Socialist Health Review 1984 Vol. 1, No. 1 June Politics and Health.pdf
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COMMUNITY HEALTH C'LL
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mARHIST VIEW OF A1E0ICAL CARE
HEALTH CARE IA A REVOLUTIOAARV FRAH1EUJORK
CRITIQUE OF fflOOERA (TIEDICIAE
POLITICAL ECOAOmV OF HEALTH CARE
SOCIALIST HEALTH REVIEW
VOLUME
I
NUMBER 1
JUNE
1984
For Private circulation only
Politics and Health
Perspective /1
Dhruv Mankad
A Marxist View of Medical Care /4
Howard Waitzkin
Health Care in a Revolutionary Framework :
Possibilities for an Alternative Praxis /24
Binayak Sen and Hina Sen
The Political Economy of Health Care in India .An Outline /29
Amar Jesani and Padma Prakash
Review Article; A Cultural Critique of Modern Medicine /45
Anant Phadke
Working Editors :
Amar Jesani, Manisha Gupte Awasthi, Padma Prakash, Ravi Duggal
Editorial Collective : Ramona Dhara, Vimal Balasubramanyam (Andhra Pradesh), C. Sathyamala,
Dhruv Mankad (Karnataka), Binayak Sen, Mira Sadgopal (Madhya Pradesh),
Anant Phadke, Bharat Patankar, Jean D'Cunha, Mona Daswani, Srilatha
Batliwala (Maharashtra) Amar Singh Azad (Punjab), Ajoy Mitra andSmarajit
Jana (West Bengal)
Contribution Rates : For one year Rs. 20/- for individuals,
Rs. 30/- for institutions
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(We have special rates for developing countries)
Address for editorial correspondence : Socialist Health Review, 19 June Blossom Society, 60 A, Pali Road.
Bandra (West) Bombay - 400 050
Printed at : Omega Printers, 316, Dr. S. P. Mukherjee Road, Belgaum 590 001
The views expressed in the signed articles do not necessarily reflect the views of the Editors.
EDITORIAL
PERSPECTIVE
TOWARDS A REVOLUTIONARY APPROACH TO HELLTH
theoretical direction for radical health action. As of
today, in India, there is little understanding of various
theoretical questions related to health and medicine:
the political economy; the bourgeois, male domina
ted ideological positions; underlying positivist out
look etc. As argued earlier, the need to develop
such a theory through mutual discussions and
debates does exist.
Given the geographical
distances that separate us, the best solution the
situation offers is a periodical.
^jometime during the last year, some of us
working in the field of health realised that there
was a need for a separate periodical which would
analyse and discuss health issues from a broadly
marxist perspective. Socialist Health Review (SHR)
is being published with a conviction that it would
fulfil this need by acting as a platform for discussion
and helping the propagation and development of a
marxist analysis of health ( i. e. determinants and
dynamics of health and disease ) and medicine (i. e.
medical technology as well as systems of medical
care).
Now, it could be argued that existing forums
like the Medico Friends Circle Bulletin could be utilised
for this purpose. We feel that periodicals like these
have played and will continue to play the very pur
poseful role of exposing socially conscious individuals
to concrete alternatives and in developing a radical
democratic critique of health and medicine. But, they
have an inherent limitation in that the divergent or
sometimes equivocal ideological commitments of
their readership makes a discussion from a particular
ideological standpoint, especially the marxist one, a
a futile’affair. Even when it does take place, much
of the rigour is lost.
It may well be asked as to what the necessity
is of a separate periodical when there exists a
plethora of journals devoted to both marxism as
well as health. Since the 70's various groups and
individuals with different ideological positions
have been working in the field of health. Many
health workers, and doctors have, through their
exposure to, people's struggles to change the
oppressive social reality, been attracted to the left
movement and specitically to marxism. They have
come to realise the need for a substantial, radical
critique of health and medicine. Moreover, most
marxist doctors, health workers in India are more or
less ignorant about marxist analysis of health and
medicine B ut with the growth of the health and scie
nce movements in India, we have all increasingly felt
the need to know and to develop a marxist analysis
of health and medicine. At the same time, many poli
tical activists and social workers too, as a result of
their exposure to health problems have realised the
relevance of such an exercise. The growth of people's
science movements in the country (e. g. Lok Vignyan
Sangathana in Maharashtra, Kerala Shastra Sahitya
Parishad, Kerala) has also contributed to this aware
ness. Activists of these movements have been
exposed to, and have also challenged the existing
health and medical care system and consequently,
have realised the need for analysing them. All
these developments have resulted in generating an
awareness amongst medicos, social workers and
political activists of the relevance of radical health
praxis to the left movement.
Periodicals like the EPW, and Social Scientist, while
publishing marxist analyses of society have an
obvious limitation in that they cover a wide field
and therefore, they cannot become platforms for
continuous debates on health and medicine only.
This in short, is the raison d'etre of a separate
periodical devoted to propagating and developing a
marxist theory of health and medical care, a task
which SHR proposes to undertake.
Editorial Policy
As stated earlier SHR will function as a forum
for propagating and developing a marxist approach
to health and medicine. By a marxist approach
we mean that analytical approach which takes a
historical materialist and dialectical view of the health
of a people and the medical care system in a given
social order. From a marxist standpoint, health can
be considered as a part and consequence of econo
mic, political and socio-cultural development of
society. The’ problems of health and the health care
system reflect the problems of the dialectic of
production forces and production relations and the
broader social order based on it. They cannot be
separated from the problems of this broader social
order. As health care and medicine operate today
Such an analysis not only advances the general
theory of radical political action — which we believe
to be critical for any fundamental change in the
health situation
but also provides a specific
1
through public institutions and private clinics,
insights into who controls them and how this
control operates is significant for such an approach.
The role played by these institutions in social control
and reinforcement of the existing ideology would
be the focus of such an analytical approach.
the US and other western countries. Many of
us are not exposed to these, as not all of us have
an easy access to the relevant reading material.
Therefore, the periodical will contain reproductions
of such articles with introductory comments when
ever necessary.
The editorial policy will aim to present the
various currents which have contributed to the
development of such an approach to health and
medicine. It must be emphasised here that in our
opinion, there does not exist one single, marxist
analysis — an all correct perfect Tine' so to say, of
health and medicine. Only a continuous interaction
at the level of praxis amongst the different trends
within the marxist movement can lead to the process
of distilling the truth. Therefore, SHR will contain
articles and viewpoints reflecting this diversity in
marxist thought albeit with the limitations spelt
out later.
In order to develop a 'concrete analysis of the
concrete situation', SHR would encourage publishing
of original articles pertaining to the Indian situation
and debates and comments thereupon. We hope
that in a short time, original articles will form the
bulk of the periodical.
Keeping in view the development of the Indian
marxist movement in general, the following, in our
view must be strictly observed while writing original
articles:
1. The central propositions of the articles must
be worked out logically with supporting empirical
evidence.
We believe that the women's health movement
has added a new dimension to the critique of the
organisation and contents of medicine. Therefore,
SHR will also contain reflections mainly of the
marxist-feminist viewpoint — and sometimes even
of the non-marxist ones — directed towards the
exposure of the ideological substructure of the
developments in medicine.
2. Subsidiary propositions and other general
statements regarding the economic and political situ
ation, for example, the nature of mode of production
in India, strategies of revolution etc. must have a
direct beating on the central propositions. This is
imperative in orderto avoid a debate on these issues
on the pages of this periodical (though these are
obviously essential for political activists) and to
prevent irrelevant generalisations.
The Illichian trend is characterised by its criticism
of the bureaucratising and centralising tendency of
modern health care systems, while overlooking the
class basis of these tendencies. It has nevertheless
contributed to the critical views on medical care in
bourgeois society. This is despite the fact that this
criticism arises from within the bourgeois ideolo
gical standpoint. Occasionally, this current may,
too, find a place in this periodical.
In addition to these main articles, SHR will
also contain features like news, book reviews, field
reports, letters to the editor and so on.
SHR's relation to the left movement : SHR
being a periodical devoted to theoretical aspects of
health and medicine does not propose to become
an action-oriented periodical in the sense of an
organiser of an action group. We believe that the
formulation and clarification of these theoretical
issues are essential for successful, politically relevant
action and in that way the periodical would facilitate
effective health action in the manner after journals
like Monthly Review or Social Scientist.
These three points of view have one common
direction : they oppose the existing ideological
position dominant in the sociology of medicine, one
rooted in the structural-functional school. This
school assumes the neutrality of medicine (and all
sciences) and examines the health care systems
without reference to the character of society.
It refrains from a political analysis of the medical
system and places great emphasis on the social
factors affecting health without enquiring into the
root cause of their existence, the economic base
of society.
We feel that the very fact of the need for such
a periodical having been felt indicates that the health
movement within the broad left movement has
reached a stage of maturity though not of a level
necessitating a formal organisation. But, this does
not and cannot, preclude the possibility of formation
of such an organisation in future.
It is this commonality that forms the justification
for including them together in this periodical.
At present, SHR would contribute to the gene
ral fund of marxist analyses which is particularly
deficient in this respect in India. We consider this
Of late, there has been a spurt in the literature
on the marxist analysis of health and medicine in
2
deficiency, even mistakes and distortions within the
left movement, as our deficiency, mistakes and distor
tions. And if they have to be criticised — which of
course they need to be — the criticism should be a
self-criticism, with a view to improve upon the past
and the present so that the movement proceeds
with unity, strength and on a politically correct path
towards its historical goal. Let me make it clear that
we do not stand for a goody-goody, come-what
may-we-shall-stay-united type of left unity but we
certainly oppose the kind of sectarianism that leads
us to mutual mud-slinging while the enemy without
goes unexposed and unchallenged.
the connection between the economic
Indian society and health system.
base of
Binayak Sen's article focusses on areas which
have either been dealt with only superficially in
Waitzkin's article or not at all.
Anant Phadke introduces the book Cultural
Crisis of Modern Medicine ed'wed by John Ehrenreich,
with his critical comments thereupon.
From this issue onwards, each issue will be
devoted to one aspect of health and medicine.
An Appeal
In this issue
Our reader friends would agree that building up
a platform for the task envisaged by SHR requires a
lot of collective effort. We appeal to our comrades
to accept this challenge and extend their fraternal
support to this venture. There are several ways in
which SHR could be helped:
To drive home the point made above regarding
the relationship of the problems of health and
medicine with those of society in general, we
open our publication with an overview of Health
and Politics.
As with any other publication of this type, SHR
too, badly needs financial support. Although
several friends have promised to collect funds, the
total amount would just be barely sufficient for
the first few issues only. Financial support for SHR
could be enlisted by either enrolling subscribers or
collecting donations.
In any class society, and by the same logic, in
bourgeois society, every institution is controlled by
a class/classes to further its/their own interests
against certain other class/classes.
Under the
hegemony of the bourgeois, health has become a
commodity and consequently, there has been a
proliferation of health 'producing' institutions and
businesses. And according to the same logic, they
are controlled by the bourgeoisie to perpetuate and
justify their hegemony. The articlesappearing in this
inaugural issue set the keynote of the marxist
approach to health and medicine.
In case, you are unable to contact a person
whom you know would be interested, his/her address
could be sent to us. We would send the first
issue with an appeal for subscription/donation.
Original articles or reproductions including
theoretical analyses, relevant research papers,
reports of alternatives in health care, reports of
health care in post-revolutionary societies, book
reviews etc. could be sent to us for publication.
(See back cover).
Howard Waitzkin in his article (a reproduction)
A Marxist View of Medical Care reviews marxist
literature on health and medicine. The article
shows how the present health system reflects
the class structure of captalist society and how
this class structure manifests itself in various ways:
control over health institutions, stratification of
health workers, health policy etc
He goes on
further to show the penetration of monopoly capital
into the 'medical-industrial complex'. The article
deals briefly with the concepts of historical mate
rialist epidemiology focussing on the effects of
economic cycles, social stress, working conditions
and sexism on health.
