The Political Ecology of Disease

Item

Title
The Political Ecology of
Disease
extracted text
Health Bulletin No. 1.

The Political Ecology of
Disease
—Meredeth Turshen

HEALTH AND SOCIETY GROUP

This is the first issue of our health bulletin series.
We have reprinted this article from ‘The Review of
Radical Political Economics’, Spring 1977. The arti­
cle is an approach to analyse the model of clinical
medicine and inadequacy of medical definitions of
health and disease. While considering the relation
between environment, disease and man, author
points how political and economic factors were
rejected as irrelevant to medicine. The article also
reviews the relation of health status and class strug­
gle considering mainly England during the indus­
trial revolution and rise of capitalism.
We have chosen this article with the hope that it
will initiate a discussion on the relation of health
and politics.
October 1981.

”nMh",,lu‘TY>^MiUNITY HEALTH CELL
326. V Main, I Block
Koramongala
Bangalore-560034

Introduction

India

The critique presented in this article is developed from
some basic propositions of a political economy of health. These
propositions, in turn, are derived from an attempt to specify
historically the development of health services and concepts
of health and disease. The purpose is to show that, even at its
most progressive limits, the paradigm of clinical medicine—
which is currently the universally recognised model of medical
science —persists as an individualistic, class-biased, and ideo­
logical mode of diagnosing, treating and preventing illness.
The first proposition is that the theoretical assumptions on
which medicine is based are subjective This is because science
is subjective and medicine is a branch of science. Science is
subjective because the development of scientific knowledge is
an integral part of human development. Both scientific and
medical knowledge depend on material production and reflect
the social organisation of that production, not an ahistorical
objectivity. Expressed differently, a body of scientific know­
ledge such as medicine is a systematic approximation of
of reality, but neither equivalent to nor the same as reality
itself. One must distinguish two aspects of scientific knowledge
— the degree of exactness with which science approximates its
cognitive object, and the relation of science to reality, which
can only be expressed in terms of adequacy, not in objective
terms1.
From this proposition follows the theory that contempo­
rary medical definitions of health and disease are inadequate
because they are abstraction derived, for specific historical
reasons, from the clinical study of the individual. The defi­
nitions are inadequate expressions of the relation of medical
stat
llnesses) to reality, since individuals are not clinical
enti
In reality the human essence is the product of
an <
I- of social relations. ’ The clinical model does not

3

encompass the social relations of the individuals it studies,
even at its most progressive limits.
The first part of this article is built around this proposition
and supports the theory by connecting the values and under­
lying paradigm of the medical profession to the forms of
economic organisation that characterise capitalist social life.
The connection between these three factors—values, the
medical modes, and prevailing social relations—is dynamic
and takes different shapes at specific periods of history in
relation to distinct modes of production. The focus here is on
nineteenth century Europe as the industrial revolution and the
capitalist mode of production were transforming the connec­
tion between health and society, as well as every other aspect
of life.
The second section considers the emerging public health
practice in the nineteenth century in the context of industri­
alisation, and asseses the extent to which medical concepts
of disease were designed to meet the health problems of the
bourgeoisie, not the entire population and to offset the threat
posed by radical public health doctrines.
The conclusion of the article speculates on the extent to
which the success of bourgeois definitions of health in indus­
trialising countries rested on the world-wide expansion of
capitalism. Imperialism and medical ecology, for example
emerged as simultaneous attempts to exploit changing material
relations in Europe and the third world, and they are
inextricably linked.
The paradigm of clinical medicine
This section explores the limits of the clinical paradigm
that has defined disease and health for centuries. This para­
digm takes individual physiology as the norm for pathology
(as contrasted with broader social conditions) and locates
sickness in the individual’s body. A typical nineteenth
century variant held that every illness was the disturbance,
exaggeration, dimunition or cessation of a corresponding
normal function3. In this view, treatment readjusted the
body until its physiological norm was restored, a mechanistic
4

approach that reduced the body to a machine whose organs
could be discretely examined and regulated. Implicit in this
notion was the concept of health as the absence of disease. No
positive concept of health was advanced.
The clinical perception of disease could not have emerged
in the nineteenth century if the science of quantification had
not been developed earlier, since it depended on operational
verification by measurement, clinical study and experiment,
and evaluation according to engineering norms. Quantification
can be traced back to Isaac Newton (1642-1727) and Rene
Descartes (1596 1650), whose ccntributions to mathematics
and mechanics became the basis of a quantitative and geo­
metric description of the material world and of human
beings4. The medical quantifiers of the nineteenth century
placed sickness in the center of a medical system that was a
mechanised framework for the investigation of the mechanical
troubles of tl.e human body5.
Foucault, in his study of the origins of modern medicine6,
makes the interesting observation that, until the end of the
eighteenth century medicine was more concerned with health,
with qualities of vigor, suppleness and fluidity that were lost
in illness and had to be restored, than with normality, an
analysis of regularity, the search for functional deviation, and
the return to an equilibrium. Foucault suggests that, from
this early concern for health there followed not only an inte­
rest in nutrition but also the possibility of self-help, since
the sick person could treat himself or herself by following a
certain diet. Nineteenth century medicine, by contrast,
with its emphasis on the normal functioning of an organic
structure, required a knowledge of physiology for its practice.
In this view, the life sciences in the nineteenth century were
built, not on the comprehensive and transferable nature, of
biological concepts, but on the opposition of health and
illness.
The proximate source of the clinical paradigm was the
hospital base of the medical perception of reality. During the
nineteenth century, the hospital became the place whore

diseased people were housed, diseases were identified and a
census of diseases was kept. Along with sickness, health
acquired a clinical status, becoming the absence of clinical
symptoms7.
Since the nineteenth century, medical knowledge has been
expanding rapidly, and, undoubtedly, clinical medicine
accounts for the largest part of that expansion. Two other
major developments are discernible : the opening of new
branches of medical science and, simultaneously, the absorp­
tion by clinical medicine of older disciplines that were not
traditionally medical. The first trend is best exemplified by­
microbiology, which has its roots in the seventeenth century
discovery' of the existence of microscopic organism the second
by psychiatry, which was traditionally' a branch of philosophy.
These developments have in common the use of the paradigm
of clinical medicine.
In the past few decades, and with increasing momentum,
the clinical paradigm has come under attack on medical and
social grounds8-11 specific attaks on its use by' psychiatry'
now appear frequently12-14. Regrettably, its application to
nutrition has been attacked by only one major critic Josue
de Castro15. Despite criticism of the practice of medicine,
the cost and distribution of medical services and the power of
providers’0-'’, few analysts have exposed the political compo­
nent of the clinical model or the ideological assumptions on
which it rests. As a result, there is no adequate account of
why the clinical paradigm has had such pervasive influence
on contemporary society.
One way' to approach the spread of the clinical medical
paradigm —a phenomenon sometimes referred to as the inedicalisation of society—is to arrange various medical disciplines
on a continuum extending from death at one end to health at
the other (see diagram). The reason for selecting this gamut
DIAGRAM

Social and
Clinical medicine,
Environmental
preventive medicine
sanitation
pathology, etc
1
1
1________
1
DISEASE
death

