The Health of Nations

Towards a New Political Economy

Gavin Mooney

• Publisher: Zed Books
• Year: 2012
• ISBN:
  9781780320625
• Edition: 1
• Topic: Medicine
• Subtopic: Health Policy

Why, despite vast resources being expended on health and health care, is there still so much ill health and premature death? Why do massive inequalities in health, both within and between countries, remain? In this devastating critique, internationally renowned health economist Gavin Mooney places the responsibility for these problems firmly at the door of neoliberalism. Mooney analyses how power is exercised both in health-care systems and in society more generally. In doing so, it reveals how too many vested interests hinder efficient and equitable policies to promote healthy populations, while too little is done to address the social determinants of health. Instead, Mooney argues, health services and health policy more generally should be returned to the communities they serve. Taking in a broad range of international case studies - from the UK to the US, South Africa to Cuba - this provocative book places issues of power and politics in health care systems centre stage, making a compelling case for the need to re-evaluate how we approach health care globally.

PART I

Introduction

Introduction: neoliberalism kills

There is something desperately wrong with our health-care systems and with our societies when, in this amazingly rich world, there is still so much ill health and premature death. What is at least as wrong is that there are such enormous differences between the rich and the poor. Hunger is of endemic proportions; obesity too. But the latter gets so much more attention as it is a disease of the affluent who can corner the market for sympathy and health-care resources. There are too few headlines in hunger.

This state of affairs can be summed up in all sorts of ways. One particularly telling way is provided by the philosopher Thomas Pogge (2008):

Many more people – some 360 million – have died from hunger and remediable diseases in peacetime in the 20 years since the end of the Cold War than have perished from wars, civil wars, and government repression over the entire 20th century. And poverty continues unabated, as the official statistics amply confirm: 963 million human beings are chronically undernourished, 884 million lack access to safe water, and 2,500 million lack access to basic sanitation. 2,000 million lack access to essential medicines. 924 million lack adequate shelter and 1,600 million lack electricity. 774 million adults are illiterate. 218 million children are child laborers. Roughly one third of all human deaths, 18 million annually, are due to poverty-related causes, straightforwardly preventable through better nutrition, safe drinking water, cheap re-hydration packs, vaccines, antibiotics, and other medicines. People of color, females, and the very young are heavily overrepresented among the global poor, and hence also among those suffering the staggering effects of severe poverty. Children under five account for over half or 9.2 million of the annual death toll from poverty-related causes. The overrepresentation of females is clearly documented.

Specifically with respect to health care, there is the grotesque situation where the poorer a country, the more likely it is to have a smaller proportion of its health-care resources in the public sector. Yet having to pay for health care, which is much more likely in the private sector, increasingly dominates poor countries’ health-care systems, while this privatisation of health care in poor countries continues to be encouraged by the rich West and global institutions like the World Bank. In India, for example, little more than 20 per cent of the spend on health care is in the public sector.

The fact that poverty kills is clear, well known and easily understood. Yet so little is done about it. The fact that inequality kills is also clear, less well known and not so easily understood. Even less is done about that. And inequality is morally disgraceful. It could be addressed; it should be addressed. Yet, for example, South Africa, freed from the chains of apartheid in 1994, is more unequal today than it was then and is now one of the most unequal countries in the world.

Inequality within countries is also growing, with truly obscene levels of incomes in many Western countries – certainly in comparison to the incomes of the poor in low and middle-income countries, but also to the poor in their own countries.

Astonishingly, in Australia a very minor use of the tax system in the 2011 budget to redistribute income from the rich to the poor (after years of movement in the opposite direction and a growing gap between rich and poor) was met with cries of ‘class warfare’ and ‘the politics of envy’.

We are soothed by the appearance of efforts to do better. At a global level there are the Millennium Development Goals, the WHO commissions on Macroeconomics and Health and on Social Determinants of Health, and the World Trade Organization’s Doha Agreement to reduce world poverty. But success? There is some movement but it is tiny, as the rich world gets more obese and more unhealthy because of its own greed. The Doha Agreement, originally launched in 2001 with great fanfare and the intent to reduce world poverty, is still being negotiated ten years on. Even if it ever were to be enacted, according to best estimates it would produce greater benefits for rich countries than for poor (Hertel and Winters 2006).

These international global institutions are not genuinely world bodies in that they do not represent world citizenry. They are controlled by governments, and only the governments of a few rich nations. In turn these governments are often swayed by large corporations who seek to maximise their profits on the basis of a market system that is built on the false premise that this maximises the public good.