SHR is a platform of discussion. Hence opinions
of the readers regarding the production of the
periodical material published and of course, the
views presented here are welcome — nay, necessary
for the growth of this periodical.
If one goes by the enthusiastic response we
have received so far it would not be too much to
hope that the Socialist Health Review in a short
time, would become a leading theoretical organ of
the growing health movement within our country
and would contribute significantly to the general
fund of marxist literature.
Amar Jesani and Padma Prakash in their article
Political Economy of Health Care in India select one
aspect of the relationship of health and politics and
put it in the Indian perspective. They lucidly trace
Dhruv Mankad
3
A MARXIST VIEW OF MEDICAL CARE
howard waitzkin
Marxist studies of medical care emphasise Political power and economic dominance in capitalist society. Although
historically the marxist paradigm went into eclipse during the early twentieth century, the field has developed rapidly
during recent years. The health system mirrors the society's class structure through control over health institutions
stratification of health workers, and limited occupational mobility into health professions. Monopoly capital is manifest in
the growth of medical centres, financial penetration by large corporations, and the "medical-industrial complex." Health
policy recommendations reflect different interest groups' political and economic goafs. The state's intervention in health
care generally protects the capitalist economic system and the private sector. Medical ideology helps maintain class
structure and patterns of domination. Comparative international research analyses the effects of imperialism, changes
under socialism, and contraditions of health reform in capitalist societies. Historical materialist epidemiology focuses on
economic cycles, social stress illness-generating conditions of work, and sexism. Health praxis, the disciplined uniting
of study and action, involves advocacy of "nonreformist reforms" and concrete types of political struggle.
* | his review surveys the rapidly growing marxist
at the request of the Prussian government, Virchow
investigated a severe typhus epidemic in a rural area
of the country. Based on this study, Virchow recom
mended a series of profound economic, political,
and social changes that included increased employ
ment, better wages, local autonomy in government,
agricultural cooperatives, and a more progressive
taxation structure. Virchow advocated no strictly
medical solutions, such as more clinics or hospitals.
Instead, he saw the origins of ill health in social
problems. The reasonable approach to the problem
of epidemics, then, was to change the conditions
that permitted them to occur. (4,5.)
literature in medical care. The marxist viewpoint
questions whether major improvements in the
health system can occur without fundamental
changes in the broad social order. One thrust of the
field, an assumption also accepted by many nonmarxists, is that the problems of the health system
reflect the problems of our larger society and can
not be separated from those problems.
Marxist analyses of health care have burgeoned
in the United States during the past decade. How
ever, it is not a new field. Its early history and the
reasons for its slow growth until recently deserve
attention.
During this period Virchow was committed to
combining his medical work with political activities.
In 1848 he joined the first major working-class
revolt in Berlin. During the same year he strongly
supported the short-lived revolutionary efforts of
the Paris Commune (6-8). In his scientific investiga
tions and in his political practice, Virchow expressed
two overriding themes. First, the origin of disease is
multifactorial. Among the most important factors in
causation are the material conditions of people's
everyday lives. Second, an effective health-care
system cannot limit itself to treating the pathophy
siologic disturbances of individual patients. Instead,
to be successful, improvements in the health care
system must coincide with fundamental economic,
political and social changes. The latter changes
often impinge on the privileges of wealth and power
enjoyed by the dominant classes of society and
thus, encounter resistance. Therefore, in Virchow's
view, the responsibilities of the medical scientist
frequently extend to direct political action.
Historical Development of the Field
The first major marxist study of health care was
Engel's The Condition of the Working Class in England
(1) , originally published in 1945, three years before
Engels coquthored with Marx 'The Communist Manifesto'
(2) . This book described the dangerous working
and housing conditions that create ill health. In
particular, Engles traced such diseases as tuberc
ulosis, typhoid and typhusto malnutrition, inadequate
housing, contaminated water supplies and overcrow
ding. Engels' analysis of health care was part of a
broader study of working class conditions under
capitalist industrialisation. But this treatment of
health problems was to have a profound effect on
the emergence of social medicine in Western Europe,
particularly the work of Rudolf Virchow.
Virchow's pioneering studies in infectious disease,
epidemiology, and "social medicine" (a term Virchow
popularised in Western Europe) appeared with great
rapidity after the publication of Engels' book on the
English working class. Virchow himself acknow
ledged Engels'influence on his thought. In 1847,
After the revolutionary struggles of the late
1840s suffered defeat, Western European govern
ments heightened their conservative and often
4
repressive social policies. Marxist analysis of health
care entered a long period of eclipse. With the onset
of political reaction, Virchow and his colleagues
turned to relatively uncontroversial research in
laboratories and to private practice.
laboratory-based medicine became the norm for
medical education, practice, research and analysis.
Recent historical studies cast doubt on assump
tions in the Flexner Report that have comprised the
widely accepted dogma of the past half century.
They also document the uncritical support that the
report's recommendations received from parts of
the medical profession and the large private philan
thropies (19-27). At least partly because of these
events, the marxist orientation in medical care
remained in eclipse.
During the late nineteenth century, with the
work of Ehrlich, Koch, Pasteur, and other prominent
bacteriologists, germ theory gained ascendancy and
created a profound change in medicine's diagnostic
and therapeutic assumptions. A unifactorial model
of disease emerged. Medical scientists searched for
organisms that cause infections and single lesions in
non-infectious disorders. The discoveries of this
period undeniably improved medical practice. Still,
as numerous investigators have shown, the histori
cal importance of these discoveries has been over
rated. For example, the major declines in mortality and
morbidity from most infectious diseases preceded
rather than followed the isolation of specific etio
logic agents and the use of antimicrobial therapy. In
Western Europe and the United States, improved
outcomes in infections occurred after the introduc
tion of better sanitation, regular source of nutrition,
and other broad environmental changes. In most
cases, improvements in disease patterns antedated
the advances of modern bacteriology (9-17).
Although some of Virchow's works gained
recognition as classics, the multifactorial and politi
cally oriented model that guided his efforts
has remained largely buried. Without doubt,
marxist perspectives had important impacts on
health care outside Western Europe and the Untied
States. For example, Lenin applied these perspec
tives to the early construction of the Soviet health
system (28). Salvador Allende's treatise on the
political economy of health care, written while
Allende was working as a public health physician
exerted a major influence on health programmes in
Latin America (29). The Canadian surgeon, Norman
Bethune, contributed analyses of tuberculosis and
other diseases, as well as direct political involve
ment, that affected the course of post-revolutionary
Chinese medicine (30-32). Che Guevara's analysis
of the relations among politics, economics and
health care— emerging partially from his experience
as a physician — helped shape the Cuban medical
system (33,34).
Why did the unifactorial perspective of germ
theory achieve such prominence ? And why have
the investigational techniques that assume specific
etiology and therapy retained a nearly mythic charac
ter in medical science and practice to the present
day ? A serious historical reexamination of early
twentieth century medical science, which attempts
to answer these questions, has begun only in the
past few years. Some preliminary explanations have
emerged; they focus on events that led to and follo
wed publication of the Flexner Report (18).
Perhaps reflecting the political ferrqent of the
late 1960s and widespread dissatisfaction with
various aspects of modern health systems (35),
serious marxist scholarship of health care has
grown rapidly. Recent work began in Western
Europe (36,37) and spread to the United States
with
the publication of Kelman's path-breaking
article in 1971 (38). The following sections of this
review focus on current areas of research and
analysis.
The Flexner Report has been held in high esteem
as the document that helped change modern medi
cine from quackery to responsible practice. One
underlying assumption of the report was the labora
tory based scientific medicine, oriented especially to
the concepts and methods of European bacterio
logy, produced higher quality and more effec
tive medical practice. Although the comparative
effectiveness of various medical traditions (includ
ing homoeopathy, traditional folk healing, chiroprac
tic, and so forth) had never been subjected to syste
matic test, the report argued that medical schools
not oriented to scientific medicine fostered mistreat
ment of the public. The report called for the closure
or restructuring of schools that were not equipped
to teach laboratory-based medicine. The report's
repercussions were swift and dramatic. Scientific,
Class Structure
Marx's definitions of social class emphasised
the social relations of economic production. He no
ted that one group of people, the capitalist class or
bourgeoisie, own or control (or both) the means of
production : the machines, factories, land, and raw
materials necessary to make products for the market.
The working class or proletariat, who do not own or
control the means of production, must sell their labor
for a wage. But the value of the product that workers
5
and state and local government bonds; their median
annual income (1975 estimates) is 114000 dollars to
142000 dollars. The "working class", at the opposite
end of the scale, makes up 49% of the population. It
is composed of annual laborers, service workers, and
farm workers, who generally earn 8500 dollars per
year or less. Between these polar classes are the
"upper middle class” (professionals like doctors,
lawyers, and so forth, comprising 14% of the
population and earning about 25600 dollars; and
middle-level business executives, 6% of the popu
lation and earning about 22700 (dollars; and the
"lower middle class" (shopkeepers, self-employed
people, craftsmen, artisans, comprising 7% of the
population, earning about 12000 dollars and clerical
and sales workers, 23%of the population, earning
about 9200 dollars per year). Although these
definitions provide summary descriptions of a very
complex social reality, they are useful in analysing
manifestations of class structure in the health system.
produce is always greater than their wage (391.
Workers must give up their product to the capitalist;
by losing control of their own productive process,
workers become subjectively ''alienated" from their
labor (40). "Surplus value", the difference between
the wage paid to workers and the value of the
product they create, is the objective basis of the
capitalist's profit. Surplus value also is the stiuctural
source of "exploitation"; it motivates the capitalist
to keep wages low, to change the work process (by
automation and new technologies, close supervision,
lengthened work day or overtime, speed-ups and
dangerous working conditions), and to resist
workers' organized attempts to gain higher wages
or more control in the workplace (41).
Although they acknowledge the historical chan
ges that have occurred since Marx's time (52-51),
recent marxist studies have reaffirmed the presence
of highly stratified class structures in advanced
capitalist societies and Third World nations (52-54).
Another topic of great interest is the peisistence or
reappearance of class structure, usually based on
expertise and professionalism, in countries where
socialist revolutions have taken place (55,56); a
later section of this review focuses on that problem.
These theoretical and empiricial analyses show that
relations of economic production remain a primary
basis of class structure and a reasonable focus of
strategies for change (57-59).
Control over Health Institutions
Navarro (60-62) has documented the pervasive
control that members of the corporate and upper
middle classes exert within the policy-making bodies
of American health institutions (Table 1). These
classes predominate on the governing boards of
private foundations in the health system, private and
state medical teaching institutions, and local
voluntary hospitals. Only on the boards of state
teaching institutions and voluntary hospitals do
members of the lower middle class or working class
gain any appreciable representation; even there, the
participation from these classes falls far below their
proportion in the general population. Local research
has documented corporate control of health insti
tutions in many parts of the United States. Navarro
has argued, based partly on these observations,
Miliband's (59) definitions of social class have
provided a framework for marxist research on class
structure in the health system. This research has
shown that the health system mirrors the class
structure of jhe broader society (60-63).
The "corporate class" includes the major owners
and controllers of wealth. They comprise 1% of the
population and own 80% of all corporate stocks
Table 1 : Social Class Composition of U.S. Labor Force and Boards of U.S. health institutions
Upper
middle
Class*
(%)
Lower
middle
Working
1
20
30
49
70
45
20
5
30
55
70
80
—
—
10
10
—
—
—
5
Corporate
U.S. labor force
Board members
Foundations
Private medical teaching institutions
State medical teaching institutions
Voluntary hospitals
* See text for definitions : source, Navarro V; Social policy issues ; an expalanation of the composition,
nature, and functions of the present health sector of the United States. Bull NY Acad Med 51:199-234, 1975
(Reference 60).