6

Medical
ecology
1
1
HEALTH

is that it reveals an interesting trend about the individualistic
bias of thd model. Initially, the clinical paradigm appeared
in association with disease, but eventually it came to dominate
the entire spectrum. The placement from left to right is both
chronological, in terms of the historical development of the
selected disciplines, and spatial, in terms of moving from
single organs to the world.
Social and preventive medicine extended the clinical model
in the direction of health, expanding its application from the
individual to his or her family and immediate environment.
Environmental sanitation reflects a further extension to the
wider physical milieu : environmental sanitation is the study
of disease based on bourgeois epidemiology, i.e, the classical
triad host, disease agent, and environment. It is in no
sense a study of collectivities. Insofar as these disciplines
remained dominated by the clinical model, none seems to
grasp the notion of collectivity, without which there can be
no adequate difinition of health. The discipline that comes
closest is medical ecology, and perhaps here is where the limits
of the medical model might best be explored.
The Limits of Medical Ecology
The dictionary defines ecology as the ‘ science of the
economy’ of animals and plants ; that branch of biology' which
deals with the relations of living organisms to their surroun­
dings, their habits and modes of life, etc.20. The relations
arc clearly two-day : surroundings affects plants, animals,
peoples and institutions, and these organisms have an impact
on their surroundings. The study of people’s impact on their
environment has dominated discussions of ecology' in the last
decade.
The idea that the human environment is a complex inter­
acting web has been accepted in the biological and social
sciences since the time of Darwin. Use of the concept entails
analysing natural phenomena in the context of their total
environment. This theory of holism rarely directs studies of
human ecology11, because many hidden assumptions preclude
the consideration -of cardinal social and political factors.

7

Enzensberger, in his critique of ecology, points out how
recent studies (e.g., the hasty global projections of the club of
Rome i fail to consider the complexity of relations between
people and their environment. He traces this failure to the
use of narrow biological methods in the analyses of problems
that are broadly social. “For in the case of man, the medi­
ation between the whole and the part, between subsystem and
global system, can not be explained by the tools of biology.
This mediation is social, and its explication requires an
elaborated social theory and at the very least some basic
assumptions about the historical process’2. foroe biologists
recognise these same limits and have resisted demands for
biological solutions to essentially social problems23.
A relationship between environment and disease has
been asserted since at least -400 BC. According to the Hippo­
cratic doctrines, “the well-being of man is influenced by all
environmental factors : the quality of the air, water and food ;
the winds and the topography of the land ; and the general
living habits
Health is the expression of harmony among
the environment, the ways of life, and the various components
of man’s nature24”. But little attention has been paid to this
social aspect of hygiene, especially since the scientific
advances of the nineteenth century gave the practice of medi­
cine a solid, though theoretically narrow, foundation. It has
remained at the level of philosophical speculation, finding
expression in the critiques of men like John Ryle, Rene Dubos
and Henry Sigerist26-2.7.. The one branch of biology that
has taken it up is medical ecology.
Medical ecology' “conceives of disease as a convergence in
time and space and within the person of the patient of
environmental stimuli (organic, inorganic, or sociocultural).
These stimuli are a challenge which induces a tissular response
that is disease (communicable, degenerative, or behavioral),
which in its turn eventually results in ecological adaptation
and survival or in total maladjustment and death24”. Culture,
defined as ' the sum total of the concepts and techniques that
human groups use and abide by in the environment in which

S

they are placed, in order to survive,” is also assigned a
role2
Medical ecology thus asserts a relation between environ­
ment, disease, and man, but selects only biological and socio­
cultural factors as relevant. It looks a.t the convergence of
environmental and community factors only within the person
of the patient. At no point is it concerned with the collecti­
vity as such. By dismissing political and economic factors as
irrelevant, it suffers from a failure to consider the relation
of people to their environment in all its complexity.
As with ecology and biology, the methodology of medical
ecology is too limited to solve the problems of public health.
It is constrained by the individualistic and ideological bias of
the clinical paradigm which medical ecology reflects.
These points can be illustrated with a brief example from
Vietnam. In discussing the influence of culture on human
disease occurrence in northern Vietnam, J. M. May, a pro­
minent medical ecologist, wrote in 1953 : ‘’From the water
the people get their food, also their cholera, their dysenteries,
their typhoid fevers, their malaria ; from the earth they get
their hookworm ; from the crowded villages they get their
plague and typhus ; and from the food .. their protein
deficiencies, their beriberi.’ 30
May, who worked as a surgeon in the French colonial
service, recognized the direct influence of scarcity and star­
vation on the pathology he described, but dismissed any
examination of their causes : “We will not discuss here the
fantastic edifice of mortgages and debts which rises above the
fraction of an acre of laud on which family life is built. Nor
shall we describe the land tenure laws and customs that have
resulted in the reduction of the size of property through the
years to insignificant proportions”31. To discuss and describe
in these circumstances was dangerous, for no intelligent
observer could escape the conclusion that the origins of
indebtedness and land tenure laws were the key to the ecology
of disease in Vietnam. The etiology was no ‘cultural mal­
adjustment’ ; it was the dislocation of the Vietnamese political

9

economy by French colonialism, which imposed a system of
land classification and taxation that impoverished the
peasantry32. Medical ecology could not take political and
economic factors into consideration without challenging the
legitimacy of colonial rule.
The record of North Vietnam after liberation from France
in 1954 provides empirical evidence of the limits of Medical
ecology. In ten years after independence. North Vietnam
constructed a health service that reached every village in the
country. This service was grounded in the agricultural
cooperatives that were established following the land reforms
which radically changed the relations of production. The
network of cooperative farms and villages met the people's
need for food, and with the improvement of nutrition, the
decentralization of the health services made a real impact
on disease. In addition to linking public health measures to
agricultural needs, the rural health service demonstrated its
concern for the collectivity in its emphasis on disease preven­
tion, its attack on social diseases, and its reliances on the
masses for the implementation of health campaigns33. The
achievements are stunning ; the eradication of small pox,
cholera and plague, the virtual extinction of typhoid,
diphtheria and polio ; the substantial reduction of malaria,
tuberculosis and trachoma ; and the control of leprosy.
Infant mortality (deaths of children under one year old),
usually considered a sensitive indicator of the state of public
health, fell from 400 per thousand live births in 1945 to
33.7 in 196S3 >.
Empirical evidence is presented in order to rule out the
possibility that some immutable geographic or climatic
condition was the obstacle to the improvement in public
health in Vietnam during the French colonial era. Clearly,
the French colonialists lacked the political will to improve the
lot of the Vietnamese, and besides, the underdevelopment of
Vietnam was at once an effect and a requirement of French
capitalism. Furthermore, a collectivized approach to public
health would have undermined French economic and political

10

control of the country. The clinical medical model is imbued
with the ideals of classical liberal philosophy which emphasises
individual enterprise and the self-regulation of the economic
system. A medical philosophy that put the concerns of the
collectivity above those of the individual was potentially
subversive.
The Ideology of Individualism in Medicine.
The general assumptions of classical liberalism about the
world and people are marked by a pervasive individualism
described well by TIobsbawn : “The human world consisted of
self-contained individual atoms with certain built-in passions
and drives, each seeking above all to maximize his satis­
factions and minimize his dissatisfactions. Tn the course of
pursuing this self-interest, each individual in the anarchy of
equal competitors found it advantageous or unavoidable to
enter into certain relations with other individuals, and this
complex of useful arrangements —which were often expressed
in the frankly commercial technology of ‘contract’ —consti­
tuted society or social or political groups’’35
It is important to distinguish between individualism and
individuality. Individualism is a political and economic
theory that asserts the rights of the individual as against
those of the community. Individuality refers to a separate or
distinct existence. The public health consequences of indivi­
dualism arc obvious in the case of birth control in a developing
country. So long as each family perceives the need for
large numbers of children in order to survive, no appeal to
social conscience about overpopulation and the need to reduce
high rates of population growth will succeed. The govern­
ment contradicts the dominant ideology of individualism
when it calls for family planning in the interest of the
nation.
The overwhelming concern with the individual is a major
limitation of the paradigm of clinical medicine. No medical
discipline can evolve on the basis of this paradigm to study
holistically the total interaction of groups of people with their
economic, political and social circumstances. Yet life, and

