Naming the Problem

We have all seen the argument. It can come in different forms, but the fundamental point remains the same. Show a plot of the increases in life expectancy during the past 200 or so years. Point out when the Industrial Revolution happened. Then say, “Thank you, capitalism.” For one example of this argument, consider an article published by the libertarian CATO Institute:

“Capitalism has liberated us from back–breaking agricultural and domestic toil, reducing average hours worked considerably. Crop yields have risen. Undernourishment has collapsed. Access to electricity has dramatically increased. Global average life expectancy rose from 52.5 years in 1960 to 71.6 in 2015 alone.” ¹

The argument is clearly not scientifically sound. We all know that correlation does not mean causation. Even if there is some arbitrary point that can be defined as the “beginning” of capitalism, the question still remains about the extent to which any positive changes in well-being and health can be attributed to capitalism itself.

However, the fact remains that life expectancy globally has increased dramatically over the past 200 years. ² So explaining why these advances have occurred is important both to ensure that these gains continue and so that these improvements can also occur in parts of the world that have not experienced similar growths in life expectancy.

Fortunately, Steven Johnson makes a compelling case in Extra life: A short history of living longer for the variety of advances that have resulted in improved life expectancy over the past 200 years. In each chapter, Johnson documents an innovation that he argues contributed to these improvements in life expectancy. Far from suggesting that these advances are due to capitalism, Johnson's book suggests that it has been capitalism itself that has created some of the most persistent challenges to health. In turn, many of the advances that have helped us live longer required actions of activists, doctors, and public health practitioners to counter these effects.

As Johnson describes early in his book, for most of human history, especially since the agricultural revolution, there were no major changes in life expectancy: “millennia pass with almost no meaningful change, followed by a sudden, unprecedented spikes over the past two centuries (p. xxxi).” When these changes did begin to occur, they were not shared equally. While such a sad fact seem obvious to us now, where we have witnessed the most pernicious effects of the COVID-19 ³ along with many other causes of death, like heart disease ⁴ and cancer, ⁵ fall disproportionately on the poor and disadvantaged, the reality of inequitable increases in life expectancy was not always apparent. In the 1960s, Johnson describes how researchers using death records from the British Aristocracy found how unequal life expectancy was:

“After two centuries of statis, right around 1750 the average life expectancy of a British aristocrat began to increase at a steady rate, year after year, creating a measurable gap between the elites and the rest of the population. By the 1770s, British peers were living on average into their mid-forties. They crossed the threshold of the fifty-year mark at the dawn of the nineteenth century, and by the middle of Victoria's reign they approach a life expectancy at birth of sixty.” (p. 21)

These patterns still remain. Even as much of the world has transitioned from a primarily feudal and agrarian economy to an industrial, capitalist economy, inequitable patterns of health improvement have remained. These disparities exist on different scales. Life expectancy in wealthier countries is greater than among the poorest countries, ⁶ although economic inequality ⁷ may be a more important predictor of differences in life expectancy between the wealthiest countries. Within the wealthiest countries, gradients in health between the richest and the poorest remain. ⁸

As the book documents, there have been improvements, but many of them occurred despite the logic of the free market. Consider one of the first examples discussed by Johnson—improvement in the safety of milk. As Johnson documents, in urban areas milk producers used a variety of unsafe methods to produce their product in an environment that was not optimal for such production:

“The cows would be tied to a single stall for their entire lives, while boiling slop from the distilleries was poured into a trough in front of them. Feeding the cows exclusively swill—the dairy producers even withheld water from the animals, thinking that there was sufficient water in the distillery waste—triggered ulcerated sores and caused their tails to fall off. Bus as gruesome as this process was, it did manage to produce copious amounts of milk, which the dairy producers adulterated with calf, flour, and eggs to make it look more like “Pure Country Milk”—the misleading branding they used to describe the product. The combination of the adverting and the cheap prices—as little as six cents per quart—soon had the working classes of Manhattan and other cities around the country hooked on swill milk. And almost immediately children began dying at a terrifying rate.” (p. 98)

Altering these unsanitary conditions required direct intervention from the government to regulate the production of milk. But even here, efforts in Chicago and other jurisdictions to require the pasteurization of milk were slowed as the milk industry used its finances to buy off politicians who might favor stricter regulation.

