Abstract
This is the first of four articles that will outline sociological concepts that are of interest to medicine and the allied health professions. This article outlines how medical sociology makes sense of capitalism and its impacts on human health. Subsequent articles will discuss sociological perspectives on medical risk, standardisation and medical conspiracy theories.
Capitalism, what Marx called a ‘civilised horror’, is the most successful economic system that the world has ever known, and, possibly, will ever know. The sociologist Frederic Jameson once noted that individuals generally find it easier to imagine the end of the world than the end of capitalism. It is quite possible that capitalism will survive the end of human civilisation as we know it; perhaps it will survive the end of all human life. Capitalism in the 21st century has developed different strains, some of which are more aggressive than others. Individuals exposed to and structured by particular forms of capitalism often have no conscious awareness that they are in systems that were, at one point, created by human beings. In its most basic sense, capitalism refers to a socioeconomic system whereby resources and assets are controlled by private interests; or to put this another way, where private interests control the means of production. Individuals and institutions within this system are driven by a desire for economic gain and, hypothetically, by their own self-centredness. In capitalist systems, some individuals (workers) compete to sell their labour; others (capitalists) employ those individuals to produce commodities that can then be sold for profit, leading to the acquisition of capital, which can be reinvested to produce more commodities and capital, and so on and so on in a continual cycle. That is the theory anyway. This is changing in the 21st century with the emergence of advanced technologies and what has been referred to as ‘financialised capitalism’ whereby profits are increasingly generated by unreal financial instruments and intellectual properties that bypass the production of tangible commodities. 1 Although capitalism is often seen as being aligned with democracy, this is not necessarily the case; as an economic system, capitalism works perfectly well under autocracy and even in some supposedly socialist systems. Sociology was initially developed as a subject to try to make sense of modern industrial capitalism and its iatrogenic consequences.
Capitalism has produced significant health benefits for humanity. It has enabled countless people to be lifted out of states of absolute poverty, led to the dynamic production of innovative health technologies and products, and driven economic growth across the world. However, it has long been recognised that capitalism also threatens human and non-human health – in some ways, profoundly so. 2 Capitalist systems have experienced rapidly increasing levels of inequality since the end of the 20th century. 1 The widespread adoption/diffusion of a very uncompromising form of capitalism known as neoliberalism in the 21st century led to the corrosion of many health systems and the undermining of some forms of health professionalism, for instance leading to increased healthcare privatisation as well as deprofessionalisation – with healthcare workers sometimes moving from becoming independent self-regulating professionals to becoming an ‘aristocracy of labour’, in some instances becoming direct servants of corporate capital. 3 It also led to negative consequences for human health more generally – resulting from increased economic precarity and insecurity, and decreased lack of access to affordable health care. In effect, this is a Darwinian system where the economically strong survive and can access commodified healthcare and the economically weak, if they are not protected, suffer and perhaps die. Marx in fact recognised that these opposite states are highly related to one another, that ‘accumulation of wealth at one pole is … at the same time accumulation of misery … at the opposite’. 4 Capitalism is furthermore a highly volatile economic system, frequently experiencing economic crises and collapses that pose serious threats to human health and wellbeing. In the 19th century, Friedrich Engels developed the concept of ‘social murder’ to describe the morbidity and mortality that resulted from what he saw as the regular functioning of unconstrained capitalism.
Capitalism has a number of inherent features, therefore, that, if not controlled, make it potentially dangerous for human health and health structures. The first of these is its need to commodify all aspects of life and health. Healthcare can – and has – become a commodity to be bought and sold for profit under capitalism. Marx refers to the generation of profit from commodities, including commodified healthcare, as the creation of surplus value. In commodified healthcare, surplus value is created through several means: charging patients more; offering them fewer services; paying healthcare workers less; making healthcare workers work longer; employing fewer healthcare workers; and making healthcare workers process more patients. Even in relatively well-off states, privatised healthcare is a commodity that many people increasingly struggle to afford. If a hardline strain of capitalism takes hold within a healthcare system, it will often seek – if it is not regulated – to extract as much surplus value as it is let get away with, leaving many poorer patients to struggle to access care in a resource-starved health sacrifice zone. 5
The second concerning feature of capitalism is its prioritisation of the accumulation of profit. In capitalism, everything has a use value and an exchange value. Use value refers to something like an item’s inherent worth; exchange value refers to what it can be bought and sold for. Individuals and healthcare workers, as well as products, have exchange values; in fact, it could be argued that exchange value is their only really important value. As the capitalist, medical or otherwise, is in intense competition with other capitalists, he or she must display a ‘werewolf’s hunger’, 6 whose personal values are solely – or at least mainly – oriented towards accumulation. The capitalist must develop an ethic that sees workers – and increasingly patients – in terms of their exchange value even if this damages the physical or mental health of those workers/patients. Alternative perspectives that would view workers in terms of their use or inherent value must be rejected, or at least dampened, as this would undermine the creation of surplus value. One of the key ways of making this system work is accepting deep within the self that ‘hunger permanent among the working class’ must be ensured. 6 Additionally, whether the commodities that workers produce are harmful or beneficial to health, useful or useless, is almost irrelevant. Profit is all. The sociologist Max Weber referred to this general ethos, the drive to accumulate, as the spirit of capitalism; it is akin to a religious calling.