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the reproduction of human life, are viable only within the
context of an economic structure, social organisatian and
political system. A medical paradigm that is not holistic and
collective produces only an inexact and inadequate body of
medical knowledge.
This suggests an additional proposition : that medicine’s
failure to develop! a positive definition of health results from
the individualistic and ideological bias that pervades medical
research and medical practice, structures relations between
practitioners and patients, shapes the approaches selected for
treatment (eg, chemical or surgical intervention) and the
technology employed, and rejects the initiation of collective
social action by communities. I examine in the next section
whether this ideological bias conforms to capital’s needs, and
whether the practice of medicine under capitalism reflects the
capitalist mode of production, by tracing the historical deve­
lopment of the paradigm of clinical medicine in the context of
the economic, social and political changes through which the
capitalist system emerged.
The Political Ecology of Disease under Capitalism.
The place of the individual in society is determined by the
forces of production and the social relations of production.
As Engels put it in the preface to the first edition of ‘The
Origin of the Family, Private Property and the State”,
‘‘According to the materialistic conception, the deter­
mining factor in history is, in the final instance, the pro­
duction and reproduction of immediate life. This, again, is
of a two fold character : on the one side, the production of
the means of existence, of food, clothing and shelter and the
tools necessary for that production ; on the other side, the
production of human beings themselves, the propagation of
the species. The social organisation under which the people
of a particular historical epoch and a particular country live
is determined by both kinds of production : by the state of
development of labour on the one hand and of the family on
the other36”.
In the ‘German Ideology”, Marx held that mode of pro­

12

duction also determines the relations of individuals to one
another with respect to the materials, instruments and product
of labour. Thus, the various stages of development involve
different forms of property.
Prior to capitalism, there were three forms of property :
tribal property, the communal and state property of antiquity,
the feudal and estates property.3’ The place of the indivi­
dual differs in each form of property. In the precapitalist
forms, as Marx observes, ‘personal dependence characterises
the social relations of production38” —in the tribal form,
the division of labour is an extension of the natural division
occurring within the family ; in ancient Greece and Rome,
citizens held power over their labouring slaves ; and in the
feudal form, there was landed property with serf labour
chained to it and small capital commanding the labour of
journeymen.
The advent of capitalism marks the separation of labourers
from control over, or personal relation to the means of pro­
duction. In this sense, the individual becomes ‘ free”.
Cooperation is no longer based on commercial ownership of
the means of production and membership in the tribe, or on
direct relations of dominion and servitude ; it is longer merely
a necessary concomitant of all production on a large scale ;
capitalistic cooperation is a method employed by capital for
the more profitable exploitation of labour, for increasing
labour's productiveness
Cooperation becomes external to
the labourers who arc isolated persons, independent of each
other, entering into relations with the capitalist, but not with
each other. Far from cooperating, labourers are now in a
competitive situation that intensifies in accordance with the
progressive production of a relative surplus population or
industrial reserve army. And not only are the labourers in
competition with each other, but the capitalists compete as
well, leading to the centralisation of capitals—the destruction
of their individual independence, expropriation of capitalist
by capitalist, and the transformation of many small into few
large capitals.39 In addition, labourers and capitalists are

13

in conflict with each other.
X\ ith caustic sarcasm, Marx wrote in ' Capital”. ‘‘This
sphere that we are deserting, within whose boundaries the
sale and purchase of labour-power goes on, is in fact a very
Eden of the innate rights of man. There alone rule Freedom,
Equality, Property and Bentham. Freedom, because both
buyer and seller of a commodity, say of labour-power, arc
constrained only by their freewill They contract as free
agents, and the agreement they come to is but the form in
which they give legal expression to their common will.
Equality, because each enters into relation with the other, as
with a simple owner of commodities, and they exchange
equivalent for equivalent.' Property, because each disposes
only what is his own. And Bentham, because each looks only
to himself. The only force that brings them together and
puts them in relation with each other, is the selfishness, the
gain and the private interests of each. Each looks to himself
only, and no one troubles himself about the rest, and just
because they do so, do they all, in accordance with the prees­
tablished harmony of things, or under the auspices of an allshrewd providence, work together to their mutual advantage,
for the common weal and the interest of all.”10
This brief review of Marx’s analysis of social formations
demonstrates the qualitative difference between the place of
the individual in capitalist society and in all previous oues.
The location of the individual is necessary to the next step ;
to show a coincidence between the individualistic and ideo­
logically biased clinical paradigm that dominates medical
science and the changing roles required of individuals by an
emergent capitalism. This coincidence can be shown by
tracing changes in the formulation of public health problems
and in prescriptions to deal with them, tlirough the period of
transition from mercantilism to capitalism.
In the period preceding the industrial revolution, the mer­
cantilist school of political economy prevailed ; in Europe
during much of the seventeenth and eighteenth centuries,
emphasis was placed on the economic, political and military

14

advantages of a large andgrowing population which, under the
control of the government, could be turned to whatever use
public policy dictated “Population growth would augment
national income and at the same time depress the hourly wage
rate, giving the workers an incentive to work longer hours and
widening the margin between national income and wage
costs.’’4 1 Since population was a factor in production, it
became essential to know not only the number but also the
economic value of people, especially of the most productive
population groups. In the seventeenth century, "efforts were
made to ascertain the basic quantitative data of national life
in the belief that such knowledge could be used to increase
the power and prestige of the state.”42 Thus, anew field
was founded by William Petty (1623-1687* who called it
‘political arithmetic it is known today as vital and health
statistics.
The mercantilists were not interested in raising individual
worker income or standards of living, but they were concerned
with any loss of labour productivity through illness and the
decrease in the number of workers through death. In
Germany, Ludwig von Seckendorff ■ 1626-1692) recommended
that means be taken to guard the health of the people so that
their numbers would increase. He proposed a government
health programme to be concerned with ‘the maintenance and
supervision .of midwives, care of orphans, appointments of
physicians and surgeons, protection against plague and other
contagious diseases, excessive use of tobacco and spirituous
beverages, inspection of food and water, measures for cleaning
and draining towns, maintenance of hospitals, and provision
of poor relief.”43 Von Seckendorff was ahead of his time;
his programme was only partially introduced and is still
pertinent three centuries later.
By the end of the eighteenth century, a health programme
to serve the ends of the German mercantile state had been
perfected by Johann Peter Frank (1745-1821). In a nine.
volume treatise, he developed the idea of ‘ Medical police” as
the core of the medical system. In the introduction to his

15

book he worte, “The internal security of the state is the
aim of the general science of police. A very important part
thereof is the science which will enable us to further the
health of human beings living in society. ’44 His aim was
to promote health through legislation and to enforce health
laws through the state organs.
Frank was aware of the economic determination of disease.
While serving as Director General of Public Health of
Austrian Lombardy, he studied the living and working con­
dition of the people in great detail and found poverty,
ignorance and disease in a region that was extremely fertile.
He knew the cause of starvation and sickness to be the fact
that the land did not belong to the people who tilled it : it
was the property of a small group of patrician families who
had been given large estates as fiefs. “The peasants were
crushed and starving in the midst of plenty ”4 5
Though Frank held the position of professor of clinical
medicine, he was not yet bound by the narrow paradigm of
clinical medicine that emerged in the nineteenth century. He
lived in Italy at the end of the eighteenth century, before the
industrial revolution. Frank saw that there was little point
in reorganising health authorities, hospitals and medical
schools so long as the people did not have enough to cat He
demanded land distribution ; ‘that every family should have
enough land to produce the food it required and a surplus that
could be sold to the cities ; .. that the prices of agricultural
goods should be such that the farmers would be enabled to
buy in the city the commodities they needed and that the
city workers, on the other hand could buy food at the price
they could afford.' 40
When Frank died in 1821, his work was already outdated.
since it presupposed conditions that still existed in only a few
European countries. The pressures of the industrial revolu­
tion called for basic changes in public health measures, and the
movement for these changes came from England. Frank made
two important contributions that were relevant to conditions
in the nineteenth century : he described the impact of social