6
Emergence of Monopoly Capital in the Health
Sector
that control over health institutions reflects the same
patterns of class dominance that have arisen in
other areas of American economic and political life.
During the past century, economic capital has
become more concentrated in a smaller number of
companies, the monopolies. Monopoly capital has
emergeo in essentially all advanced capitalist nations,
where the process of monopolisation has reinforced
private corporate profit (70, 76, 78) (In a much
different form monopolisation also occurs within
socialist countries, where the state owns major
capital assets and strongly limits private profitabi
lity). Monopoly capital has become a prominent
feature of most capitalist health systems and is
manifest in several ways.
Stratification within Health Institutions
As members of the upper middle class, physicians
occupy the highest stratum among workers in health
institutions. Composing 7% of the health labor force,
physicians receive median net income (approximately
53900 dollars in 1975) that places them in the upper
5% of the income distribution of the United States.
Under physicians and professional administrators
are members of the lower middle class : nurses,
physical and occupational therapists, and techni
cians. They make up 29% of the health labor force,
are mostly women, and earn about 3500 dollars. At
the bottom of institutional hierarchies are clerical
workers, aides, orderlies, and kitchen and janitorial
personnel, who are the working class of the health
system. They have an income of about . 700
dollars per year, represent 54% of the health labor
force, and are 81% female and 30% black (60,63).
Medical Centers
Since about 1910, a continuing growth of
medical centers has occurred, usually in affiliation
with universities. Caoital is highly concentrated in
these medical centres, which are heavily oriented
to advanced technology. Practitioners have received
training where technology is available and speciali
sation is highly valued. Partly as a result, health
workers are often reluctant to practise in areas with
out easy access to medical centers. The nearly
unrestricted growth of medical centers, coupled
with their key role in medical education and the
"technologic imperative" they encourage, has cont
ributed to the maldistribution of health workers and
facilities throughout the United States and within
regions (38, 64).
Recent studies have analysed the forces of
professionalism, elitism, and specialisation that
divide health workers from each other and prevent
them from realising common interests. These patterns
affect
physicians (64), nurses (65, 66), and
technical and service workers who comprise the
fastest growing segment of the health labor force
(67-72).
Bureaucratisation, unionisation, state
intervention, and the potential "proletarianisation"
of professional health workers may alter future
patterns of stratification (73).
Finance Capital
Monopoly capital also has been apparent in the
position of banks, trusts and insurance companies,
the largest profit making corporations under
capitalism. For example, in 1973, the flow of
health-insurance dollars through private insurance
companies was 29 billion, about half of the total
insurance sold. Among commercial insurance
companies, capital is highly concentrated; about
60% of the health-insurance industry is controlled
by the 10 largest insurers. Metropolitan Life and
Prudential each control more than 30 billion dollars
in assets, more than General Motors, Standard Oil of
New Jersey, or International Telephone and
Telegraph (60).
Occupational Mobility
Class mobility into professional positions is
quite limited. Investigations of physicians' class
background in both Britain and the United States
have shown a consistently small representation of
the lower middle and working classes among medical
students and practising doctors (23, 24, 74, 75). In
the United States, historical documentation is
available to trace changes in class mobility during
the twentieth century. As Ziem (23, 24) has found
despite some recent improvements for other dis
advantaged groups like blacks and women, recruit
ment of working class medical students has been
very limited since shortly after publication of the
Flexner Report. In 1920, 12% of medical students
came from working class families, and this percen
tage has stayed almost exactly the same until the
present time.
Finance capital figures prominently in current
health reform proposals. Most plans for national
health insurance would permit a continuing role for
the insurance industry (79,80). Moreover, corporate
investment in health maintenance organisations is
increasing, under the assumption that national
7
the policy recommendations of Fnany groups
advocating health reforms. From this perspective,
these groups' viewpoints and proposals reflect
largely their own political and economic interests,
rather than simple concern for improving the health
system.
Alford's (106,107) research delineates three
major interest groups vying for power and finances.
The professional monopolists include physicians,
specialists, and health research workers in medical
schools, universities, or private practice. The main
consequence of their activity is a "continuous
proliferation of programs and projects" that
"provide a symbolic screen of legitimacy while
maintaining power relationships" in the health
system. 'Corporate rationalisers' are persons in top
positions within health organisations : hospital
administrators, medical school deans, and public
health officials. The corporate rationalisers''overall
effect, according to Alford, is to complicate and
elaborate the bureaucratic structures of the health
system. As third interest group is the diverse
community population actually needing and affected
by health services. Generally, Alford observes, this
interest group's efforts are likely to fail. A high
probability of cooptation means that leaders may
assume symbolic positions on advisory boards or
planning agencies, without real change in power
structures.
The analysis of interest group politics has pro
ved helpful in understanding local controversies
such as attempts at community control of health
institutions (111); conflicts among the governing
boards, administrators, and professional staffs of
hospitals (112); failures in comprehensive health
planning and regulation (113-116); and the expan
sion of medical institutions into urban residential
areas (117-1 20). A similar perspective has led to a
clearer picture of national health policy decisions,
for example, those pertaining to cancer research
and occupational health legislation (83-123).
health insurance, when enacted, will assure the
profitability of these ventures (81.)
The ' Medical-Industrial Complex"
The "military-industry complex" has provided a
model of industrial penetration in the health system
popularised by the term, "medical-industrial comp
lex." Investigations by the Health Policy Advisory
Center (82,83) and others have emphasised that
the exploitation of illness for private profit is a pri
mary feature of the health systems in advanced
capitalist societies (64). Recent reports have
criticised the pharmaceutical and medical equipment
industries for advertising and marketing practices
(82-86), price and patent collusion (87), marketing
of drugs in the third world before their safety is
tested z88-89), and promotion of expensive
diagnostic and therapeutic innovations without
controlled trials
showing
their effectiveness
(13,90-9?).
In this context, "cost-effectiveness" analysis
has yielded useful appraisals of several medical
practices and clinical decision-making, based in
part on analysis of cost relative to effectiveness
(94-100). Although recognising its contributions,
marxist researchers have criticised the cost-effecti
veness approach for asking some questions at the
wrong level of analysis. This approach usually does
not help clarify the overall dynamics of the health
system that encourages the adoption of costly and
ineffective technologic innovations. The practice
evaluated by cost-effectiveness research generally
emerges with the growth of monopoly capital in the
health system. Costly innovations often are linked
to the expansion of medical centers in the health
system, and the promotion of new drugs, the
penetration of finance capital and instrumentation
by medical industries. Cost-effectiveness research
and clinical decision analysis remain incomplete
unless they consider broader political and economic
trends that propel apparent irrationalities in the
health system (90).
These studies' implications for reform within the
present system tend to be pessimistic. Because an
"institutional and class structure creates and sustains
the power of the professional monopolists and
corporate rationalisers". Alford writes, "change
is not likely without the presence of a social and
political movement which rejects the legitimacy of
the economic and social base of pluralist politics."
(106).
Interest Group Politics
Marx argued that class position and economic
resources usually determine political power. He
noted that the dominant economic class is composed
of various groups with sometimes different interests.
Although these groups unite when they face basic
threats from the working class, their varying
interests generate contradictions that can provide a
focus for political strategy (101-105). In studies
of health care, the analysis of interest group politics
has focussed mainly on the United States and
Great Britain (106-110). This approach demystifies
The State and State Intervention
Because the state encompasses the major
institutions of political power, its strategic import
ance is obvious. The state acts generally to repress
8
hreatens
°r P°,itical action tha‘
wav X
rreSent SyStem in any fundamental
way after S0CIahst revolutions, the state apparatus
mod if dT'St
3 l0n9 time' but with greatly
modif ed functions. Before focussing on health care,
a brief overview and definition of the state are
necessary.
A general theme of Marxist analysis is that the
Private sector drains public resources and health
or ers time, on behalf of private profit and to the
detriment of patients using the public sector. This
rame work has helped to explain some of the problems
a^uen 'n SUCh COuntries as Great Britain
(75) and Chile (130, 131), where private sectors
persisted after the enactment of national health
services In these countries, practitioners have faced
financial incentives to increase the scope of private
Ptact.ce,
which they often have conducted
PUt> IC hospltals or clinics. In the United
such
MXHPanSiOn °f PUblic Payment pr°9ra™
such as Medicare and Medica aid has led to
increased public subsidisation of private practice
and private hospitais, as well as abuses of these
programs by individual practitioners (64).
Marx and Engels emphasised government's
crucial role is protecting the: capitalist economic
system and the interests of the capitalist class.
The famous homily of The Communist Manifesto,
was "the state is the executive committee of the
bourgeoisie (2). Lenin (124) concluded that the
capitalist class would intervene forcibly to block
any electoral victory that seriously threatened the
private enterprise system. More recent analysts have
studied the structural patterns that preserve the
dominance of the capitalist class over state policies
(53. 59), the mechanisms by which the state eases
the recurrent economic crises of the capitalist system
(1 25-127); and ideologic techniques by which the
state reinforces popular acquiescence (128, 129).
Similar problems have undermined other public
heaith programs. These programs frequently have
obtained finances through regressive taxation, placl0.W.''nc0me taxpayers at a relative disadvantage
(79). Likewise, the deficiencies of the Blue Cross
and Blue Shield insurance planshave derived largely
from the failure of public regulatory agencies to
control payments to practitioners and hospitals in
the private sector (132). When enacted, national
health insurance also would use public funds to
reinforce and strengthen the private sector, by
assuring payment for hospitals and individual physi
cians and possibly by permitting a continued role for
commercial insurance companies (64, 80).
In this context the following definition, though
limited by the subject's complexity, is appropriate.
The state comprises the interconnected public
institutions that act to preserve the capitalist
economic system and the interests of the capitalist
class. [This definition includes the executive
legislative, and judicial branches of government'
the military; and the criminal justice system all of
which hold varying degrees of coercive power. It
also encompasses relatively noncoercive institutions
within the educational, public welfare, and health
care systems. Through such noncoercive institutions,
the state offers services or conveys ideologic
messages that legitimate the capitalist system.
Especially in periods of economic crisis, the state
can use these same institutions to provide public
subsidisation of private enterprise.
Throughout the UnitedStates the problems of the
private-public contradition are becoming more acute.
In most large cities, public hospitals are facing
cutbacks, closure, or conversion to private owner
ship and control. This trend heightens low-income
patients' difficulties in finding adequate health care
(133). It also reinforces private hospitals'tendency
to ''dump" low-income patients to public institu
tions (134).
The Private-Public Contradiction
General Functions of the State within
the Health System.
Within the health system, the "public sector," as
part of the state, operates through public expen
ditures and employs health workers in public institu
tions. The "private sector" is based in private
practice and companies that manufacture medical
products or control finance capital. Nations vary
greatly in the private-public duality. In the United
States, a dominant private sector coexists with an
increasingly large public sector. The public sector
is even larger in Great Britain and Scandinavia. In
Cuba and China, the private sector essentially has
been eliminated (64).