A related concern is the rationalisation that accompanies modern advanced capitalism. Rationalisation means that actors and systems under capitalism, including healthcare actors and systems, become focused on control, calculability and quantification, efficiency and, where possible, the replacement of humans with technology (as with no labour costs more surplus value can be created). 7 Actors within this system develop what Weber referred to as an instrumentally rational mindset; their focus is on achieving the most productive ends through the most efficient means. It is a mindset that seeks ‘possession, mastery and transformation’. 8 However, rationalisation does not mean rational in the commonsense understanding of the term. Rationalised systems are often irrational. One reason for this is that capitalism is involuted; its focus is on refining and controlling a world that it itself has created. Any byproduct of this system that capitalism cannot make sense of, or which comes with a cost that threatens profit, must be treated as externalities, even though it is these externalities, climate change, environmental destruction, breakdown of biodiversity, mental health crises induced by the products of surveillance capitalism 9 and so on that ultimately threaten human life and health on earth. 2 Instrumental rationality, when pursued to the extreme (as capitalism must be) ultimately leads ‘in the final analysis neither for profit nor for the well-being of the human race’. 8 Capitalism, however, is a system that is effectively addicted to rationalisation.
The fourth challenge to health is capitalism’s need for acceleration. Acceleration is a key feature of capitalism. 10 The quicker that capital can be converted to a commodity and back again, the quicker that surplus value can be created. The greater the pace at which workers operate the more surplus value can be extracted from the commodities that they produce. The quicker that financial capital can create and trade electronic products the greater the profit that they can be created. Health systems are reformed with greater and greater frequency in order to wring more and more (and possibly, smaller and smaller) financial and productivity efficiencies from them. Increased acceleration can lead to a focus on the present and on immediate returns and a discounting of the future – the place where most of the health risks that are generated by capitalism reside. Widespread acceleration creates systemic stress (healthcare systems are encouraged to process patients faster and faster, patients damage their physical and mental health – in Marx’s terms, use more and more of their life force – in order to work faster and faster) and can create a situation of ‘permanent liminality’, 11 an undermining of the stability that is necessary for human and health system functioning. Permanent liminality often results in a widespread sense of exhaustion and meaninglessness. Acceleration in capitalism is potentially limitless.
A fifth issue stems from capitalism’s status as a hyperobject. 12 A hyperobject is an object that is so spatially and temporally transcendent that it cannot be fully understood; individuals can only understand and interact with a component of it. Patients and healthcare workers do not interact with capitalism as a whole, only a particular strain of it that is manifested in a particular way in a particular time and space. As such, it is difficult to get a sense of what this system is doing to human and non-human health and healthcare beyond the immediate horizon, and to figure out how to ameliorate its effects; or alternatively, people might have a sense of what capitalism is doing to population health as a whole but struggle to understand its local manifestations. Individuals within this hyperobject often surrender their sense of personal agency before it, often feeling uncertain about how to even begin to comprehend this thing and its negative health impacts. Most people, including health professionals, probably never even try. Increasingly, the 21st century has seen the emergence of capitalist institutions and corporations that themselves are akin to hyperobjects. The emergence of these institutions stems from capital’s tendency to accumulate most strongly in places where capital has already accumulated. As such, while capitalism is, in theory, based on intense competition (and is experienced as such by many ordinary people, often to the detriment of their health), at another level its institutions – including medical corporations – tend to become oligarchic and unchallengeable for extended periods of time. Even the most powerful champions of capitalism have stated that oligarchic capitalism, ‘capitalism without competition, is not capitalism … it’s exploitation’. 13
What do healthcare professionals do about this system? Perhaps the first thing is trying to begin to recognise what it is, in its positive and negative manifestations as these relate to health. The genuine alternatives to capitalism are unclear – in the 20th century, the clearest alternative was totalitarian socialism, ostensibly putting the lessons of Marx into practice, which led to mass deaths, mass imprisonments, the corruption of psychiatry and imperialistic ideological aggression across the world. Marx himself would have been horrified by systems that most directly adopted his concepts. Today, there are various specific proposals across the world that are seeking to control unregulated capitalism and its negative health consequences. These may be resisted by global financial elites, including medical corporations. Perhaps another way of thinking about these issues is to return to first principles, to ask not what medicine can do about capitalism, but instead asking what capitalism can learn from medicine. The key teaching of medicine is to first, do no harm. To place a limit over the individual’s actions. Somehow, if we are all going to survive the 21st century, capitalism will need to absorb this lesson, to develop a new spirit 14 to place a limit on its limitless drive for profit. Otherwise, it is entirely possible that capitalism will not take us to a place of health. It will take us somewhere else entirely.