16

conditions on people’s health from birth to death as the feudal
mode of production was crumbling ; and he revealed the eco­
nomic interest of the state in the health of its subjects.
The Impact of Capitalism on Health
In the eighteenth century, England was still largely depen­
dent on agriculture ; by the mid-nineteenth century, the
census showed that the urban population had become greater
than the rural. The transformation during that period that
made possible vastly increased agricultural productivity was
social rather than technological. The enormous success of
agricultural machinery was due rather to its labour-saving
capacity' than to any increase in harvest yield. Scientific
agriculture was not introduced before the mid-nineteenth
century ; till that time, mechanical ingenuity was in advance
oi any scientific knowledge of the growth of plants.17
The enclosure movement ended communal cultivation and
common pasture, remnants of a medieval society. Self-suffici­
ent farming was liquidated and old-fashioned uncommercial
attitudes towards the land disappeared. Britain became a
country of a few large landowners, a moderate number of
commercial tenant farmers, and a groat number of hired
labourers. By the census of 1851 capitalism had penetrated
the countryside. ‘ In terms of economic productivity this
social transformation was an immense success ; in terms of
human suffering a tragedy, deepened by the agricultural depre­
ssion after 1815 which reduced the rural poor to demoralised
destitution.”1 8
If the landless wage labourers, rural domestic workers,
land-poor peasants and peasants living on infertile land starved
and died in dire poverty, those who joined the nineteenth
century ‘ forced draft urbanization” to swell the ranks of the
new urban industrial proletariat fared no better. Change
from the traditional diet and overcrowding were probably the
two major factors that combined to render the immigrants so
vulnerable to the harshness of their new working and living
conditions.
It became popular in the 1830’s to publish reports on

17

urban life which exposed the appalling health conditions of
the industrial population. Engels was the first to deal with
the working class as a whole and not only with particular
sections or industries ; he did not simply survey working class
conditions, but made ‘a general analysis of the evolution of
industrial capitalism, of the social impact of industrialisation
and its political and social consequences—including the rise
of the labour movement.”49
Engels catalogued the ways in which deprivation created
an environment where workers’ could not remain healthy or
enjoy a normal expectation of life : the air was polluted,
shim houses were poorly ventilated and overcrowded, there
was neither clean water nor sewerage, there was no medical
care available, and the workers mental health was threatened
by continual insecurity. Wages were almost stationary for
many workers until the 1870’s, when they began to rise.
The price of a staple such as wheat did not fall significantly
or steadily until after 1880. Mortality was clearly associated
with class. Engels cites a house-by-house investigation carried
out in a suburb of Manchester by a doctor for the Health
of Towns Commission ; the mortality in the best houses on
the best streets was 1 in 51 in the worst houses on the worst
streets I in 25. Towns were on the whole more lethal, and
deaths of children under five years of age in urban areas more
numerous, than in rural areas.
Engels rejected the position, then commonly held, that
poverty was an offense meriting severe punishment as a
warning to other potential paupers. He understood that
what drove a worker to drink excessively was his general
environmental circumstance, and that drunkencss was not a
vice for which the drunkard must accept responsibility. In
an eloquent indictment of the middle classes, he labels the
crime of exploitatian .
‘‘Murder has been committed if society places hundreds of
workers in such a position that they inevitabily come to
premature and unnatural ends. Their death is as violent as
if they had been stabbed or shot. Murder has been committed

18

if thousands of workers have been deprived of the necessities
of life or if they have been forced by the strong arm of the
law to go on living under such conditions until death inevitabily releases them Murder has been committed if society
knows perfectly well that thousands of workers cannot avoid
being sacrificed so long as these conditions arc allowed to
continue.”80 The attitude of the ruling class towards the
labouring poor is well described by Marx in a chapter of
“Capital” entitled ‘ Bloody legislation against the expropria­
ted” ; in it he traces the invidious and cruel poor laws and
labour laws from the end of the fifteenth to the middle of the
nineteenth centuries.
In addition to their pious opinions about poor relief, the
ruling classes adopted a new population theorist. Thomas
Robert Malthus (1766-1834) reversed mercantilist ideas on
the need to guard the health of the people so their numbers
would increase. In his “Essay on the Principle of Population,”
published in 1798, Malthus argued that population, unchec­
ked, increases in a geometrical ratio, while subsistence
increases only in an arithmetical ratio. Hence, as Ei gels
summarised it. ”
the earth is perenially overpopulated,
whence poverty, misery, distress, and immorality must
prevail ; it is the lot, the eternal destiny of mankind, to exist
in too great numbers, and therefore in diverse classes, of
which some are rich, educated, and moral, and others more or
less poor, distressed, ignorant, and immoral.’ 5 1
Publication of the Essay was timely ; it provided an
argument for tightening relief laws, and its philosophy is
reflected in the 1834 Poor Law. By making poverty seem a
natural phenomenon, the Essay legitimised the dominant
position of the propertied classes. It fit their frame of
reference admirably : the secular ideology of the bourgeoisie
was classical liberalism.
While the plight of the rural poor could be conveniently
ignored, the condition of the urban proletariat could not.
First, the rise of working class consciousness was reflected in
the formation of trade unions, in demands for better living

19

and working conditions, and in strike action to force through
reforms. No trade unions of agricultural labours were formed
before 1875—an attempt in Dorset in 1634 was crushed with
force.52 For a desciption of the urban trade union movement
see the Hammonds,53 and for an account of strikes see
Frow.5’ Second, mortality and morbidity were becoming
so extensive that the capitalists attempt to extract maximum
profit through lower real and social wages, were coming into
conflict with their need for a productive and reproductive
labour force. There was a physiological limit to reductions
in the wage rate. Third, sanitary conditions became so
serious that the epidemics formerly confined to the east ends
of large cities, where the poor lived, were spreading to the
rich west ends and beginning to kill members of the ruling
class.
The Sanitary Reform Movement.
One response to these conditions in Britain was the Sani­
tary Reform Movement. Historically it grew out of the reform
of the old Elizabethan Poor Law that had empowered parish
officers to enter into general contracts for the care of the poor.
The new, more restrictive, Poor Law of 18: 4 confined that con­
tract to “a person licenced to practise as a medical man” and
limited care to those classified as ‘‘sick paupers.” These
limitations reflected changing power relations in the new class
society : the law was pushed by the old rural aristocracy,
but it would not have passed without the support of the
rising urban industrialists who saw it as a way of controlling
the growing proletariat.
The 1834 law was “the culmination of a protest movement
launched by the landed aristocracy and gentry to reduce
what they considered to be the outrageous cost of the poor
rate55 ’. Between 1770 and 1830, a period of enclosures in
rural areas the relief rolls swelled ; unemployment was
further aggravated after 1815 with the demobilisation of
British troops, and the post-war agricultural slump created
misery everywhere. Since relief was paid out of taxes, the
Boards of Guardians were concerned to keep down the cost