The state's functions in the health system have
increased in scope and complexity. In the first
place, through the health system, the state acts to
legitimate the capitalist economic system based in
private enterprise (135, 136). The history of public
health and welfare programs shows that state exp
enditures usually increase during periods of social
protest and decrease as unrest becomes less wide
spread
(137, 138). Recently a Congressional
committee summarised public opinion surveys that
uncovered a profound level of dissatisfaction with
9
perhaps even more than the earlier emphasis on
government and particularly with the role of
specific cause, obscures important sources of ill
business interests in government policies : " . . .
ness and disability in the capitalist work process
citizens who thought something was 'deeply wrong'
and industrial environment; it also puts the burden
with their country had become a national majority ...
of the health squarely on the individual, rather than
And, for the first time in the ten years of opinion
sampling by the Horris Survey, the growing
seeking collective solutions to health problems
trend of public opinion towards disenchantment
(147, 148).
with government swept more than half of all
The issues that the state has downplayed in its
Americans with it" (139). Under such circumstances,
research and development programs are worth not
the state's predictable response is to expand health
ing. For example, based on available data, it is
and other welfare programs. These incremental
estimated that in Western industrialised societies
reforms, at least in part, reduce the legitimacy
crisis of the capitalist system by restoring confidence . environmental factors are involved in the etiology
of approximately 80/o of all cancer (149). In its
that the system can meet the people's basic needs.
session on "health and work in America," the
The cycles of political attention devoted to national
American Public Health Association in 1975 produ
health insurance in the United States appear to
ced an exhaustive documentation of common
parallel cycles of popular discontent (135). Recent
occupational carcinogens (150). A task force for
cutbacks in public health services to low-income
the Department of Health, Education, and Welfare
patients follow the decline of social protest by
on Work in America, published by a nongovern
low-income groups since the 1960s.
ment press in 1973, reported In an impressive 15The second major function of the state in the
year study of aging, the strongest predictor of
health system is to protect and reinforce the private
longevity was work satisfaction. The second best
sector more directly. As previously noted most
predictor was overall -happiness'... Other factors
plans for national health insurance would permit a
are undoubtedly important — diet, exercise, medical
prominent role and continued profits for the private
care, and genetic inheritance. But research findings
insurance industry, particularly in the administration
suggest that these factors may account for only
of payments, record keeping, and data collection
about 25 per cent of the risk factors in heart
(64,80, 140). Corporate participation in new health
disease, the major cause of death... "(151). Such
initiatives sponsored by the state — including health
findings are threatening to the current organisation
maintenance organisations, preventive screening
of capitalist production. They have received little
programs, computerised components of professional
attention or support from state agencies. A frame
standards review organisations, algorithm and
work for clinical investigation that links disease
audiovisual aids for patient education programs — is
directly to the structure of capitalism is likely to
providing major sources of expanded profit (81,141).
face indifference and active discouragement from
A third (and subtler) function of the state is
the state.
the reinforcement of dominant frameworks in
Limits and Mechanisms of State Intervention
scientific and clinical medicine that are consistent
•
with the capitalist economic system and the suppre
State
intervention
faces
certain
structural
limits.
ssion of alternative frameworks that might threaten
Simply summarised, these limits restrict state inter
the system. The United States government has
vention
to policies and programs that will not
provided generous funding for research on the
conflict in fundamental ways with capitalist econo
pathophysiology and treatment of specific disease
mic processes based on private profit, or with the
entities. As critics even within government have
concrete interests of the capitalist class during
recognised, the disease-centered approach has
specific historical periods.
reduced the level of analysis to the individual
organism and, often inappropriately, has stimulated
the search for unifactorial rather than multifactorial
origin (142). More recently, analyses emphasising
the importance in individul "life-style"- as a cause
of disease (14, 143, 144) have received prominent
attention from state agencies in the United States
and Canada (145, 146). Clearly individual differ
ences in personal habits do affect health in all
societies. On the other hand, the lifestyle argument.
'Negative selection mechanisms" are forms of
state intervention that exclude innovations or activi
ties that challange the capitalist system (125, 126).
For example, agencies of the state may enact oc
cupational health legislation and enforcement
regulations. However, such reforms will never
reach a level strict enough to interfere with profi
tability in specific industries. Nor will state owner
ship of industries responsible for occupational or
10
environmental diseases occur to any major
alisationnotSeJeCti0n alS0 applies t0 the potential.
caoS
heal,hsyS,emasa wh°le- 'n most
Xt^a|Sr°hC'St'eS'lheState 9eneral|yhas opposed
structural changes that infringe on private medica.
Practice; private control of most hospitals; and the
profitability of the pharmaceutical, medical equipiTrh' h'nS,UuanCe' and °ther industries operating
n the health system. While excluding nationalisation
tnrough negative selection, the state sponsors
incremental reforms that control excesses in each of
these spheres, thus maintaining the legitimacy of
the whole. As an example of negative selection
congressional deliberations in the United States
systematically exclude serious consideration of health
service (as opposed to national health insurance)
that mignt question the appropriateness of private
medical practice or the nationalisation of hospitals
( 152). Another example is governmental regulation
of the drug and insurance industries; aside from
its erratic effects, state regulation rules out public
ownership of these industries.
of domination ( 153, 154). Marxist analysis empasises the subtle "ideologic hegemony" by which
institutions of civil society ( schools, church, family,
and so forth ) promulgate ideas and beliefs, that
support the established order ( 129,155 ); the
"ideologic apparatuses" that the capitalist class
uses to pressurise state power (128); and the
i eologic features of modern science that legitimate
social policy decisions made by “ experts" in the
interests of the dominant class (1 56).
Along with other institutions such as the educa
tional system, family, mass media, and organised
religion, medicine promulgates an ideology that
helps maintain and reproduce class structure and
patterns of dominalion. Medicine's ideologic feature
in no way diminish the efforts of individuals who
use currently accepted methods in their clinical
work and research. Nevertheless, medical ideology,
when analysed as part of the broad social super
structure, has major social ramifications beyond
medicme itself (157). Recent studies have identified
several components of modern medical ideology.
Disturbances of Biological Homeostasis are
Equivalent to Breakdowns of Machines
The state also can use "positive selection
mechanisms
that promote and sponsor policies
strengthening the private enterprise system and the
interests of capital ( 125, 126 ). The positive selec
tion of financial reforms like health insurance, for
instance, contrasts sharply with the exclusion of
organisational reforms that might change the broader
political and economic structures of the present
system (135).
Modern medical science views the human
organism mechanistically. The health professional's
advanced training permits the recognition of specific
causes and treatments for physical disorders. The
mechanistic view of the human body deflects atten
tion from multifactorial origin, especially causes of
diseases that derive from the environment, work
processes, or social stress. It also reinforces a
general ideology that attaches positive evaluation to
industrial technology under specialised control
(5, 135, 158, 159).
Medical Ideology
Ideology is an interlocking set of ideas and
doctrines that form the distinctive perspective of
a social group. Marx introduced a distinction
between two levels of social structures. The “infra
structure , or “economic base," comprises the
concrete relations of .economic production; social
class, as determined by ownership or control of the
means of production, or both, is the primary feature
of the infrastructure On the other hand, the
“superstructure" includes governmental and legal
institutions, as well as the dominant ideologies of
a specific historical period (39). The events of history,
in the Marxist perspective emerge mainly from
economic forces; this "economic determinancy" gives
causal primacy to the sphere of production and
class conflict. Thus, the economic infrastructure
generally determines features of the superstructure.
Ideology and other parts of the superstructure,
however, help sustain and reproduce the social
relations of production and, especially, patterns
Disease is a Problem of the Individual
Human Being
The unifactorial model of disease contains
reductionist assumptions, because it focusses on
the individual rather than the illness-generatinq
conditions of society. More recently, a similar
reductionist approach has discovered sources of
illness in lifestyle. In both cases, the responsibility
for disease and cure rests at the individual rather
than the collective level. In this sense medical
science offers no basic critical approach of class
structure and relations of production, even in the
implications for health and illness (135, 159).
Science Permits the Rational Control of
Human Beings
The natural sciences have led to a greater control
over nature. Similarly, it is often assumed that
11
modern medicine, by correcting defects of indivi
duals, can enhance their controllability. The quest
for a reliable work force has been one motivation
for the support of modern medicine by capitalist
economic interests (19, 26). Physicians’ certification
of illness historically has expanded or contracted to
meet industry's need for labor (160, 161). Thus,
medicine is seen as contributing to the rational
governance of society, and managerial principles
increasingly are applied to the organization of the
health system (113-115).
Many Spheres of Life are Appropriate for
Medical Management
This ideologic assumption has led to an expan
sion of medicine's social control function. Many
behaviours that do not adhere to society's norms
have become appropriate for management by health
professionals. The "medicalisation of deviance'' and
health workers' role as agents of social control have
received critical attention (14, 64, 162-166). The
medical management of behavioral difficulties, such
as hyperkinesis and aggression, often coincides with
attempts to find specific biologic lesions associated
with these behaviours (167-171). Historically,
medicine's social control function has expanded in
periods of intense social protest or rapid social
change (172).
Medical Science is Both Esoteric and Excellent
According to this ideologic principle, medical
science involves a body of advanced knowledge
and standards of excellence in both research and
practice. Because scientific knowledge is esoteric,
a group of professionals tend to hold elite positions.
Lacking this knowledge, ordinary people are
dependent on professionals for interpretation of
medical data. The health system therefore repro
duces patterns of domination by "expert” decision
makers in the workplace, government, and many
other areas of social life (173, 174). The ideology
of excellence helps justify these patterns, although
the quality of much medical research and practice
is far from excellent, this contradiction recently has
been characterised as "the excellence deception”
in medicine (175). Ironically, a similar ideology of
excellence has justified the emergence of new
class hierarchies based on expertise in some coun
tries, such as the Soviet Union, that have under
gone socialist revolutions. Other conutries, such as
the People's Republic of China, have tried to over
come these ideologic assumptions and develop a
less esoteric "people's medicine" (176).
professional journals or the mass media), as well as
state and corporate officials whose organisations
regulate or sponsor medical activities (177).
However, health professionals also express ideologic
messages in their face to face interaction with
patients (1 60, 163). The transmission of ideologic
messages within doctor-paVent interaction currently
is the subject of empirical research (1 78-180)
Comparative International Health Systems
Marxist studies have focussed on three topics in
this area: imperialism, the transition to socialism, and
contradictions of capitalist reform.
Health Care and Imperialism
Imperialism may be defined as capital's expan
sion beyond national boundaries, as well as the
social, political and economic effects of this expan
sion. Imperialism has achieved many advantages for
economically dominant nations. Marxist critiques
have dealt with imperialists of both advanced capit
alist countries and socialist superpowers (especially
the "social imperialism" of the USSR). (28,181,182).
Health care has played an important role in several
phases of imperialism.
One basic feature of imperialism is the extraction
of raw materials and human capital, which move
from third world nations to economically dominant
countries. Navarro (183) has analysed how the
"underdevelopment of health" in the third world
follows inevitably from this depletion of natural and
human resources, The extraction of wealth limits
underdeveloped countries' ability to construct
effective health systems. Many Third World countries
face a net loss of health wokers who migrate to
economically dominant nations after expensive train
ing at home. Workers abroad who are employed by
multinational corporations also face high risks of
occupational disease (184).
By imperialism, corporations seek a cheap labor
force. Workers' efficiency was one important goal of
public health programs sponsored abroad, especially
in Latin America and Asia, by philanthropies closely
tied to expanding industries in the United States
(27,27.). Moreover, population-control programs
initiated by the United States and other dominant
countries have sought a more reliable participation
by women in the labor force (185, 186).
One thrust of imperialism is the creation of new
markets for products manufactured in dominant nati
ons and sold in the third world. This process
enhancing the accumulatianof capital by multinational
corporations, is nowhere clearer than in the
Studies of medical ideology have focused on
public statements by leaders of the profession (in
12
nutrition, sanitation, housing and other, services.
These changes can lead, through a sometimes com
plex chain of events, to remarkable improvements in
health. The morbidity and mortality trends that
followed socialist revolutions in such countries as
Cuba and China now are well known (190,191.