Where life-saving interventions did emerge in private industry, it was not without resistance. As automobile fatalities increased with the increasing use of vehicles for transportation, the initial reaction of the automobile industry was not to find solutions to the problem but rather, as Johnson writes, to: “[throw] up its hands. Automobile fatalities were inevitable, they argued. It was simple physics. The forces in a crash were too great, and the human body was too fragile” (p. 175).

When innovation did eventually emerge, it was from Nils Bohlin's invention of the 3-point restraint system while working in Sweden for Saab, not from car manufacturers in Detroit. Fortunately, following the example of Jonas Salk, who famously declined to patent the polio vaccine, ⁹ Bohlin and Volvo also did not patent their seatbelt design, but rather made it freely available. One wonders how many lives would not have been saved had Volvo patented the 3-point safety belt design.

In Johnson's book, he brilliantly documents how, as he writes “progress is not merely the result of scientific discovery. It also requires other forces: crusading journalists, activism and politics. Science alone cannot improve the world. You also need struggle” (p. 100). What he does not do is explicitly name the problem that often forces this struggle: capitalism.

In the chapters of Extra Life, the forces of capital and profit are often an impediment to saving lives. We can see this same problem in the modern world, where the profit motive has often prevented vaccine companies from sharing their vaccine patents, ¹⁰ frequently produced with state-support, with less economically developed countries. Even more insidiously, sometimes the profit motive even incentivizes businesses to act in a way that threatens life. Perdue Pharma marketing their opioid painkiller oxycontin in a deceptive manner in order to sell more pills ¹¹ and thereby contribute to the opioid epidemic is perhaps the best example of this tendency.

We have reached a strange point in the United States where even for several years before the COVID-19 pandemic life expectancy has declined, ¹² in contrast with decades long trends that Johnson describes in his book. Now in the years since the pandemic these declines have accelerated with a particularly acute effect among Black and Native Americans. ¹³ These prepandemic declines were tied to drug overdoses, suicides, and alcoholic liver diseases, famously termed by the economist that first documented these patterns—Anne Case and Angus Deaton—as “Deaths of Despair.” ¹⁴ Deaths from these causes has fallen disproportionately on the working class, ¹⁵ especially those in physically demanding and less secure jobs. ¹⁶ The places where globalization has resulted in the biggest declines in manufacturing have often fallen victim to these deaths more than other parts of the country. ¹⁷

Many of the forces that have driven risk for mortality during the pandemic were also tied to the profit motive. Pandemic deaths among working-age people fell on workers employed in nonremote jobs ¹⁸ and essential industries, ¹⁹ which disproportionately employ workers of color. ²⁰ Companies compelled workers to work in unsafe environments. Only briefly did the government provide for the humane option that almost every country on earth offers, paid sick leave so that time could be taken off from work while sick without the fear of losing one's livelihood. In one of the most callous cases management at Tyson Foods, a meat-processing company where many outbreaks of the virus occurred, management took bets on how many of the plant's workers would contract the disease. ²¹ This same relentless pursuit of profit is also threatening human health in other ways, including the devastating health effects of climate change driven by fossil fuel companies.

As Johnson's book relates, understanding and preventing premature mortality has required us to identify the fundamental causes of this premature mortality. In a similar way, it is necessary to identify and indeed name a central factor that increasingly compels us to de-value what should be among the most important aspects of life: health and well-being, namely our profit-centered economy. As we study and understand this factor, we can hopefully, with the support of science and activism, which compelled other changes in the past, begin to control it.