20

by making relief less attractive, cutting it down to subsistence
leved, and accompanying it by an irksome discipline. The
underlying philosophy of the 1834 Act was that most paupe­
rism was “voluntary”, the result of moral defects such as
idleness, intemperance, and improvidence. It thus proposed
a rigorous “workhouse test” to weed out the “able-bodied”
paupers who were henceforth ineligible for aid.
Investigations undertaken in connection with the Poor
Law50 had been made by, among others Edwin Chadwick,
who was later appointed to carry out a further inquiry into
conditions affecting the health of the working class. His
“Report on the Sanitary Condition of the Labouring Popu­
lation of Great Britain” was published in 1842. It dealt with
the evil social and sanitary conditions in the industrial centres
particularly with housing and conditions at places of work,
with the comparative chances of life in different classes, and
with evidence of the effects of preventive measures in raising
the standard of health and chances of life57.
Although
evidence of unsanitary conditions in rural areas was also con­
sidered, the main thrust of subsequent legislation was on
reform in urban centres. A Public Health Act was finally
passed in 1S4S, for the first time appointing medical men as
public health officers. By 1875, there was a rapidly expan­
ding public health service that engaged medical officers in
“sanitary areas” covering the whole country, as provisions
in the successive public health acts of 1866, 1872 and 1875
were implemented58.
The legislation that emerged was of a limited, bureau­
cratic and interventionist nature. Chadwick believed firmly
in the capitalist system, in a free labour market, and p nhindered competition. But his investigations showed him
that the system would best be served, particularly in the
area of disease prevention and sanitation, by a strong central
administration, so he was forced to abandon his laissez-faire
ideology, at least temporarily. Educated in the Ricardian
school of political economy and a loyal disciple of Bentham,
Chadwick drafted his reforms with a common purpose—to keep

21

the way clear for individual initiative by administering strong
sanctions to remove obstructive customs or vested interests.
In choosing government intervention, Chadwick created the
institutions that were to become the bureaucracy of the
Welfare State. In the language of Poulantzas, Chadwick was
the architect of several of the Ideological Apparatuses of the
state (including the repressive apparatus of the constabulary,
whicn he recommended in the report of his police inquiry
in 1839).
In 1S86, the General Medical Council established a public
health diploma in sanitary science. Other specialities deve­
loped within public health : factory surgeons were appointed
under the Factory Acts ; school doctors were employed ;
under the Maternity and Child Welfare Act of 191S, another
health corps was provided ; and in the period 1912—16.
medical officers were appointed to public medical services for
tuberculosis, veneral disease, and mental deficiency. The
function of each of these medical corps can be understood in
terms of the labour force : for example, factory surgeons— the
pioneers of occupational health services were to maintain
productivity by keeping workers in good physical condition
and by making it difficult for malingerers to “choose” to be
ill59 ; the function of maternal and child welfare officers was
to ensure the reproduction of the work force ; and so on.
I find it difficult to sustain the frequently-heard argument
that capitalists lay on medical services to improve labour
productivity. In every recession, rather than spend money
on medical services, capitalists find it more profitable to fire
sick workers and replace them with healthy people picked
from a labour pool that is swelled by widespread unemploy­
ment. Productivity is more dramatically altered by industrial
technology than medical care, and rates of profit change more
with cuts in the work force than with increased output of
individual workers.
During prosperous times when there is full employment
and the working class is relatively strong, worker demands
for healthier working and living conditions are transformed by

capitalists who respond with medical services This transfor­
mation was historically conditioned in the nineteenth century
when the hegemony of clinical medicine was established, the
domain of public health narrowly confined, and capitalists
realised that demands for good health could be met only by
radical and costly changes in the work process.
The argument that medical services improve labour pro­
ductivity is thus the capitalists’ rationalisation of the expendi­
tures they are forced to make. In addition, this formulation
deflates the victory of the working class by turning its health
demand into a productivity gain for the capitalists. The end
product is the bargain that ties workers’ benefits to increased
labour productivity.
The outcome of the Sanitary Reform Movement substanti­
ates this view. By the end of the nineteenth century, public
health had become a technical engineering speciality ; public
health services were limited to sewage systems, food and
water inspection, and the prevention of epidemics ; and the
prestige of public health practitioners declined. Recent studies
have shown that the Sanitary Reform Movement contributed
more to improved health status in Nineteenth Century Eng­
land than the improved practice of physicians and surgeons
on hospitalised patieuts.®0 However, public health officers
gained little in terms of status, either from the public or their
colleagues in other branches of the medical profession. The
usual explanations of this phenomenon are : 1) thatrpublic
health deals with collectivities rather than individuals ;
2) that public health practitioners do not have the same inti­
mate relationship with patients as personal doctors ; and
3) that public health improvements are neither as dramatic
nor as noticeable as curative techniques like surgery.
There are, however, more fundamental reasons for the low
regard of public health, and the limitations placed upon it. Its
major beneficiaries were the urban working class, “the group
least able to confer status and prestige upon the Medical
Officers of Health,” while its Major targets of attack were ' the
slum houses, noxious and odious factories .. inefficient w'ater

23

boards and offensive burial grounds.’ 61 More importantly,
public health work tended to highlight the failings of capita­
lism. Many of the regulations of the public health acts entailed
considerable financial losses for industrialists and other influ­
ential members of the rising bourgeoisie It is no wonder,
therefore, that public health practitioners were not honoured
in the same way that successful hospital practice was rewarded.
If Chadwick, a prominent figure in the Sanitary Reform
Movement, was disliked, it was far less because he was over­
bearing and ambitious than because his investigations had left
starkly exposed the tainted sources of many ‘ respectable”
fortunes. Four examples, follaw, taken from areas of waste
disposal, housing, water supply, and occupational health which
explain the resistance to reform.
In the matter of sewerage, profits were made out of selling
the vast dumps of ashes, night-soil, rotten vegetables, straw,
dung the sweepings of the streets, the offal of the slaughter
houses, and the contents of public latrines refuse of all kinds
in thousands of tons, occupying hundreds of cubic metres. If
the privy were to be replaced by the water closet, dealers who
retailed the sewage by the cart-load and the barge-load to
farmers, would lose a source of revenue.
Vested interests in housing stood to suffer similar losses
from the Sanitary Reforms. The immense expansion of the
urban population was a boon to the speculating builder and
the greedy landlord. If census returns gave the impression
that housing had increased at the same pace as population,
it was because every occupation under the same roof was
counted as a separate dwelling In Blackfirars Paris, Glassgow,
the population increased 40 per cent between 1831 and 1841,
while the number of houses remained the same.02 The workers
were forced to take any accomodation they could get. In the
old districts of towns, landlords packed them into decaying
and abandoned houses, the former mansions of the rich. In
the new suburbs, speculators built on every scrap of land, be
it narrow, damp or near a public dump. The result was cellar
dwellings lacking drains or conveniences of any kind ; back-to-