200-207). The transition to socialism in every case
has resulted in reorganisation of the health system,
emphasising better distribution of health care
facilities and personnel. Local political groups in
the commune, neighbourhood, or workplace have
assumed responsibility for health education and
preventive medicine programs. Class struggle conti
nues throughout the transition to socialism. During
Chile's brief period of socialist government, many
professionals resisted democratisation of health
institutions and supported the capitalist class that
previously and subsequently ruled the country
(130,131,192-195). Countries such as China and
Cuba eliminated the major source of social class:
the private ownership of the means of production.
However, as mentioned previously, new class
relations began to emerge that were based on
differential expertise. Health professionals received
larger salaries and maintained higher levels of
prestige and authority. One focus of the Chinese
Cultural Revolution was the struggle against the
new class of experts that had gained power in the
health system and elsewhere in society (56,202).
Other countries, including Cuba, have not con
fronted these new class relations as explicitly (191).
pharmaceutical and medical equipment industries
(88,89). The monopolistic character of these indus
tries as well as the stultifying impact that imported
technology has exerted on local research and deve
lopment, has led to the advocacy of nationalised
drug and equipment formularies in several countries
(187,188)
Imperialism reinforces international class rela
tions, and medicine contributes to this phenomenon
(54,189). As in the U. S., medical professionals
in the third world most often come from higher in
come families. Even when they do not, they frequently
view medicine as a route of upward mobility. As a
result, medical professionals tend to ally themeselves
with the capitalist class, the "national bourgeoisie",
of third world countries. They also frequently support
cooperative links between the local capitalist class
and business interests in economically dominant
countries. The class position of health professionals
has led them to resist social change that would
threaten current class structure, either nationally or
internationally. Similar patterns have emerged in
some post-revolutionary socieities. In the USSR,
professionals' new class position, based on expertise,
has caused them to act as a relatively conservative
group in periods of social change (28). Elitist ten
dencies in the post-revolutionary Cuban profession
also have received criticism from Marxist analysts
(190,191). Studies of several countries have analy
sed the relation among class, imperialism, and
professional resistance to change (1 30,131,1 90-195).
Improved health care remains linked to the
general level of economic development. In some
African nations, for instance, severe poverty hampers
organisational and programmatic changes. Countries
like Tanzania and Mozambique have undertaken
health planning that ties general economic develop
ment to innovations in health care (208-211).
Frequently imperialism has involved direct
military conquest; recently health workers have
assumed military or paramilitary roles in Indochina
and Northern Africa (196-198). Health institutions
also have taken part as bases for counter-insurgency
and intelligence operations in Latin America and
Asia (199).
Contradictions of Capitalist Reform
Health Care and the Transition to Socialism
Although they retain the essential features of
their capitalist economic systems, several nations in
Europe and North America have instituted major
reforms in their health systems. Some reforms have
produced beneficial effects that policy makers view
as possible models for the United States. Recent
Marxist studies, although, acknowledging many
improvements, have revealed troublesome contradic
tions that seem inherent in reforms attempted within
capitalist systems. These studies' conclusions are
not optimistic about the success of proposed reforms
in the United States.
The number of nations undergoing socialist
revolutions has increased dramatically in recent
years, particularly in Asia and Africa but also in
parts of Latin America, the Caribbean and Southern
Europe. Socialism is no panacea. N umerous problems
have arisen in all countries that have experienced
socialist revolutions. The contradictions that have
emerged in most post-revolutionary countries are
deeply troubling to Marxists; these contradictions
have been the subject of intensive analysis and
debate.
Great Britain's national health service has
attracted great interest. Serious problems have
On the other hand, socialism can produce
major modifications in health-system organisation,
13
people live and work. These studies try to transcend
the individual level of analysis to find how historical
social forces, at least in part, determine health and
balanced many of the undeniable benefits that the
British health service has achieved. Chief among
these problems is the professional and corporate
dominance that has persisted since the service s
inception. Descision-making bodies contain large
proportions of professionals, specialists, bankers
and corporate executives, many of whom have
direct or indirect links with pharmaceutical and
medical equipment industries (75, 110).
disease
Social Class and Economic Cycles
Considerable evidence
indicates that the
incidence and prevalence of mental illness closely
follows periods of economic growth or recession
The relations are complex and differ by social
class ( 217). Recent studies also have linked econo
mic cycles, particularly those that involve expanding
or contracting employment, to general mortality and
morbidity trends among various social classes and
age groups ( 218, 219 ).
The private-public contradiction, discussed
earlier, has remained a source of conflict in several
countries that have established national health ser
vices or universal insurance programs. Use of public
facilities for private practice has generated criticism
focusing on public subsidisation of the private sector.
In Britain, for example, thisconcern (along with more
general organisational problems that impeded com
prehensive care) was a primary motivation for the
recent reorganisation of the national health service
(110). In Chile, the attempt to reduce the use of
public facilities for private practice led to crippling
opposition from the organised medical profession
(130, 131,194). The private-public contradiction
will continue to create conflict and limit progress
when countries institute national health services
while preserving a strong private sector.
Stress and Social Organisation
Previous interest in stress usually has focused
on the individual life cycle or family unit Historical
materialist epidemiology shifts the level of analysis
to stressful forms of social organisation connected
to capitalist production and industrialisation (220).
Hypertension rates, for example, consistently have
increased with the disruption of stable social com
munities and organization of work that is hierarchically
controlled and time pressured. These observations
apply to countries that have followed caoitalist lines
of development and socialist countries that have
industrialised rapidly (221,222). Similar investiga
tions of coronary heart disease ( 223, 224 ), cancer
( 225 ), suicide (226) and anxiety ( 227 ) currently
are in progress.
The limits of state intervention also have become
clearer from the examples of Quebec and Sweden.
Both have tried to establish far-reaching programs of
health insurance, while preserving private practice
and corporate dealings in pharmaceuticals and
medical equipment. Recent studies have shown the
inevitable constraints of such reforms. Maldistribu
tion of facilities and personnel have persisted, and
costs have remained high. The accomplishments of
Quebec's and Sweden's reforms cannot pass beyond
the state's responsibility for protecting private enter
prise (136, 242). This observation leads to skepticism
about health reforms in the United States that rely
on private market mechanisms and that do not
challenge the broader structure within which the
health system is situated. (64, 213).
Work and Profit
Marxist studies in occupational health emphasise
the contradictions between profitability and improved
health conditions in capitalist industries (184,228).
Specific research has clarified the illness-generating
conditions of the work place and profit system with
reference to disease entities such as asbestos and
mesothelioma ( 83 ), complications of vinyl chloride
(123). drug abuse ( 229, 230 ), and accidents
( 231 ). On the other hand, observation of occupa
tional health practices in socialist countries have
shown that rapid improvements are possible when
private profit is removed as a disincentive to change
( 176, 232 ).
Historical Materialist Epidemiology
Historical materialist epidemiology is a rapidly
growing field in Marxist studies of health care. Its
antecedents derive from the classic research of
Engels (1), Virchow (3, 4) and the nineteenth-century
school of social medicine in Europe. Simply defined,
historical materialist epidemiology relates patterns of
death and disease to the political, economic, and
social structures of society (214-216). The field
emphasises changing historical patterns of disease
and the specific material circumstances under which
Studies in this area focus on the interplay among
sex, class structure, and work processes.-The varying
experiences of women and men are related to their
mortality rates and life expectancy ( 233, 234 ).
Historically, women's use of health facilities and the
attitudes of medical practitioners towards women's
health problems have depended largely on women's
14
class positions (161 ). This conclusion is especially
evident from the history of the birth control move
ment (235). psychiatric diagnosis (236), and gyne
cologic surgery ( 237 ). The unique health hazards
and difficulties that women face as housewives (238)
and paid workers ( 239, 240 ), currently are attrac
ting greater attention.
One unifying theme in the field is modern
medicine's limitations (15). Traditional epidemiology
has searched for causes of morbidity and mortality
that are amenable to medical intervention. Although
it acknowledges the importance of traditional techni
ques, historical materialist epidemiology has found
causes of disease and death that derive from broad
social structures beyond the reach of health care
alone.
1 he contradictions of patching have no simple
resolution. Clearly health workers cannot deny
services to clients, even when these services permit
clients' continued participation in illness-generating
social structures. On the other hand, it is important
to draw this connection between social issues and
personal troubles (242). Health praxis should link
clinical activities to efforts aimed directly at basic
socio-political change. Marxist analysis has clarified
some fruitful directions of political strategy.
Reformist Versus Non-reformist Reform
When oppressive social conditions exist, reforms
to improve them seem reasonable. However, the
history of reform in capitalist countries has shown
that reforms most often follow social protest, make
incremental improvements that do not change over
all patterns of oppression, and face cutbacks when
protest recedes. Health praxis includes a careful
study of reform proposals and the advocacy of
reforms that will have progressive impact.
Health Praxis
Marxist research conveys another basic message :
that research is not enough. " Praxis," as proposed
throughout the history of marxist scholarship, is
the disciplined uniting of thought and practice,
study and action ( 129). It is important to consider
political strategy, especially as it concerns the health
system of the United States.
A distinction developed by Gorz (243) clarifies
this problem. "Reformist reforms" provide small
material improvements while leaving intact current
political and economic structures. These reforms
may reduce discontent for periods of time, while
helping to preserve the system in its present forms :
"A reformist reform is one which subordinates
objectives to the criteria of rationality and practi
cability of a given system and policy... (It) rejects
those objectives and demands — however deep the
need for them — which are incompatible with the
preservation of the system." "Nonreformist reforms"
achieve true and lasting changes in the present
system's structures of power and finance. Rather
than obscuring sources of exploitation by small
incremental improvements, nonreformist reforms
expose and highlight structural inequities. Such
reforms ultimately increase frustration and political
tension in a society; they do not seek to reduce
these sources of political energy. As Gorz (243)
puts it: "... although we should not reject inter
mediary reforms... it is with strict proviso that they
are to be regarded as a means and not an end, as
dynamic phases in a progressive struggle, not as
stopping' places." From this viewpoint, health
workers can try to discern which current health
reform proposals are reformist and which are non
reformist. They also can take active advocacy roles,
supporting the latter and opposing the former.
Although the distinction is seldom easy, it has
received detailed analysis with reference to specific
proposals (64, 83,.107, 213, 244).
Contradictions of Patching
Health workers concerned about progressive
social change face difficult dilemmas in their day-today work. Clients' problems often have roots in the
social system. Examples abound : drug addicts and
alcoholics who prefer numbness to the pain of
unemployment and inadequate housing; persons
with occupational diseases that require treatment
but will worsen upon return to illness-generating
work conditions; people with stress-related cardio
vascular disease; elderly or disabled people who
need periodic medical certification to obtain welfare
benefits that are barely adequate; prisoners who
develop illness because of prison conditions(64,241).
Health workers usually feel obliged to respond to
the expressed needs of these and many similar
clients.
In doing so, however, health workers engage in
'■patching". On the individual level
patching
usually permits clients to keep functioning in a
social system that is often the source of the problem.
At the societal level, the cumulative effect of these
interchanges is the patching of a social system
whose patterns of oppression frequently cause
disease and personal unhappines. The medical
model that teaches health workers to serve
individual patients deflects attention from this
difficult and frightening dilemma (64).
15
pressure for change. In particular, these proposals
would permit the continuation of private practice
and, therefore, the inequities of the private-public
dichotomy. Yet, because a national health service
provides a model for a more responsively organised
system, advocacy of this reform seems a key part of
health praxis (207).
Reformist reforms would not change the overall
structure of the health system in any basic way. For
example, national health insurance chiefly would
create changes in financing,rat her than in the organi
sation of health system. This reform may reduce the
organisation of the health system. This reform may
reduce the financial crises of some patients; it would
help assure payment for health professionals and
hospitals. On the other hand, national health insurance
will do very ittle to control profit for medical indus
tries or to correct problems of maldistributed health
facilities and personnel. Its incremental approach and
reliance on private market processes would protect
the same economic and professional interests that
currently dominate the health system (64,83,213).