Yet worship at the altar of the market, and especially the neoliberal market in the wake of the fall of the Berlin Wall, is seldom seriously challenged. The Communism of the former Eastern Bloc is gone. Its departure is welcome, but the hegemony of neoliberalism that has replaced it is most unwelcome on a number of fronts. Here I focus on its perpetuating and fostering of ill health.

This book concentrates its criticism of macroeconomic and global economic systems on the political economy of neoliberalism. This is the form of capitalism that was ushered in in the late 1970s by President Reagan in the US and Prime Minister Thatcher in the UK, and heralded by the Washington Consensus. It is explored at greater length in Chapter 3. While the focus on that form of capitalism is appropriate in examining most of the issues in this book, since they primarily relate to modern times, capitalism has existed ever since the dawn of the industrial revolution in the eighteenth century, and some of today’s current ills – particularly global warming but also the continuing impact of colonialism – have their origins in those earlier times.

We know that solidarity and social cohesion are good for health and that individualism and inequality are not. Yet it is the latter that neoliberalism fosters. There remains debate as to whether neoliberalism fosters economic growth, since comparison with the counter-factual is difficult – and even more difficult when it comes to the impact on health. Whether economic growth is good for health also remains debatable. Poverty is bad, so lifting people out of poverty is good for their health. But the distribution of the benefits of economic growth are all too often skewed to the rich; ‘trickle down’ has been exposed as a myth. There is also evidence that how a society uses and organises its resources may have a greater impact on health than simply the level of those resources. The rich get the diseases of affluence, the poor of deprivation. Inequality seems to breed ill-health in society as a whole. It is those at the bottom, however, who really suffer – in terms of both health and humiliation. What is perhaps most humiliating for them is the seeming indifference of the rich to the situation of the poor.

Debates about health all too often centre on health care rather than the so-called social determinants of health – poverty, inequality, housing, transport, education, et cetera. This is especially true at a governmental level, where ministries of health are ministries of only health care. And too often, in the West at least, they are not about health care so much as illness care, their services dominated by hospitals. The idea of the social determinants of health, while given a boost by Sir Michael Marmot’s WHO Commission, has been slow to percolate through to health policy.

Neoliberalism brings with it low taxes. It also breeds freer movement of money and resources across national boundaries. The extent to which governments in a neoliberal world are any longer prepared to use taxes to redistribute income from rich to poor is severely limited. If the UK gets out of line on, say, its company taxes and becomes less attractive than other countries to profit-hunting industrial investors, then – so the argument goes – the UK will lose out on investment and thus on jobs. Similarly, seeking to increase levels of income tax, and especially to make income tax more progressive, is seen as likely to scare the brightest and best into moving overseas. There is a race to the bottom on tax rates, with company taxes declining markedly over the last couple of decades. Thus we learn that ‘The OECD average top (federal) statutory company tax rate fell from 44 per cent in 1985 to 31 per cent in 2004, on a GDP-weighted basis’ (Kelly and Graziani 2004: 24).

It was not always thus. I recall Conservative governments in the UK, in my early years, having a real concern to take care of the poor and disadvantaged – and that was when we were all much poorer than we are now. Between the West and the others on the planet today there is a massive barrier; and this despite the fact that our TVs allow us to see and almost smell the devastation wreaked by poverty across the globe – in Haiti, in so many African countries, or in the wake of the 2004 Boxing Day tsunami. The words of the Turkish writer Orhan Pamuk (2001) ring true: ‘The Western world is scarcely aware of this overwhelming feeling of humiliation that is experienced by most of the world’s population.’

The freedom of movement of labour internationally from poor to rich countries is problematic, as those who move are those with skills. Rich countries continue to steal doctors and nurses from, for example, sub-Saharan Africa. Again, bearing out the indifference highlighted by Pamuk, it is remarkable how little concern is expressed by governments and medical associations in the West at this process of adding to the global divide – especially in health.

The growth imperative – or the growth fetishism as Hamilton (2003) has called it – that drives this is born of neoliberalism. That economic thinking may well result in faster economic growth (although that remains unproven), but to be conducive to improved population health it needs to be accompanied by reductions in poverty and in inequalities. The neoliberal panacea of the ‘trickle down’ effect, the ‘rising tide that lifts all boats’, has not stood up to examination.