24

back bouses with no thorough ventilation ; and closed courts
with a water tap at one end and latrine at the other. Pro­
perty owners raised the most bitter objections to sanitary
reforms : they feared the additional costs of installing drains
and laying on water supplies for their tenants. Slum land­
lords maintained that stink and damp were part of the tenants’
risk.
Water companies made their profits from the provision of
an intermittent supply of unfiltered water from the rivers
that also served as sewers. No investment was made in new
plant nor any attempt made to apply the newly discovered
principles of hydraulics to improve the system. The Sanitary
Reforms threatened them with the municipalisation of water
supplies.
Of all the regulations concerning public health, the ones
that were potentially the most costly to industrialists were
the Factory' Acts. Bad working conditions in the factories
were a major cause of ill-heatlh - the exhausting hours, the
lack of time off for meals, physical dangers of accidents, and
the absence of such sanitary arrangements as ventilation for
workrooms that wore overheated, polluted by noxious fumes
and overcrowded. Five labour laws had been passed between
1802 and 1833, but Parliament voted no money' for their
implementation.
Industrial unrest in 1833 prodded the government into
appointing a commission to study the condition of children
in factories. The evils of child labour in textiles factories
had been a paramount political issue in the north of England.
Marx has shown how the so-ealled domestic industries and
the intermidiate forms of production between them and manu.
factoring depended on the use of child labour and an un­
restricted working day, since the sole basis of their competi­
tive powers was the unlimited exploitation of cheap labour63.
Between 1833 and 1864, a series of Factory Acts was
passed, regulating the working day and the employment of
women and children. The specific clauses in the Factory Acts
dealing directly with public health were in feat few. While
COMMUNITY HEALTH CELL
326, V Main, I Block
Koram&ngaia
Bangalora-560034
India

25

washing of walls and other matters of cleanliness, ventilation,
and protection against dangerous machinery. This last, since
it involved the greatest expense by capitalists, provoked the
most intense opposition Mine owners were amongst the most
flagrant exploiters ; they were the subject of special acts
in 1842 and 1860. They invested no more in the collieries
than was absolutely necessarj' to get the coal out : shafts
were ill-constructed, pits poorly drained and ventilated, roadways and bays badly prepared. The result was an appalling
accident rate and a high loss of life. In I860, an average
of 15 men died each week in the mines ; some 8,500 were
killed between 1852 and 1S6164. These human sacrifices
were mostly due to the inordinate greed of the mine owners.
Factory owners resisted the enforcement of legislation
requiring the installation of safety devices. In 1854, manu­
facturers formed the nati onal Association for the Amendment
of the Factory Laws in Manchester, assessing members two
shilings per horsepower in order to finance their defence
in court proceedings initiated by factory inspectors. And
in 1856 manufacturers succeded in serving an Act of Par­
liament, that deprived labourers of all special protection and
referred them to the common courts for compensation in the
event of industrial accidents. Marx called this “sheer mock­
ery” because the costs of a law suit in England were for
beyond the means of nny worker.
Legislation did not always benefit the working class ; in
particular, the new poor law reduced, rather than expanded,
the availability of relief. However, the Royal Commissions
and Select Committees investigated the appalling material con­
ditions of the masses wore appointed as a direct result of indu­
strial unrest. In the Webbs’ wards.
“Although, as it now seems, the danger of a popular upris­
ing on any considerable scale, in the England of the first few
decades of the nineteenth century, was never very substantial
there was a continual undercurrent of seditious talk, which
did not fail to become known to the Government, and which
seemed to be illustrated by spasmodic little attempts at rcbell-

26

ion. From the food riots of 1795-1801 ..right down to the im­
pulsive ‘Jacquerce’ of the South Eastern Countries in 1830,
and the tensions of the struggle over the Reform Bill, there
was, it seems clear, what was regarded as a very ugly spirit
among the mass of the people. 166
The role of labour in forcing industrialists to improve
working and living conditions was key. Chadwick and his
fellow reformers were motivated to support legislation disadva­
ntageous to the bourgeoisie, not because they were humani­
tarian champions of the working class, but because they be­
lieved it would be good economy to prevent rather than cure
disease.
To summarise this section on the Sanitary Reform Move­
ment:
The reforms required to deal properly with public health
would simply have been too costly and ever ruinous —to the
pitalists. Reforms were won onlj’ as a direct result of the
class struggle-piecemeal legislation granted grudgingly by
Parliament and resisted by industrialists. Even the half­
hearted attempts to deal with the health of the collectivity
flourished only between 1850 and 1875. By 1880 govern­
ment funds were being withdrawn, and by 1898 official in­
terest had so far declined that the government medical officer
testified that he “occupied the lowest status of anyone in the
whole public service who has any corresponding position’’6’
The need for public health measures was not less ; the pro­
gressive deterioration of physique in English working-class
men was recognised during the call-up for the South African
war, when rejections averaged 40 percent nationally and rose
to 60 percent in some areas a government committee found
that poverty, leading to defective diet, overcrowding and
poor sanitation, were the causal factors.6 ’ Nor were public
health measures ineffective ; they were responsible in large
part for the decline in mortality from typhus, typhoid and
cholera68. Nor did their effectiveness go unrecognised:
whenever a cholera epidemic threatened, the Medical Depart­
ment could be sure of an appropriation from the Treasury6’.

27

The problem rather, was that a systematic response to the
public health problems of the collectivity would have been
antithetical to copitalism. The committees of inquiry set
up by Parliament were used affectively by the sanitary refor­
mers. As one historian has said, ‘ A few doctors, led by
Southwood Smith, a few officials led by Chadwick, a few mem­
bers of Parliament led by Normanby, Ashley and Slarey,
were, able, with the powerful help of Charles Dickens, to bring
this machinery into use in the cause of public health For
one moment it looked as if the English people was about to
take in hand the most urgent of its new tasks.”70 But by
the end of the mineteenth century, relatively little had been
accomplished. ‘‘The commission which sat in 1867 found in
existence the main evils that were revealed by the committee
of 1840 ; the Comission of 1884 found in existence the main
evils that had been revealed by the Commission of 1867. In
many towns the death rate was higher in 1867 them in
1842”71.
This was not seen as a a problem in the organisation and
planning of town life ; collective formulations of disease cousation could not be allowed to gain currency. The dominant
classes of capitalist society wanted to avoid the development
of public health because collective action on health problems
could strengthen political resistance. The corollary is the
clinical medical practice, by situating the diagnosis and treat­
ment of disease at the level of the individual, provided the
ruling classes with a means of social control ; patients would
fail to make common cause with each other or to protest the
external, underlying conditions that make them ill. The
effect is to de-politicise malnutrition, alcoholism, drug
addiction and mental illness by defining the , as medical prob­
lems. The medical profession - made up predominantly of
members of the ruling classes-—is thus invested with power in
order to control the behaviour of the working class. Especially
in the field of psychiatry, this aspect of social control is very
clear.
Public health became an unrewarding career with little
28

prestige and less pay ; at the same time, various branches of
public health, for example, occupational health, nutrition,
and maternal and child care, wore forced into the mould of
the clinical medical paradigm.
Imperialism and Living Standards in England and
the Third world.
From the mid-nineteenth century, mortality began to
decline in England. Infact mortality fell from over 130
deaths per thousand live births in 187C to under 30 per
thousand in 19707 2 . Tuberculosis which accounted for half
the deaths registered as being due to infection in the second
part of the nineteenth century, declined from 2,231 deaths
per million in 1871—80 to 768 per million in 1921 —3073.
These reduced rates are generally thought to be due, most
importantly, to a rising standard of living, of which the
significant factor was improved diet71.
One explanation for the improvement in living standards
has already been given ; it was due to the success of working
class struggles for better working and living conditions. A
second and, I believe, complementary explanation is that the
English working class benefited from imperialism, even
as subject populations experienced impoverishment with the
expansion of the capitalist system in the third world. The
evidence for the second argument is considered briefly.
The imminent social revolution in England predicted by
Engels in 1845 never came to pass. As he points out in
the preface to the 1892 edition of ‘The conditions of the
■working class”, ‘the truth is this : during the period of
England’s industrial monopoly the English working class have,
to a certain extent shared in the benefits of the monopoly75.’’
With respect to health, this ‘’sharing” involved shifting part
of the burden of death from England to areas of the world
whose development was now to be dictated by the needs of
English manufacturing capital.
There can have been no improvement in diet before the
repeal of the Com Laws in 1846. The object of the Corn
Laws had been to keep the price of wheat at the famine level
29