Health Care and Political Struggle
Fundamental social change, however, comes
not from legislation but from direct political action.
Currently, coalitions of community residents and
health workers are trying to gain control over the
governing bodies of health institutions that affect
them (111, 117-120). Unionisation activity and
minority group organising in health institutions are
exerting pressure to modify previous patterns of
stratification (248-252).
Other examples of reformist reforms are health
maintenance organisations, prepaid group practice,
medical foundations, and professional standards
review'organisations (64,213). With rare exceptions
that are organised as consumer cooperatives,
these innovations preserve professional dominance
in health care (245). There have been incentives to
improve existing patterns of maldistributed services.
Moreover, large private corporations have entered
this field rapidly, sponsoring profit-making health
maintenance organisations and marketing tech
nologic aids for peer review (81).
Until recently, support for a national health
service in the United States has been rare. For several
years, however, marxist analysts have worked with
members of Congress in drafting preliminary propo
sals for a national health service (152). These
proposals, if enacted, would be progressive in
several ways. They promise to place stringent limita
tions on private profit in the health sector. Most
large health institutionsgradually would come under
state ownership. Centralised health planning would
combine with policy input from local councils to
foster responsiveness and limit professional domin
ance. Financing by progressive taxation is designed
explicitly to benefit low-income patients. Periods of
required practice in underserved areas would address
the problem of maldistribution. The eventual develop
ment of a national drug and medical equipment
formularly promises to curtail monopoly capital in
the health sector.
Although these proposals face dim political
prospects, support is growing. For instance, the
Governing Council of the American Public Health
Association has passed two resolutions supporting
the concept of a national health service that would
be community based and financed by progressive
taxation (246, 247). This reform contains contradic
tions that probably would generate frustration and
Gaining control of the state through a revolu
tionary party remains a central strategic problem for
activists struggling for the advent of socalism (1 24).
Party building now is taking place throughout the
United States. Advocates of "vanguard party"
believe that historically all successful revolutions
have resulted from the efforts of a small vanguard
who hold consistent ideology and attract mass
support during periods of political and economic
upheaval. Activists adopting the vanguard approach
frequently take jobs as lower-echelon health workers;
they recruit members during unionisation efforts and
oppose cutbacks in jobs and health services. Sup
porters of a "mass party" argue that mass organising
must precede rather than follow the development of
a coherent ideology; therefore, political energies
should go toward building alliances that embrace a
spectrum of anticapitalist views. Mass party organi
sers work toward comm unity-worker control over
local health programs; occupational health and
safety, women's health issues, minority recruitment
into medicine, and electoral campaigns for improved
health services (254).
Recognising the impact of medical ideology
has motivated attempts to demystify current ideolo
gic patterns and develop alternatives. This "counterhegemonic" work often involves opposition to
the social control function of medicine in such areas
as drug addiction, genetic screening, contraception
and sterilisatian abuse, psychosurgery, and women's
health care. A network of alternative health programs
has emerged that tries to develop self-care and
nonhierarchical, anticapitalist forms of practice; these
ventures then would provide models of progressive
health work when future political change permits
their wider acceptance ( 255-259 ).
16
In anti-imperialist organising, severalgroups have
assisted persecuted health workers and have spoken
out against medical complicity in torture ( 130, 131,
260 ). Health and science workers also have used
historical materialist epidemiology in occupational
health projects and unionisation struggles.
10.
11.
12.
A common criticism of the Marxist perspective
is that it presents many problems with few solutions.
Recent advances in this field, however, have clarified
some useful directions of political strategy. This
struggle will be a protracted one and will involve
action on many fronts. The present holds little room
for complaisance or misguided optimism. Our future
health system, as well as the social order of which
it will be a part, depends largely on the praxis we
choose now.
13.
14.
15.
16.
Acknowledgements
17.
The author thanks Betty Boujoukos, Deborah
Helvarg, Alexander Leaf, Vicente Navarro, John
Stoeckle, Barbara Waterman, and referees of Annals
of Internal Medicine for their assistance, criticism,
and encouragement.
18.
19.
Grant support : in part by grants from the
National Center for Health Services Research (HS02100) and the Medical Clinics Complex Education
Fund of the Massachusetts General Hospital.
20.
21.
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23
HEALTH CARE IN A REVOLUTIONARY FRAMEWORK :
Possibilities for an Alternative Praxis
binayak sen and ilina sen
Any health care work is by its very nature, political. It is necessary for revolutionaries to get invovted in the non
reformist reforms to achieve the aim of social revolution. Starting from these premises the authors analyse health care
in the revolutionary frame ivork from their own experiences of health care work in the militant workers' and peasants
movement in Rajhara. They have presented their views as a commentary on and a supplement to Howard Wartzkm s article
in this issue.
health care systems have a social, cultural, economic
and political significance that goes beyond their
impact on health status has not been given its due
importance. Even when some attempts have been
made to come to terms with this aspect of the
matter, it has largely been on the basis of trivial
notions such as "health as an entry point into the
community." This is because the participants in
these debates have hardly ever taken the political
significance of their work as health professionals
seriously. While many of them have sincerely and
actively taken up political roles, this has almost
always been in areas of work outside the field of
health care itself. Both theory and practice have
suffered in consequence.
’ | 'he note that follows is a commentary on and
"E’ a supplement to Howard Waitzkin's article on a
marxist view of Heath Care. The main theme of
this note is the relevance and significance of health
care work within a left paradigm in India today.
To begin with however, a general point about
politics and health needs to be made. It is common
in left political circles to regard health care work as
apolitical, or at best, as reformistic. We would argue
that politics — the process of exercising power to
enhance the material interests of a particular class
or social group — permeates all aspects of the super
structure, including health care. The dominant
ideology at different times has projected feudal or
capitalist models of health care work. It is upto the
left movement to expose their ideological foun
dations and concretely shape a future alternative.
Some Lacunae in Current Approaches
to a Theory of Health Care
Health Care and Health Status
The realisation that health care and health status
are only distantly related has created a feeling of
deep frustration among many of those health profe
ssionals who are seeking a means, within the health
care system, to give expression to their own deep
commitment to the people's welfare. Lacking a
revolutionary scientific perspective about health
care work that would give meaning to their profe
ssional practice, tney have taken up one of two
types of roles. On the one hand some have ret
reated into the practice of health care essentially
within the bourgeois "welfare" paradigm, seeking
to give their work greater relevance by working
among rural or urban poor (often at considerable
personal cost). In many cases, they have also tried
to give their work scientific and technical validity by
incorporating positivist notions of a more rational
epidemiology, with the intention of creating more
efficient models of health care system for the future.
The words "health care work" have been chosen
deliberately, because the distinction between
"health" and "health care" has not been fully
realised even in debates among groups of politically
conscious health professionals. It is generally appre
ciated in such groups that health care is only one
among many determinants of the health of the com
munity, (other important determinants being political
economy, education, culture and so on). However,
the other side of the coin that health care work and
^3hat health care work and
health care system have a social
cultural economic and political
significance that goes beyond
their impacts on health status,
has not been given its due
importance-^
The other group, claiming for themselves a
greater familiarity with the revolutionary theoretical
apparatus, have nevertheless confined themselves
24
in Waitzkin's article, is therefore deserving of care
ful study and reflection. However, the necessity
of such reforms to any revolutionary programme
has not been given adequate importance in Waitz
kin's article. He contents himself by saying in the
opening sentence of this section, that "when oppre
ssive social conditions exist reforms to improve them
seem reasonable."
'jftc entire question of revolution
us process of the elaboration of
an alternative praxis based on
prevailing, material conditions
and incorporating currently
available elements of revoluti
onary theory has been by-passed.95
The necessity of social reform programmes was
put forward much more strongly by Roza Luxemburg
in her attack on Bernsteinian reformism, "Reform or
Revolution", she starts at the very outset, "Can the
social democracy (i. e. Communists) be against
reforms ? Can we counterpose the social revolution,
the transformation of the existing social order, our
final goal, to social reforms ? Certainly not. The
daily struggle for reforms, for the amelioration of the
workers within the existing social order, and for
democratic social institutions, offers to the social
democracy the only means of engaging in the prole
tarian class war and working in the direction of the
final goal — the conquest of political power and the
suppression of wage labour. Between social reforms
and revolution there exists for the social democracy
an indissoluble tie. The struggle for reforms is its
means; the social revolution, its aim."
almost exclusively within a vulgarised version of the
Leninist framework of Party and State policy. Their
attention especially in India has largely been focussed
on attempting critiques of existing health service
systems. This has largely been from the standpoint
only of political economy, the general thrust of the
argument being something like 'Health problems
cannot be solved within the bounds of the capitalist
economy.' Some have attempted to devise alterna
tives, but these have again been based either on
existing text book techniques such as epidemiology
or on new techniques rooted in capitalist culture
such as operations research — these alternatives wait
for their realisation on a dens ex machina, characte
rised variously as "political will" (D. Banerji) or
"dictatorship of the proletariat."
The distinctions mentioned by Gorz apply main
ly at the level of health policy rather than the
practice of health care. Moreover, Waitzkin seems
to sound as though there are. or can possibly be, a
set of independent criteria on the basis of which it
is possible to decide whether a proposed reform is
reformist or non-reformist. The fundamental ques
tion of the basic political framework within which
the struggle for these reforms is to be carried out, is
not emphasised.
In both these cases, the entire question of
revolution as process — of the elaboration of an
alternative praxis, based on prevailing material
conditions and incorporating currently available
elements of revolutionary theory — has been by
passed. This is not to negate the importance of
capturing State power, but to emphasise that the
process of delegitimising the existing ideology in
all walks of life has to begin here and now.
How are the differences between reformist and
non-reformist health care praxis to be established?
Waitzkin's Paper : Critical Comments
The importance of Waitzkin's article is that it
serves as an overview — ableit a very brief one — of
the area of interaction between the practice of
health care and current concepts in Marxist revolu
tionary theory.
For the last three years, in Rajhara, the Chhathisgarh Mukti Morcha has been running a health
programme based on a militant organised workers'
and pesants movement. Some indications may
It remains to comment upon some of the points
that he has raised in his article.
between social reforms and
revolution there exists for the
social democracy an indissoluble
tie. dhe struggle for reforms is
its means, the social revolution,
its aim.yy
66
a) Reformist Versus Non-Reformist Reform
With the exeeption, perhaps, of academic and
technical research, all the kinds of work available
for the revolutionary practice of health care require
participation in piecemeal reform programmes. The
distinction between reformist and non-reformist (or
revolutionary) reform, outlined by Gorz and quoted
25
perhaps .be obtained from the experiences gained
in the course of this work.
constant dynamic tension to existing perceptions,
so that the two may come close to each other in a
series of successive approximations.
The first difference, is that reformism is directed
primarily at suppressing emerging class antagonisms
and contradictions between state power and peo
ples' power. Revolutionary reform, on the other
hand by the very fact that it is based on a militant
recognition of class antagonisms and of the oppre
ssive nature of state power, is directed towards
precisely the opposite goal. Consequently, the most
important goal of a revolutionary reform programme
is not the achievement of the reform towards which
it is putatively directed, but to further the political
struggle of which it forms a part.
The third difference is that revolutionary reform
is vitally conscious of the inevitability of its own
failure. That is, we believe that the ills which owe
their existence to an oppressive social order cannot,
except marginally, be cured except by a radical
restructuring of that order - that is - revolution Con
sequently, we do not hope nor expect that our
praxis will succeed in effecting more than marginal
improvements in the health of the people or even in
the availability of curative care. However, our atte
mpt is to direct the energies of the people into the
establishment of an institution and a programme
which reflects their aspirations. This presents to the
people a radically new vision of an alternative social
order, and a living critique of the existing one.
