The recent revelation that Tory cuts led to 130,000 preventable deaths has reignited a debate about health inequality. What does your new book say about what’s behind it?
The central message is that health is socially determined.
The dominant definition of health has been a “biomedical” one, which sees health mainly as the relationship between human biology and nature.
Of course natural diseases are part of the picture, but much more importantly health is a product of the societies we live in.
It’s determined by the diet we have, by the sort of housing we live in and by our income. In the US poor diets directly contribute to around 678,000 deaths every year and the indirect contribution is not calculable.
IT workers in Hong Kong are running a campaign called 996 ICU. Their message is that if you work from 9am until 9pm for six days a week you end up in the intensive care unit.
The way that societies are organised shapes our health.
Why is neoliberalism important?
Healthcare is fast becoming a commodity.
The US privatised health service has been sold as the way to run health services across the world.
In Britain the impact of that has been the fragmentation of health and social services.
Since the 1990s and the rise of Tony Blair and New Labour, the direction of travel has been more private involvement in healthcare.
That’s when Private Finance Initiatives (PFI) really took off across the NHS.
You had private companies build hospitals, then the NHS pay to rent the buildings.
That’s since been extended to all sorts of health services, which have to be put out to tender.
And it’s a similar story in social care. The “independent sector” grew from providing just 5 percent of services in 1993 to 89 percent by 2013.
This widens the health inequality gap, because some people can afford to go private and get the best health services.
Alongside private health provision growing, we’ve got an ever decreasing public health provision. A number of reports have said austerity is responsible.
One points out how life expectancy increased since the Second World War, but that increases in the US have now ended.
Life expectancy has also stopped improving in Britain and for some groups it has decreased.
You describe the NHS as a revolution half-made. What does this mean?
Before the Second World War there was a widespread recognition that health provision in Britain was substandard.
It wasn’t even good enough to ensure that British capital had a fit and healthy enough workforce.
A leading voice was the Socialist Medical Association (SMA), which tried to establish principles that a public health service should be based on.
It set out a vision of a national service that was “preventative as well as curative” and which would tackle health inequality.
There would be local democracy, with health services provided in tandem with local authorities. And there would be a salaried doctoral staff, not one with private practice.
By the early 1930s the Labour Party had pinched the ideas and put them into its manifesto.
An Emergency Health Service (EHS), which was state-run, was set up at the beginning of the Second World War.
And it was a preventative, as well as curative service, as the government put in broader policies.
Food rationing, for instance, actually saw an improvement in diet for many people.
There was a much greater potential for the NHS when it was set up in 1948. But a lot of the old pre-war thinking then came back.
The Labour health minister, Aneurin Bevan, said he had to “stuff the doctors’ mouths with gold” by letting them keep private practice.
The democratic and preventive elements were abandoned.
In some ways, it was a step back—the SMA talked about it as the “National Illness Service”.
The Labour government, with a big mandate and supported by a very active working class, didn’t need to stuff anybody’s mouths with gold.
The NHS is still a world leader in standards of provision—and we have to defend it—but it could have been so much better.
When do genuine changes happen?
Science in general, but also medical science, tends to move along at a regular pace.
But there are periods when big developments happen. And these often coincide with great leaps forward in society generally.
One of the figures I look at in the book is Thomas Sydenham, an English doctor in the 1600s.
Sydenham thought that medicine could progress by monitoring therapies and patients, and he developed new treatments for diseases such as smallpox.
As the English Revolution of the 1640s tore the old society apart, it tore apart the ideas that had governed it. The French Revolution of 1789 saw huge changes in ideas about how the state can intervene in health.
The Russian Revolution of 1917 saw working class people briefly take political power. It points to how social revolutions can throw open ideas as the old society is uprooted.
There were huge strides as resources were directed to health.
You can see that, whether it’s health centres and spas for ordinary people or training workers from factories to deal with the shortage of doctors.
What sort of policies do we need to tackle health inequality?
If you follow a socially determined health approach, you need to address social problems that are causing poor health.
Any future society needs to address what’s causing bad health. We’ll need better diets, housing and working conditions that are good for health.
Yet, as I explain in the book, for the majority of people working under capitalism this means being “exploited”.
This describes a process where workers don’t get back the full amount of the value they have created.
So exploitation, which is central to capitalist production, makes us ill. Through the process of being exploited, part of us is taken away and we don’t have control over what we create.
We need to end the system of exploitation.