it had reached during the Napoleonic wars and from 1815 on,
all wheat imports were forbidden whenever prices fell”.
Necessary as it was, the repeal was not sufficient, for ever
after abolition, wheat prices remained high. It was not until
about 1870, when the vast wheat belt of the midwestern
United States had been opened up by railways, and steamships
had greatly increased transatlantic trade, that really large
quantities of grain flowed into England, prices fell, and diet
improved.
The significance of the repeal of the Corn Laws lies
elsewhere—it was the first of the Free Trade legislation and
represented the ascendancy of the manufacturing capitalists
over the landowning aristocracy. Domestic and foreign commer­
cial and financial policy were adjusted accordingly. As Engels
described it : “Every obstacle to industrial production was
mercilessly removed. The tariff and the whole system of
taxation were revolutionised. Everything was made subor­
dinate to one end, but that end of 1 he most importance to the
manufacturing capitalists ; the cheapening of all raw produce,
and especially the means of living of the working class ; the
reduction of the cost of raw materials, and the keeping down
—if not yet the bringing down of wages”7 ’.
Britain had been a predominantly importing country since
the eighteenth century, but between 1800 and 1900 imports
multiplied tenfold in value while exports multiplied eight­
fold78. In 1866, Britain’s world-wide sources of supply were
described as follows by Jevons :
The several quarters of the globe are our willing tributaries
The plains of North America and Russia are our cornfields :
Chicago and Odessa our granaries, Canada and the Baltic our
forests ; Australia contains our sheep farms, and in South
America are our herds of oxen. Peru sends her silver and
the gold of California and Australia flows to London ; the
Chinese grow tea for us ; and coffee, sugar and spice arrive
from the East Indian plantations. Spain and France arc our
vineyards, and the Mediterranean our fruit garden our
cotton grounds, which formerly occupied the Southern
ted

30

States, arc now everywhere in the many regions of theearth”.
Britain's free access to these supplies, until at least 1870,
was assured by British, colonialism and domination of the
world market. Thereafter British hegemony was contested by
a number of countries, but these affected markets for her
exports more than sources of raw materials. In any event,
the problem of competing national capitals was temporarily
resolved by the partition of the world that marked the emer­
gence of imperialism. British capitalism gained a new lease
on life and was able to sustain a dense population, complex
industry, and a rising standard of living for a while longer.
Engels thought that the loss of monopoly would damage
the position of both'capitalists and workers in England. But
as Lenin showed in imperialism, the Highest Stage of
World Capitalism, workers obtained higher real wages
through the stepped-up inflow of low-priced goods from the
Empire. The prosperity of British capital also meant that
many of the abuses of the early years of the nineteenth cen­
tury, which were so injurious to health of workers, disappeared
with the concentration of capital in the leading industries.
Working conditions improved as a result. As Sweezy wrote,
‘‘
the working class of any country can gain most from
an extension of foreign trade and capital export if the profits
of the capitalists are enhanced, cheap imports of wage goods
are fostered, and there is little danger of a collision with
rival countries. This was precisely the piculiar situation in
which the English working class fonnd ■ itself throughout a
greater part of the nineteenth century, a fact which amply
accounts for the complacent and even favourable attitude
which the British working class movement adopted towards
the extension of British interests abroad in the years before
the First World War80.

Conclusions :
This article has examined the theoretical assumptions of
medicine and found that these cannot be understood apart

9^

COMM’JNI i'Y H•£ \ -T3H-

from the mode of production in which medicine developed.
Even the so-called pure sciences of physics and chemistry take
their aim and their material from industry and commerce. As
the practical application of scientific knowledge, medicine is,
if anything, even more determined by the economic formation
in which it is practised.
The clinical medical paradigm, as the ideological expression
of capitalistic medicine, was described and its historical deve­
lopment traced ; it was found to be dominated by a mecha­
nistic conception of the human body and to be inadequate as
a representation of the reality of human life. It was therefore
unable to inform the development of public health as a disci­
pline. Because it is of historical necessity in harmony with
the general philosophy of capitalism, ie. classical liberalism,
the clinical paradigm is overwhelmingly concerned with the
individual and neglects the study of collectivities. Thus it
was unable to provide a framework for the solution of public­
health problems produced by industrialisation and urbani­
sation in England. Instead, medicine served the needs of
the dominant classes.
-The clinical medical paradigm rejects political economy as
irrelevant to medicine and therefore fails to explain changes
in health conditions in Vietnam after liberation. A truly
political ecology of disease recognises the deteminant influence
of the mode of production on health status.
Engel’s analysis of the social impact of industrilisation and
its political and economic consequences is perhaps the arche­
type exposition of the political ecology of disease. It was
completed in 1845, before Marxist theory was fully developed
later, Engels was to compare it with a human embryo. But
even at that early date his analysis included not only an out­
line of what might serve as the basis for a socialist medical
pradigm, but also an indication of what socialist medical
practice might be. Until Marx elaborated a set of categories
for analysing social systems in the process of change, there was
in my opinion, no adequate social theory for a new medical
paradigm. Biology would prove inadequate, and no later

32

methodology would escape the ideological distortion that
Marx predicted would constitute the principal stumbling block
for scientific investigation81 the clement of Marx’s theory
relevant to medical practice, which already appears in Engel’s
analysis of the English working class, is social revolution.
Engels made clear that redness of unhealthy social conditions
was contingent upon revolution : relief would come only with
collective action to overthrow the capitalist system. It is
this emphasis on social initiative that could inform a new
paradigm of medicine.
Finally, the clinical paradigm failed to produce a positive
definition of health which requires as its theoretical base,
not only mathematical or biological science, but also social
science, especially historical sociology and political economy.
The closest I have ever come to finding a positive definition of
health is the following formulation: Marx regarded as the
aim of the socialist movement ‘‘a society, in which men, liber­
ated from the ‘alienations’ and ‘mediations’ of capitalist so­
ciety, would be the masters of their own destiny, through
their understanding and control of both Nature and their own
Social relationships.”82

Meredeth Turshen
Washington

SOURCES

1.

2.

3.

4.

Ralls, E. “Critique ideologique de la science on epistemologie de 1’ambiguite” 1975, Institut d’etudes du develop
pement, Geneva, p. 4, mimeo.
Arthur C. J. (ed), Marx K and Engels, F. the German
Idelogy, 1974, Lawrence and Wishart, London, p 122
Bernard, C. Introduction to the Study of Experimental
Medicine, 1865.
Bernal, J. D., Science in History, 1969, C. A. watts,
London, vol. 2, p 442.
—

33

Illich, I. Medical Nemesis, 1975, Calder and Boyars, Lon­
don, p 112.
6.
Foucault, M. Naissance de la Clinique, 1972, Presses
universitaines de France, Paris, pp. 35,39,
7.
Illich, I. op. cit-,pll4.
S. Canguilhem, G. Lc nomal et le pathologique, 1969, Press­
es universitaires de France, Paris,
9. Dubos, R. Man, Medicine and Environment, 1968, Pen­
guin Books Harmondsworth.
10. Powles, ^T. “On the limitations of modern medicine,”
Science, Medicine and Man, 1973, I, 1, pp 1-30.
— 11. Illich, I. op. cit.
12. Szasz, T. Myths of Mental Illness, 1961, Harper and
Row, N. Y.
13. Foucault, M. Madness and Civilization, New American
Library, N. Y.
14. Laing R. D. The Politics of Experience and tire Pird
of Paradise, Penguin Books, Harmondsworth.
[5. de Castro, J. Geopolitique de la, Faim, 1971, les Editi­
ons Ouvrienes, Paris.
16. Polack, J. C. La Medicine de Capital, 1972 Franccrs
Maspero Paris.
17. Seveno, M, Le Scandale de la Sante, 1970, La Table
Ronde, Paris.
18. Ribicoff A. The American Medical Machine, 1972,
Harrow Books N. Y.
19. Hart, J. T The National Health Service in England
and (Pales, n. d. Marxists in Medicine. London.
20. Murray, J. A. H. (ed), Oxford English Dictionary,
1933, vol. 7, p. 64.
21. Roger, E. S. and Messinger, H. B. “Human ecology; to­
ward a holistic method,” Milbank Memorial Fund
Quarterly, 1967, 45, 1, p. 25.
22. Enzensberger, H. M. “A critique of political ecology,"
New Left Review, 1974, 84 p. 17.
23. Luria, S. E. ‘What can biologists solve ?” New York
Review of Rooks, 1974, 21, 1, pp, 27, 28.
5.