The second difference is that revolutionary re
form does not derive its strength from any exogenous
group of "reformers' standing outside the main
stream of the popular consciousness. Instead, its
primary reasources are the political consciousness,
organised strength and creative power of the wor
king class and peasantry. Consequently, we cannot
take a single step in such a programme without
b)
Medical Care and Ideology : Hegmony and
Counter Hegemony.
Waitzkin refers in the first paragraph of the
section on Medical Ideology to the thought of Grammsci. However, once again the reference is so brief
that anyone not already familiar with the Gramscian
idea of Hegemony would be unable to make much
of the reference. It is worth going into the idea in
slightly greater detail, since it forms one of the chief
plants on which a revolutionary medical praxis is
based.
^J/te ‘Revolutionary reform docs
not derive its strength from any
exogenous group of "reformers"
standing outside the mainstream
of the popular consciousness. 99
Gramsci considered that the ruling classes
exercised and perpetuated their control over the
whole of society not only through the exercise of
political force, but also through the power of the
ideology elaborated by the ruling class intellectuals.
Through this process of legitimisation the ruling
class obtained the consent of the whole of society
to exercise the power of Government on its behalf.
considering the direction in which the people want
it to proceed. Any attempt to work out new ideas
has to be preceded by an effort to explain these to
the people, and to establish them in the popular
consciousness.
"In order to establish its own hegemony the
working class must do more than struggle for its own
narrow sectarian interests, it must be able to present
itself as the guarantor of the interests of society as a
whole. .". Gramsci had a broader view of the party
than Lenin perhaps partly because he had greater
experience of a developed bourgeois society. He
conceived of it as deeply committed to an ideological
and cultural struggle as well as to the seizure of
state power. . . Thus he advocated a party that
was an educational institution offering a counter-cul
ture whose aim was to gain an ascendancy in most
aspects of the superstructure (as opposed to directly
political institutions) before the attempt was made
on state power. The party organisers trained the
workers in the assumption of control over their own
This also means that at any given moment, the
direction of the programme cannot be governed by
a "a priori" consideration of the appropriateness of
the measures taken. The existing direction is always
limited by the existing perception of the people, of
the issues around which the programme is formed,
based on their collective past experience. Never
theless, it is necessary for those leading such
programmes to have a deep and concrete historical
understanding of similar programmes, and of the
issues as they exist in the community, (In the case
of health care, this would mean that we should
possess a knowledge of epidemiology and a know
ledge of the health service programmes.) This
knowledge is necessary so that it may be posed in a
26
lives and thus anticipated a post-revolutionary situa
tion. (David Melellan : Gramsci, in "Marxism after
Marx").
influence and thus reinforce working class militancy
and self confidence.
(b) Ideology and Technology:
Ideology in Health Care
The second area of ideology in health care that
needs to be considered is that relating to medical
technology. Waitzkin's article does go into this
aspect briefly, in the section entitled “Medical
Science is both esoteric and excellent." A much
more penetrating and thorough going critique of the
disabling and iatrogenic nature of modern medical
technology is contained in the work of lllich- to
which, surprisingly, this section makes no reference.
Illich's work also contains the notion of a demy
stified, locally-controlled, human-scale technology.
His notion of a society incorporating these ideas
is free of class, free of history and independent of
political process. He makes a fetish of Technology.
Through its medical institutions — ranging all the
way from state run hospitals through the Jasloks and
the mission hospitals to the lovliest private practitio
ner, the ruling class is constantly engaged in the
elaboration and perpetuation of an ideology that
serves to oppress and control the workers and the
poor.
There are three specific elements of ideology in
health care which are not adequately dealt with by
Waitzkin and hence need special consideration.
a) The Concept Of Charity .
The first, and in our view, the most important
of these, is the concept of charity, or "daya". This is
not considered in Waitzkin's article. Perhaps this is
because he writes from aWestern background, in
which there already exists a clear distinction between
the humanist and technical aspects of medical
practice.
This is not the place to embark on a critique of
lllich. However, irrespective of the viability of the
important part of the ability
of the existing, health care system
to reproduce ruling class
ideology is due to Us basis in
an esoteric, monopolistic
technology, seemingly divorced
from its roots in ordinary
manual and human skills.))
However, in India, we are all familiar with the
idea that the medical practitioner, be he ever so
crass, attains spiritual merit with each transaction in
which he plays the role of healer. The objective
caste status and the subjective Brahminical manner
of most practitioners of modern medicine further
reinforce this tendency. The influence of this tendency
is yet again reinforced and consciously generalised
by the religions symbolism that pervades the
atmosphere and even the architecture in many of the
important centres of modern clinical excellence.
(Apart from admittedly religious hospitals—Christian,
Hindu, Muslim or Jain — good examples are com
mercial-community based hospitals like Jaslok in
Bombay and the Calcutta Hospital in Calcutta).
solutions proposed by him, the notion of demy
stification of technology is important to any alter
native praxis in the field of health care. This is
because an important part of the ability of the exist
ing health care system to reproduce ruling class
ideology is due to its basis in an esoteric, monopo
listic technology, seemingly divorced from its roots
in ordinary mannual and human skills. It is this
technological basis that creates within the field of
medical practice a steadily widening gap between
mental and manual work.
Of course, the function of the healer neither can
nor should be totally divested of transcendent
elements of spiritual and psychological authority.
Neither can the role of the patient ever be totally
divested ofits elements of spiritual and psychological
dependency.
However, where the healing institution has been
built up on the initiative and with the resourcee of a
militant organised working class movement, and
functions specifically within a revolutionary frame
work, and with healers who live among the people
and aspire to be identified as revolutionaries rather
than as do-gooders, this relationship of authority
and dependence can have a counter hegemonic
It is to reverse this trend that the concept of
the voluntary health worker is important.
In the health programme at Rajhara, a training
programme for voluntary health workers has been
put into operation. However, these workers are not
seen primarily as agents who, by performing simple
27
tasks in a decentralised fashion, increase the effici
ency of the health programme. Rather, the VHWs are
seen as ordinary workers, who, by undertaking to
perform certain healing functions on the basis of
their skills in and understanding of modern medical
technology, render the entire range of medical tech
nology accessable to ordinary human understanding.
The training programme also repeatedly empha
sises the idea that the primary duty of the VHWs is
to spread their understanding of health care tech
nology among their comrades.
Secondly, throughout this note, in order to
achieve the limited aims which the note seeks to
fulfil, an attempt has been made to emphasise.
a) health care as against health status.
b) Superstructural elements as against
more fundamental aspects related to
political economy.
c) the revolutionary possibilities of an
alternative praxis of health care as
against the humanist values embodied
(or at least imminent in) more tradi
tional form of health care work.
C) Internal Organisation
A third ideological function that a health care
programme can perform is to create, within the
internal organisation of the programme, an image
of what the social dynamics of such a programme in
a socialist society might be. In particular, the
undemocratic and hierarchical
functioning of
most health care institutions is something that any
alternative praxis of health care must try to change.
It would be disastrous if on the basis of this
note, anyone should conclude that we consider the
second halves of these contrasts to be unimportant.
On the contrary, in each case, it is only possible to
emphasise the former where the latter is already
taken for granted. This selective emphasis must be
kept in mind throughout the reading of this note.
Finally, except where direct quotations have
been made, no references are included. The points
made in this note have emerged through discus
ions and practice engaged in with many groups of
friends and colleagues over a long period of time.
Conclusion
In conclusion, the limits of this note — all too
apparent to the authors must be emphasised strongly.
In the first place, it is a comment on Waitzkin's
article, and must be read against the background
of the article i. e. not independently.
Orwell's Hints to Writers
George Orwell in his 'Politics and the English language' attacks jargons severely
and says: "Modern writing at its worst does not consist in picking out words for the
sake of their meaning and inventing images in order to make the meaning clearer. It
consists in gumming together long strips of words which have already been set in order
by someone else, and making the results presentable by sheer humbug...... They will
construct your sentences for you, even think your thoughts for you, to a certain extent
and at need they will perfrom important service of partially concealing your meaning
even from yourself." He has given some rules for writers to follow: (i) Never use a
metaphor, simile or other figure of speech which you are used to seeing in print
(ii) Never use a long word where a short one will do (iii) If it is possible to cut a word out,
always cut it out (iv) Never use the passive when you can use the active, (v) Never
use a foreign phase, a scientific word or a jargon word if you can think of an everyday
English equivalent (vi) Break any of these rules sooner than say anything outright
babarous..... The most important thing to remember is that good writing is not a
collection of beautiful phrases or idioms. Good writing is the result of clear thinking.
(Excerpted from The Hindu May 8, 1984)
28
POLITICAL ECONOMY OF HEALTH CARE IN INDIA
An Outline
amar jesani and padma prakash
Medicine is not a socially independent activity. It is always articulated within a specific mode of production. Therefore,
the dominant medical practice in India is bourgeois medicine and health care helps to strengthen and expand the capitalist
mode of production. It also reproduces the capitalist relations of production at every level of its operation. The development
of health care in India is examined m the context of the dynamics of socio-economic changes which have taken place
since independence.
"My inquiry led me to the conclusion that
neither legal relations nor political forms could be
comprehended whether by themselves or on the
basis of so-called general development of the
human mind, but that on the contrary they originate
in the material conditions of life, the totality of
which Hegel, following the example of English and
French thinkers of the eighteenth century, embraces
within the term 'civil society', that the anatomy of
this civil society, however has to be sought in
political economy."
satisfy hunger or other needs was the predominant
consideration. But with the evolution of a more
complex social organisation leading totheevolution
of a social system based on commodity production
such goods which were necessary and useful for life
also acquired, exchange value of their own. Every
commodity in the capitalist economy has therefore,
two characters, the use value and the exchange value.
But this exchange value cannot be located or identi
fied in the commodity. Exchange value is then, an
exclusive social category which has no analogy in
nature. "The main tendency of the developmental
process that arises in this way is the constant in
crease both quantitative and qualitative of purely or
predominantly social components, the 'retreat of
the natural boundary' as Marx puts it. "(Lukacs,
1978).
Karl Marx
Preface to
A Contribution to the Critique of Political Economy.
very human being, in the last analysis, after
removing all covers of social existence, is natu
ral and therefore, biological. The flesh, blood and
bones comprising the human body are too materia
listic for anyone to deny their existence. But this
natural living individual is not a lone, isolated
entity. Through centuries of social development, the
individual has evolved socially, coming into inter
action with nature and while transforming it, has
himself/herseif been transformed. In the course of
this social development, human beings have entered
into various types of relationships in order to
produce the necessary means of subsistence and
to reproduce his/her own species and so given
rise to the complex organisation of, to use Hegel's
term, the 'civil society.'
Health and medicine are such social categories
which have reference not simply to the biological
existence of the human being, but to the social
nature of such existence. That is why the understand
ing of health has changed according to the needs
of different social systems and the needs of the
ruling elite of that social system..
Features of the Marxist Approach to
the Critique of Political Economy of
Health
Four major features of the Marxist approach to
the political economy of health may be identified—
The 'natural' or the biological forms the funda
mental basis on which, historically, the social exis
tence ;of human beings has developed. In the course
of this development completely new forms of objec
tivity have arisen and although such objectivity have
no analogy in nature, they still remain socially trans
formed natural objectivities.
