By Adam Gaffney, M.D.
From the Introduction
Thus, where the human right to healthcare is indeed a recent rhetorical convention and ethical notion, ideas and practices around the right to healthcare – that is, around healthcare universalism – stretch back considerably further. Yet a conceptualization of a “right to healthcare” developed over time in tension with the far more typical practice of providing healthcare as a commodity or consumer good. In some moments and places, healthcare was conceived of and provided by right on the basis of needs; more typically, it has been a service sold on the basis of means, like other commodities.
The first aim of this book then is to trace what might be termed a healthcare “rights-commodity dialectic” through history…
The second aim of the book is to examine how healthcare rights are realized. Where and why rights to healthcare goods were fought for – and achieved – relates little to changing interpretations of rights and more to political struggle and economic change. Though ideas about equality have existed since antiquity, constituencies strong enough to challenge social, economic, and, indeed, healthcare inequalities have usually been too scattered over time and space to challenge the status quo in a meaningful way. Potent proposals for social welfare, including healthcare, most often arose when such constituencies became sufficiently mobilized to at least be perceived as a credible threat: examples in Europe include (among others) the eras of the English Civil War, the French Revolution, the Revolution of 1848, and the years following the Second World War; in the United States, such periods include the New Deal era and the Civil Rights era; and in the developing world, as we will see, revolutionary moments during the post-colonial period were most critical (to generalize broadly). The emergence of such political challenges, in turn, can only be understood in the setting of innovations, disruptions, and profound strains imposed by an economic system that evolved not gradually, but in great fits and starts, whether that be the advent of industrial capitalism in the nineteenth century or of economic crises like the Great Depression in the twentieth.
Similarly, the successes and the failures in the achievement of the human right to healthcare in the twenty-first century – the healthcare right-commodity dialectic today – have to be understood in the context of the latest stage of global economic history, what is often called “neoliberalism.” The mobilization of corporate power in the past few decades has often served to substantially favor the commodification of healthcare services throughout the globe, to constrain the vision of universal healthcare reform in the United States. Still, the story is by no means all negative: during these very same decades, there have been activist movements and even major political achievements that have helped enhance the right to healthcare, in ways small and large, in countries throughout the world.
The fate of the “right to healthcare” – whether it will rise to a universal reality, remain a privilege for some classes or some nations, or shrink to little more than pleasant but irrelevant rhetoric – will, in the final analysis, depend on the outcome of such struggles.
From Chapter 3: Public Health, Social Medicine, and Industrial Capitalism
One day during the cold Scottish spring of the year 1838, three impoverished women – all out of work, all with young children – were seen by the physician William Pulteney Alison. Alison cam from an established family and was a very prominent physician in Edinburgh. Yet throughout his career, Alison had also served as a physician to the poor.
All of the women, he later recounted, were living in a “miserable state of destitution.” There was little relief to be had from the public purse: the nineteenth-century Scottish Poor Law, even in comparison to the English Poor Law, was notable for its draconian frugality and largely voluntary system of funding. And so, when the women were denied admission to the local workhouse, they – and their infants – were essentially left to their own meager resources. After several weeks of “severe suffering,” as Alison noted, all of the children – presumably from some combination of cold and malnutrition – were dead.
Alison told this story in his 1840 “Observations on the Management of the Poor in Scotland, and Its Effects on the Health of Great Towns.” In this book, he does not simply bemoan the inevitable sadness of life, but instead counters the establishment Malthusian notion that attempting to improve the condition of the poor through public aid would not be useful, and indeed would only worsen their moral condition. Alison seemed to find such arguments repulsive. Reflecting back on his encounter with the three women and their children, he thought the neglect of the poor was shameful, and that the resultant loss of life was as preventable as it was reprehensible. “If any one supposes,” he wrote with more than justified acidity, “that the effect of this sacrifice of innocent life was to improve the morals of these women or their associates, I can only say, that he knows nothing of the effect of real destitution on human character and conduct.” What they deserved was neither moralistic rejection nor the unpredictable provision of voluntary charitable relief, but instead the supply of relief by public provision, by way of right. Alison advocated a relatively more expansive system of welfare for Scotland, which would be supported by taxation and include medical staff to treat the sick poor.
In March 1848, unrest broke out in Berlin, a turn of events that brought (Rudolf) Virchow, eager to be involved, back to his city. Indeed, soon after his return, Berlin was in full revolt, and he did not hesitate to join the barricades. Following the initial success of the Berlin revolution, Virchow then became involved in the Prussian “medical reform” movement, and with a friend, Rudolf Leubuscher, started a journal of that name. In the first issue of his journal, Virchow put forth the egalitarian aims of the movement. “Medical organization is to be reformed not so much for the benefit of physicians as for that of the patients,” he wrote, and later continued with the argument that “physicians surely are the natural advocates of the poor and the social problem largely falls within their scope.” In subsequent issues, his articles dealt with a wide array of social and political issues connected to medicine. He argued against capital punishment, for the gradual end of war, and in favor of a variety of reforms ranging from social welfare and the regulation of working hours to periodic physician recertification. He also touched poignantly on the notion of a right to health and healthcare that government is responsible to ensure, arguing that “the concept of all having equal rights to healthful existence follows form the definition of the state as the moral unity of its members, i.e. of individuals enjoying equal rights and obligated to act in solidarity. The endeavor of the state to implement these rights mainly falls to the Public Health Services.”
By Don McCanne, M.D.
There is much discussion today about the right to health care. Adam Gaffney provides us with a thoroughly researched history of the sociological and economic considerations of the concept right up to the present day. He provides us with a springboard not simply for the rhetorical dialectic, but, more importantly, for what use we make of our knowledge of what has transpired and use that to make this a better world, not just for our health and health care, but with the more ambitious goal of achieving social justice for all.
Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.