34

24.
25.
26.

27.
28.

29.
30.

31.
32.

33.

34.

35.
36.

37.

38.

39.
40.
4.1.

Cited in Dubos, R. op. cit. p. 82.
Ryle, J. Changing Disciplines, 1968, Oxford Univer­
sity Press London.
Dubos, R. Mirage of Health, 1971, Perennial Library,
N. Y.
Sigerist H. E. Civilization and Disease, 1970 Univer­
sity of Chicago Press, Chicago.
Marti — Ibanez, F. '“Foreword” in May, J, M. The Eco­
logy of Human Disease, 1958, MD Publications, N. Y.
p. xvii.
May, J. M. op. cit. p. 29.
May, J. M. ’’The cultural aspects of tropical medicine,”
American Journal of Tropical Medicine, 1954, 3, p' 3,
Ibid.
Ho Chi Minh, “Annamese peasant conditions,” La Vie
Ouvriere, Jan, 4,1924, in Fall, B. B. (ed)’ Ho Chi Minh
on Devolution, 1967, Pall Mall Press, London.
Ngugen Khac Vien, (ed), North Vietnamese Medicine
Facing the Trials of War, 1967, Vietnamese Studies,
Hanoi, p. 11.
McMichael, J. K. Health in the Third, World Studies
from Vietnam, 1976, Spokesman Books, London pp.
152, 218.
Hobsbawn’ E. J. The Age of Revolution, 1789-1848,
1962, New American Library, N. Y. p. 279.
Leacock, E. B. Tye Origin of the Family Private Pro­
perty and the state by Frederick Engels, 1972 La­
wrence and wishart, London, p. 71.
Excerpted in Bottomorc, T. B, and Rubel. M (eds) Karl
Marx, Selected Writings in Sociology and Social Phi­
losophy, 1974, Penguin Books, Harmondsworth, pp.
126-130.
Marx, K Capital, 1957 ed., Allen and unwin, Moore
and Aveling trans. Vol 1, pp. 311-326.
Ibid, pp 635-642.
Ibid, p. 155.
U. N,, The Determinants and Consequences of Popula-

x

35

tion Trends, 1953, UN, N Y, p 24.
Rosen, Ct. A History of Public Health, 1958, MD
Publicdtions. N Y pp 110-111.
43 Ibid, pl 18.
44. Sigerist, H E Landmarks in the History of Hygiene
1956, Oxford University Press, London, p 52
45. Ibid, p 49.
46. Ibid, p 50.
47. Bernal, J. D. op cit Vol 2 pp 653, 679.
48. Hobsbawn, E«J, The Age of Revolution. 17S9—1848,
op cit p 69.
49. Hobsbawn, E “Introduction” to Engels, F, The Condition of the Working Class in England, 1969, Panther
Books, Froginore, p 9.
50. Henderdon, W.O. and Chalorier, W.H. (eds) Engels, The
Condition of the Working Class in England, 1958,
Basil Blackwell, Oxford, p 108
51. Engels, F. The Condition of the Working Class in England, op cit p 309.
52. Marlowe, J. The Tolpuddle Martyrs, 1971, Andre
Deutsch, London.
53. Hammond, J. L. and B The Town Labourer, 1760-1832,
1966, Longmans, London.
54. Frow, R. et al Strikes : a Documentary History, 1971,
Chas Knight, London.
55. Gill, D. G, ‘‘The British National Health Service.” Inter­
national Journal of Health Services, 1971, 1, 4, p 344.
56. Checkland, S. G and E. O. A (eds) The Poor Laio Report
of 183-1. 1974, Penguin Books, Harmondsworth.
57. Flinn, M. W, Edwin Chadwick, Report on the Sani­
tary Condition of the Labouring Population of Great
Britain, 1842, 1965, The University Press, Edinburgh.
58. Macleod, R M ‘‘The anatomy of state medicine : concept
and application” in Medicine and Science in the ISGO’s,
1969, Wellcome Institute of the History of Medicine,
London, pp 199-227.
59. Dreitzel, H P “Introduction” to Dreitzel, H P (ed),

42.

36

COMMUNITY HEALTH CELL
326, V Main, 1 Block
Koramongala
Bangalore-560034
India

x

The Social Organisation of
1971 MaemilIan
N. Y. P. Xi.
'
60. McKeown, T. et al. “An interpretation of tho modern
rise of population in Europe,’’ Population Studies
1972, 26, 3, p 341.
61. Gill, D. G. op. cit p 345.
62. Lewis, R. A. Edwin Chadwick and the Public Health
Movement, 1832-1854, 1970, Augustus M. Kelley, N..Y
p 51.
63. Marx K. Capital. 1974 ed vol 1, Lawrence and Wishart
London, p 446.
64. Ibid. Vol 3, p 88.
65. Webb, Sand B. English Poor Law History Part II :
The Last Hundred Years, 1929, Vol 1, Longmans,
Green and Co London p 32.
66. Dr. Richard Thorne—Thorne, cited by Macleod, R. M
'"The frustration of state Medicine, 1880-1899” Medical
History, 1967, 11, p 36.
67. Clements, F. W ‘‘Some effects of different chiets” in
Boyden, S. V (ed), The Impact of Civilisation on the
Biology of Man, 1970, National University Press, Can­
berra, pl 16.
68. Mckeown, T. and Record, R. G '“Reasons for the decline
of Mortality in England and Wales during the Nine­
teenth Century,” Population Studies 1962, 16, 2, 2, pp
94-122.
69. Macleod, R- M. op. cit.
70. Hammond J. L. and B The Rise of Modern Industry,
1927. Methnea and Co., London, p 226.
71. Ibid.
72. Powles, J- op. cit p 5.
73. Hill A. B Principles of Medical Statistics, 1962, Lancet,
London, p 64.
74. Mckeown, T. and Record, R .G op. cit.
75. Engels, F. The Condition of the Working Class op. cit
P 34.
76. Morton, A. L. A People's History of England-, 1974,

77.
78.

Lawreno' nji- V<fishart London p 401.
Engels, P- The Condition of the Working Class op. cit
Palmer’. P- R and Cotton, J. A History of the Modern

World, Knopf, N. Y, p 569.
79. Quoted in Palmer R.R and Cotton, J op. cit., pp 574-575. (
SO. Sweezy, P. M The Theory of Capitalist Development,
1946, Dennis Dobson, London p 315.
81- Bottomore, T. B. and Rubel, M- (eds), op. cit. pp 38, 3982. Ibid., p 43.

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