The Social Production of Illness ; Medical
definitions of health and illness are located in the
clinical pathology of the individual. In its narrowest
and most limited form this definition locates the
cause of disease entirely in the human body and
disease is seen as a consequence of an unwanted
attack of biological entities, bacteria, or virus, onthe
human body. The control of disease is seen to mean
the control or eradication of these bacterial or
causative agents. The concept that ill health is
To illustrate, in primitive societies, the exchange
of necessary goods was not the rule but, more the
exception. Here the natural use of those goods, to
29
to work falls off, and with it, the amount of surplus
value that will be generated. The capitalist is simply
not interested in the level of health beyond this,
even though the worker will be vitally interested
from the point of view of the quality of life and not
of productive capacity (Schatzkin, 1978).
directly related to the socio-economic formation and
to the production relations in society has been put
forward by several analysts since Engels wrote the
‘The Conditions of the working class in England'. Turshen
traces the origins of what is termed the 'clinical
paradigm' and discusses its weakness. According to
her the discipline that comes closest to explaining
the notion of collectivities is medical ecology.
"Medical Ecology, thus asserts a relationship bet
ween environment, disease and man but selects only
biological and socio cultural factors as relevant.
(Turshen 1977). This too ignores the illness genera
ting forces in society. Doyal and Pennell in their
book Political Economy of Health have elaborated on
the evolution of the clinical paradigm in modern
medicine. They discuss the direct and intimate rela
tionship between the process of commodity produc
tion and destruction of health and between
economic underdevelopment and health. (Doyal &
Fennel, 1981). This view does not exclude or deny
the operation of the biological mechanism which
From this point of view of health as labour
power, Schatzkin argues that medical care services
are designed for maintaining the requisite level of
health, a kind of labour power 'repair and mainte
nance service'. While educational services help to
maintain the knowledge and skill component of
work capacity, medical services help to maintain
the physical and psychological components. Since
the provision of health is part of maintaining labour
power, it represents to the capitalist, a part of the
wages he must pay out, directly as wages or indi
rectly as 'social' wages in the form of medical
services.
The commodification of health care: A com
modity is an external object which through its
qualities satisfies human needs of whatever kind
and is produced for exchange in the market. Health
care is one such commodity. Historically, throughout
most of human history, health care was an organic
part of a communal society. It has often been
indistinguishable from religious or social activities,
none of which were exchanged (although gifts were
often presented to traditional healers). As communal
societies were conquered by feudal and eventually
capitalist societies, health care was taken out of the
hands of traditional healers and placed in the do
main of doctors and midwives, who engaged in
health care for a price i.e. as part of a money ex
change. The physician was an independent producer
selling the product of his or her own labour (Roder
and Stevenson, p. 19-108).
and medicine are social
categories which have reference
not simply to the biological
existence of the human being,
but to the social nature of
such existence.^
cause illness. The concept that ill health can only
be understood as a consequence of the dynamics of
class contradictions in society, and that the occur
rence of disease is intimately related to the social
formation within which the biological, physical and
chemical operate is one of the major marxist contri
butions to the critique of political economy of health.
But "capitalist production is not merely the
production of commodities, it is by its very
essence, the production of surplus labour"
Health as labour power . Under capitalism
health is defined as an integral component of an
individual’s labour power or productive capacity.
Labour power being a commodity under capitalism
has a specific exchange value — the quantity of
social labour necessary to reproduce it.... just as any
other commodity does. In other words, the exchange
value of labour power is the value of consumer
goods and other services necessary to keep the
worker and his/her children fit enough to work at a
given intensity of effort. But to maintain this level
of effort, or the maximum level of productivity, a
certain level of physical and mental health is vitally
necessary. Below that level of health the capacity
(Marx Capital, p. 644). The capitalist can organise
the production of surplus value through the provi
sion of health care and can realise high profits in
this service industry. It is immaterial whether the
surplus value is realised directly through the produc
tive activities in the clinics and hospitals owned by
the capitalist or indirectly, through the provision of
health care by the state to maintain or increase the
productive capacity of labour.
Medicine as a social relation: Vicente Navarro
has concretised our understanding of how medicine
should be viewed within the perspective of the so
cial system. He argues that medicine or health
30
services is a social relation and reproduces the
dominant relations of production. Medicine, there
fore, has been different under different modes of
production. He argues that since the mode of
production is reproduced not only at the economic
but also at the political and ideological levels, medi
cine contributes to the reproduction of the mode of
production at the economic, political and the
ideological levels and that medicine is always
articulated within a specific mode of production.
century. The first medical men to set foot on the
sub-continent were the surgeons sailing with the
merchant ships of the maritime nations of the time.
Throughout the century a number of Europeans
found employment as surgeons and physicians in
the Courts of the kings and nawabs. By the end of
the 18th Century all the factories of the East Indian
Company had at least one surgeon in their employ
and the Indian Medical Service had been founded
(Crawford, 1914).
These are the features of Marxist approach or
methodology which we will use to examine the
political economy of health care in India. But any
attempt to examine the development of health care
in India in the context of socio-economic develop
ment brings into focus the subject of the mode of
production in Indian agriculture. We are aware that
this subject has generated a lot of debate amongst
Marxists in the last decade and there are divergent
viewpoints. We will not here review the entire
debate that has taken place nor put forward our
viewpoint on the subject and substantiate it. Our
focus is the political economy of health care. We
will, therefore, endeavour to show that, the very
efforts of the Indian State to penetrate the remotest
corners of the agrarian set-up through the provi
sion of health care facilities; is not any isolated and
non-social phenomenon. But the efforts in fact
strengthen and reproduce the already existing and
expanding capitalist relationsof production (whether
in "pure" forms or intertwined with the pre-capita
list forms).
At that point of time the medicine practised by
the company doctor was hardly different from local
systems. The doctor of the day had a limited range
of therapeutics and curative procedures .... herbal
medicines, a very few disease-specific chemical
preparations, the new 'exotic' drug the Peruvian
cortex (cinchona) for intermittent fevers, blood
letting, venesection and other such procedures which
^Since the mode of production
is reproduced not only at the
economic but also at thepolitical
and ideological levels, medicine
contributes to the reproduction'
of the mode of production at
the economic political and
ideological levels and that
medicine is always articulated
within a specific mode of
production.^
At the same time, we must admit that this
analysis is our first attempt and the vastness of the
exercise has made us very aware of the inadequ
acies in the sphere of information and data. The
most evidently thin area of the outline is the lack of
analysis and attention to the social roots of illhealth and disease in India. By and large, we have
merely assumed that the patterns of illness are
reflective of the class, caste and sexual contradic
tions and are influenced by the level of develop
ment, both quantitative and qualitative, of the
social system. We have also assumed that changes
in the patterns of illness are directly related to
changes in socio-economic system, and have proce
eded to focus on the changes in health care in
light of the change in the mode of production. Our
objective is to locate the crisis in health care and
medicine within the larger political perspective for
class struggle.
had been in vogue since the time of Galen. The
birth of modern scientific medicine was yet to be. In
the following century however, there were enormous
developments in the content, theory and practice of
medicine in Europe. Not only had the knowledge
base of medicine expanded but it was being struc
tured to meet the needs of the dominant class. For
instance, the two major disease casuality theories
that were competing for acceptance, the contagion
theory and an environment theory were more than
medical theories and their incorporation into contem
porary medical thought was dependent on how they
affected the operations of the dominant class of the
time. During the first half of the 19th century the
contagion theory which suggested quarantine
measurs as a means of controlling disease, was the
best accepted. But with the increased movement of
goods and of people towards the middle of the 19th
Health care under British imperialism
Western medicine came to India in the 17th
31
training centres were set up to teach midwives the
'modern' methods of childbirth. The funding for
these came from wealthy Indians who wished to
set up hospitals as memorials. (Billington, 1973).
century, quarantine measures proved ruinous to the
new entrepreneurs and merchants. One important
reason for the acceptance of the miasma theory
which located the cause of disease in unsanitary
conditions was the potentially disastrous effects the
acceptance of the contagion hypothesis would have
caused (Tesh, 1982).
Medical Colleges were set up to train assistants
and a large number of Indians were takingavantage
of the opportunity. The upper castes were specially
encouraged to enter these colleges. Right from the
beginning allopathic medicine in India acquired an
upper caste elite base. (Banerji. 1974). Women too
were given special concessions, so that the new
maternity homes could be well-staffed.
By the end of the 19th century, the sanitary
reform movement in Britain had resulted in limited
state intervention in the form of legislations and in
the creation of institutions for administering them.
But these refoms were actually self-limiting. Although
they affected a section of the capitalists whose
profits came from housing, water supply and sewe
rage dealerships, they served the needs of capital by
decreasing the cost of disease. At the same time
public health work and preventive medicine could
never gain the status nor weild the same influence
as clinical medicine. Public health work highlighted
the shortcoming of capitalism and it would mainly
benefit a class which was incapable of conferring
status. (Turshen, 1977). On the other hand, clini-
The development of 'scientific clinical medicine
which embodied bourgeois ideology and relations of
production was far more important than the crea
tion of a public health system which might expose
the true nature of British imperialism.
The health care network under the British
comprised desultorily implemented sanitary measures
and a fair number of hospitals and dispensaries with
a growing number of medical research facilities
undertaking work on tropical diseases under the
tutelage of European doctors and researchers.
The path of deveiopment consciously
adopted by the Indian ruling classes
at the time of Independence.
b^One op f/te aims of the planning
was to aid the capital accumu
lation in the private sector.')')
The increasing popularity of modern allopathic
medicine amongst the Indian elite strata was not an
accidental phenomenon. It was rather a part of the
process of emergence of Indian bourgeoisie as an
economically powerful and politically shrewd class
under British imperialism. As we will show later in
this section, the choice of modern allopathic ("scie
ntific") medicine as a basis of development of
health-care system in India was deliberate (despite
the fact that other choices and concrete proposals
existed), and was in consonance with the path of
socio-economic development adopted by the Indian
ruling classes. To substantiate this statement, we will
examine the situation at the time of independence
under three headings : a) the strength of Indian
bourgeoisie at the time of independence, b) the
political and economic strategy adopted by the Indian
bourgeoisie for strengthening its class rule, and c)
the health care strategy adopted as a part of
development perspective.
cal medicine with its focus on the individual rather
than the social conditions underlying disease states
offered a means of diverting public attention from
the ills of capitalism.
The origins of the sanitary reforms in India are
rooted in a different set of circumstances. After
1857, and the take over by the Crown, the number
of troops on Indian soil increased and the health of
the army became a subject of discussion. More
over, cholera which had been confined to India so
far broke out in a devastating epidemic in Europe.
The British colonial government was pressurised into
initiating sanitary measures in the Presidency areas.
But these measures did not give rise to a public
health system and the government chose instead, to
encourage the setting up of medical research facili
ties for the assault on tropical diseases, an assault
master minded in England. (Ramasubban, 1982).
(a) The strength of the Indian bourgeoisie
at the time of independence : On the eve of
Outside the government framework, a number
of missionary groups and individuals had also begun
to set up hospitals and medical institutions. For
instance, a number of maternity hospitals and
independence, although, India's total economy
was overwhelmingly agricultural, substantial indu
strialisation had taken place. In fact, India was much
32
better placed than most other colonial or semi
colonial countries of that time.
hands of Indian bourgeoisie, keeping the socio
economic structure of the society more-or-less intact.
Moreover, under the Mountbatten plan this transfer
was affected through negotiation and bargain.
Therefore, after taking over the reins of State power,
the Indian bourgeoisie did not adopt radical mea
sures attempting to do away with India's pre
capitalist forces. In so far as those forces did not
seriously obstruct its plan of gradual transformation
of Indian agriculture through state intervention it
adopted a policy of compromise and accommodation.
India's domestic capital, at the time of indepen
dence nearly occupied an equal place with foreign
capital in Indian economy.-(Bettelheim, 1968). Accor
ding to the same source, foreign capital's sphere of
influence was particularly in the principal foregin
currency earning industries (tea, jute and cotton)
and in those which were the main sources of power
in India (petroleum, coal, electricity).
In assessing the political strength of the Indian
bourgeoisie at the time of independence, two points
should be understood. