of Education (Preschool Education). The programme operates with the participation of the Ministries of Public Health, Culture, and Sports, the Federation of Cuban Women, the National Association of Small Farmers, the National Committee for the Defence of the Revolution, and student associations.
“This extended network includes 52,000 Promoters (teachers, pedagogues, physicians, and other trained professionals), 116,000 Executors (teachers, physicians, nurses, retired professionals, students, and volunteers), and more than 800,000 families. During the 1990s the programme was extended, reaching 99.8 percent of children aged 0-5 years in 2000 – probably the highest enrolment rate in the world.” (Our emphasis)
So what is it that makes it possible in a poor country like Cuba to do what is deemed impossible in a rich country like Britain, ie, to give free and equal access to quality, community-based pre-school education to every single child, and to mobilise their families to active participation in that process too?
It is the same thing that ensures equal and free access to some of the best health care in the world, along with an unparalleled network of local health practitioners; the same thing that offers free lifelong education to every Cuban citizen and ensures jobs and decent housing for all: it is the socialist organisation of Cuba’s economy.
And if Cuba can deliver all this to its citizens in the teeth of a 40-year economic blockade, with only the meagre resources of a tiny island and a small population to call upon, how much higher a material and cultural existence would be enjoyed in Britain under socialism, where the natural resources and potential for wealth creation are so much greater?
The healthy life expectancy at birth for the average Cuban is 75 for men and 79 for women, while in Britain it is 69 for men and 72 for women. Moreover, in Britain, as we have seen, the variations that are covered by this average statistic are far wider.
Cuba spends 7.6 percent of her GDP on health provision, while Britain spends 8.2 percent, yet the Cuban provision, at $333 per person is a fraction of the cost of Britain’s, which in 2005 stood at $2,597 per person.
Socialist Cuba focuses on overall quality of life and provides jobs, houses and equal educational opportunities for all, despite its relative poverty and scant resources. Meanwhile, its medical system is geared towards promoting health rather than treating chronic and severe disease, with as many necessary medications as possible produced cheaply by the state.
Britain, on the other hand, pours millions of pounds of taxpayers’ contributions each year into the bottomless pockets of the PFI hospital builders, the subcontracting ‘service providers’ and the big pharmaceutical monopolies.
As if to emphasise the point that movements towards socialism are movements in the right direction, Brazil’s landless peasant movement is praised in the WHO report for its role in improving members’ health, under the heading ‘Creating fair employment and decent work’.
“In Brazil, 45 percent of agricultural land is held by around 1 percent of landowners, while around 50 percent of proprietors together own only roughly 2 percent of all arable land. About 31 million Brazilian people (18.8 percent of the total population) live in the countryside. These people, known as agregados, are extremely poor and suffer high rates of many psychosocial, educational, and health problems. In 1984, landless families organised into the Movimento dos Trabalhadores Rurais Sem Terra (MST), or Movement of Rural Landless Workers.
“MST is probably the largest social movement in Latin America, with around 1.5 million members. Its fundamental success has been the increasing number of landless families being allocated their own piece of land, rising from a few thousand to more than 300,000 in 2000 settlements. Research has shown that members of MST communities enjoy better health than other agricultural workers. The improved health of MST community members was attributed to a higher production of livestock, better nutrition (partly due to a greater diversity of produce), community support in case of need, and direct involvement in community decisions. MST has limitations but, from its inception, it has acted as a catalyst for reform – not only agrarian reform, but also reform of health, with a direct impact on governmental decisions, influence on public policies, and a role in the civil society council of the Bolivarian Alternative for the Americas.”
Meanwhile, the report cites privatisation of essential utilities such as electricity and water as key to undermining people’s access to healthy living conditions all over the world – privatisation that is a key mainstay of the global capitalist system and a founding principle of the IMF’s ‘structural adjustment programmes’. In other words, the major condition for the delivery of ‘aid’ to poor countries by this imperialist institution is that the country in question is required to open up its utilities and other nationalised industries to takeover by foreign corporations, who can then take advantage of their monopoly position in the provision of these utilities to make massive profits by jacking up their prices. The fact that such price hikes utterly impoverish many ‘customers’, or force others to do without essential electricity and water supplies altogether, is of no consequence whatsoever in a world geared to facilitate capitalist accumulation and profit-taking.
And it is not only third-world citizens who suffer when utilities are privatised. Since the sell-off of British Gas, British Electricity and the water board, the numbers of people being cut off has risen astronomically. More often, this is carried out at one remove – those unable to meet bills find a (more expensive per unit) meter installed (and are charged for the privilege). When they run out of money to pay for essential supplies, no-one has to come and ‘cut them off’, they simply ‘choose’ to do without themselves.
On all the key drivers for good health identified by the report, the poorest in Britain have seen a deterioration over the last 30 years. Not only they, but many currently better-off people can look forward to more of the same under the present conditions, as the overproduction crisis forces further austerity measures (ie, more wage and pension cuts, with many occupational and investment pensions disappearing altogether), and the drive to find avenues of profitable investment leads inevitably to the further privatisation of health and education.
The report stresses the importance of local practitioners, for example, pointing out that “Population health is better in geographic areas with more primary care physicians”, but in Britain today, the NHS is closing down many local GP surgeries in favour of fewer, centralised ‘primary care trusts’, run along business lines. This is the opposite approach to that seen in Cuba or north Korea, for example, where there are extremely high numbers of GPs per head of the population and everyone knows and lives near to their local GP.
Another factor identified by the report in reducing health inequality is social empowerment – the involvement of communities themselves in decision-making about use of health resources, as well as raising awareness of health issues and healthcare systems and mobilising health actions. Zimbabwe’s Community Working Group on Health is cited positively in this regard, which could not be further from the situation in Britain, where decisions are taken and resources allocated by and in the interests of big business and their government stooges and management consultants rather than by communities themselves, whether locally or as part of a national plan
Meanwhile, no hint is given as to how to tackle the vested interests of the big pharma, sugar or agribusiness monopolies in pushing expensive drugs and cheap yet nutrition-free processed snacks and foods.
It is not just a question of advertising and awareness. For a start, salt- and sugar-laden snacks are ubiquitous, sitting by the checkout of every supermarket, garage and corner shop, raking in billions in profits for the confectionery monopolies that produce them.
For many people, moreover, junk food is the only food available, not because they are inherently stupid or ‘prefer it’ (although undoubtedly, the one thing manufacturers of such garbage have succeeded in doing is making their products extremely addictive), but because it is cheap and filling and therefore appears to be doing its job.
Under conditions of capitalism, wages for the lowest-paid (and, in imperialist countries, that means those on benefits, too) are set at the absolute minimum level required for maintenance of the worker.
The hundreds of thousands of people on low wages or on benefits have no choice but to live in the cheapest possible accommodation, wear the cheapest possible clothes and eat the cheapest possible food, however detrimental to their health those things may be.
Is it surprising that, thrown onto the scrapheap and with no prospect of a decent job on the horizon, many embrace alcohol and drugs as offering at least a temporary respite from the apparent pointlessness of their lives and from the frustration of not being able to provide all that they would wish for their children?
The conclusions pointed to by the report are clear: if people are to enjoy the health and longevity that they are biologically capable of, they need to live in decent housing, eat healthy food, have equal access to decent, lifelong education from the earliest years, feel empowered to take decisions as part of a cohesive community, be gainfully employed and decently remunerated, be organised in their workplaces, have a tolerable balance between the demands of work and home life and have equal access to healthcare provision.
From the perspective of the imperialist world, where such things can only be dreamed about even by the richest nations, the idea that they could ever be delivered to everyone on the planet is simply laughable.
Each one of the measures required has only ever been granted by capitalists on the retreat – fearing the revolutionary upsurge of the proletariat and hoping to buy themselves time to regroup and stabilise before coming back on the attack to remove what has been temporarily granted.
If workers wish to create a society in which people are educated and empowered, with equal access to decent health provision, there is only one solution: they must do away with the anarchy of capitalist production for profit, with its inevitable crises and drives into horrendous and all-engulfing wars, and replace it with a socialist society, where resources are used for the benefit of all and production is planned to meet the needs of the people.
> Film: Sicko - October 2008
> Privatisation and fragmentation of the NHS has resulted in a debt that we continue to service - April 2008
> End in sight for National Health Service - August 2006
> Book - Save the NHS From Capitalist Greed