The behaviour of the pharmaceutical industry – ‘Big Pharma’ – and the way it exercises power over doctors and governments are deeply concerning. These issues have been exposed, but again what needs to be recognised is that these companies are acting according to the rules of the market place. Their goal is profit maximisation, not health maximisation.

This book is not intended in any sense as an attack on doctors as doctors, nor on medicine as a discipline. But when medical associations and the medical profession become political I have concerns. In individual countries the medical associations dominate debates about much more than medicine, and seek to speak with authority on matters of health. All too often governments treat them as spokespersons for the health of the population. In reality they are the doctors’ trade unions.

While the problem here may be created by the medical profession, and more particularly by their associations when they take on a political role, it can only be solved by governments being more ready to see these associations for what they are – organisations whose first and foremost interest is the well-being of the medical profession. Governments need to be prepared, instead, to serve the public whose health is at stake.

Decision making regarding resources for health must be understood as the exercise of power at two levels: health care and society. The power in health care currently rests all too much with the medical profession and the pharmaceutical industry, and all too little with the citizenry. That this needs to change is a major theme of this book.

The extent to which the medical profession is in the pockets of the big pharmaceutical companies is extraordinary, with massive amounts of money being used by the industry to ‘persuade’ doctors to prescribe their products. This is done openly, in the sense that we all know it happens – and yet somehow the practice and the culture have become acceptable. We know too that pharmaceutical companies have ghost-written articles for journals and then paid doctors to put their names to them, and this practice continues despite having been exposed. We know that drug trials that are funded by the industry are more likely to come up with results that are favourable to the product, but such funding remains the main source for researchers wanting to test the effectiveness of drugs. Too many academics have sold out to ‘Big Pharma’.

So many societies today – and the trend continues – are dominated by the market and large corporations. Very little power within so-called democracies rests with the people. Australia, for example, has seen the power of the mining industry exerted on government policy recently, when the industry’s $20 million campaign to stop a mining tax on excess profits denied the government $10 billion in annual revenue which had been earmarked to provide, inter alia, better health services. Another example is the influence of industry in seeking to undermine policy on global warming in many countries.

The problems that arise in dealing with these two issues – the dominance of the medical profession and the pharmaceutical industry in health care, and the dominance of corporate power in society – are the centrepiece of this book. It examines the reasons why we need to change, as well as what we need to change to.

The book also deals with the fact that my own sub-discipline of health economics – which in many ways ought to be well placed to analyse what is, in our terms, the inefficient and inequitable use of scarce resources – fails to do so. We have been caught like rabbits in the headlights of neoliberalism and cannot see an alternative. We have followed the doctors down the micro-clinical road and viewed health-care systems as only consequentialist – and very narrowly consequentialist, where nothing counts but health. We have not stopped to ask citizens what they want from health-care systems, perhaps because we are so tied to neoclassical economics that we do not see citizens qua citizens – only consumers. Our neglect of the social determinants of health is astonishing.

Can the changes be made? They need to be made and some suggestions are put forward. If I can convince the reader that the current organisation and financing of health care (like the economic basis of many of our societies) is bad for the health of the population, then the question of how to bring about change will become the key focus of health-policy debates. Currently it is not. That shift of focus is my main target in writing this book.

Map of the book

The book is in six parts. Between the introduction (Part I) and the conclusion (Part VI) there are case studies of the bad and the good, and some thoughts on solutions to the global problems of ill-health and premature death. These are massive problems and that is where we have started. The book does not dwell on them. Most readers will know of them already – though it is worth stopping and recognising anew just how big they really are, and how unfair, given the wonderfully good health of some and the miserable health of others.

Part II looks at why things are so bad. It examines policies on health care and on health and why these are failing. While it would be wrong to argue that there is a single cause of the malaise, I place much of the explanation for not doing better at the door of neoliberalism. This form of capitalism – which has increasingly dominated the world stage over the last 30 years and sees the market as the solution to virtually all the world’s problems – has direct economic consequences for health, but also broader social ones. It breeds inequality and individualism and discourages a sense of community and feelings of compassion. I have also examined the way it dominates our global institutions.

In Part III there is a series of case studies which serve to exemplify many of the points made in...

Table of contents

• Front Cover
• About the Author
• More praise for The Health of Nations
• Title Page
• Copyright Page
• Contents
• Acknowledgements
• Preface
• Dedication
• Part I Introduction
• Part II Why are things so bad?
• Part III Case studies
• Part IV Solutions
• Part V How things might get better
• Part VI Conclusion
• References
• Index