By Steffie Woolhandler and David Himmelstein
Monthly Review, September 2012
Howard Waitzkin, “Medicine and Public Health at the End of Empire” (Boulder, Colo.: Paradigm Publishers, 2011), 256 pages, $25, paperback.
For the past three decades Howard Waitzkin has been (along with Vicente Navarro) the leading social medicine theorist in the United States. “Medicine and Public Health at the End of Empire” provides a superb sampling of Waitzkin’s wide-ranging work, and a readily accessible introduction to the searching insights offered by a Marxist view of medicine.
Trained as both a sociologist and physician, Waitzkin’s career has melded clinical involvement as a primary care doctor in oppressed communities with writing and activism, in both the United States and Latin America. He currently works with GIs resisting military deployment.
Much of the book is devoted to meticulous delineation of the myriad ways that globalized capitalism creates the social conditions that make us sick and puts a straightjacket on the health system’s ability to respond.
In an initial chapter, Waitzkin reviews the historical role of seemingly benevolent foundations (e.g., Rockefeller) and international health organizations in smoothing the way for the imperial project. He then traces the emergence of the tradition of revolutionary social medicine from Frederick Engels through Rudolph Virchow (a 19th-century German physician, much-revered in the mainstream of medicine as father of modern pathology) and Salvador Allende (who was a physician before becoming Chile’s first socialist president).
Engels, in his “Condition of the Working Class,” chronicled occupational conditions such as lead poisoning, black lung, and repetitive stress injury, and he also observed that the noxious conditions in English factories sickened the surrounding communities — prefiguring much of the modern work in environmental and occupational medicine. Virchow’s classic investigation of the social origins of cholera and tuberculosis epidemics was reflected in his ardent support for the uprisings of 1848. And Allende, long before emerging as a world-renowned political leader, made major contributions both as a theoretician of the social origins of ill-health and as a practical innovator when he served as Minister of Health in Chile. Waitzkin reminds us that the recent discovery of the “social determinants of health” is merely a rediscovery, generally in defanged form, of these earlier vibrant understandings.
Waitzkin brilliantly exposes the forces that pushed the development of (highly profitable) coronary care technology and assured that this unproven technology overwhelmed alternative approaches to the modern epidemic of heart disease. Indeed, Bernard Lown, who features prominently in Waitzkin’s tale as a founder of the intensive care approach to heart attacks, often decries the damage wrought by the focus on medical commodities and high-tech interventions in cardiology, and the concomitant neglect of the human beings who house the hearts.
Much of the book focuses on Latin American health politics and social medicine. Waitzkin offers hopeful glimpses of progress in Cuban health care and in social medicine in Brazil, as well as a bleaker portrait of the reversals in Chilean health care, first under the U.S.-backed dictatorship, and more recently due to the continuing domination of neoliberal policies.
He explores the unifying features of the efforts to make profit, rather than health, the ends of medicine. His carefully documented analysis of multinational firms, the World Bank, international trade and health organizations, and major philanthropic foundations demonstrates that the commodification of medicine represents a collective project of empire.
Waitzkin’s critique of neoliberal health policies is fleshed out by meticulously documented case studies of international managed care firms’ efforts to penetrate Latin America and the health care privatization that has paved the way for profit-making. In some nations, public-sector social-insurance systems have succumbed to the onslaught, and have been transformed to for-profit insurance and delivery schemes (a situation mirrored in the United States by the 2003 Medicare “reform” that pumped $50 billion annually in public dollars into managed-care firms). But in other countries, popular movements have mounted successful resistance to the efforts to wrest health care from public or quasi-public control. Waitzkin details the hard-fought struggle to preserve and strengthen public-sector health care in El Salvador; the victories of Bolivia’s indigenous communities against corporate efforts to privatize water systems; and the health successes wrought by Mexico City’s left-leaning local government. Nor does he neglect the United States, reiterating the importance of the ongoing struggle to achieve a single-payer health care reform.
Ultimately, “Medicine and Public Health at the End of Empire” is a hopeful book, persuasively reminding us that capitalist society, and particularly capitalist medicine, generates cogent discontents, oppositional social forces, and hence the seeds and motive force of its own transcendence.
Steffie Woolhandler, M.D., M.P.H., and David Himmelstein, M.D., are professors of public health at City University of New York, visiting professors of medicine at Harvard, and co-founders of Physicians for a National Health Program.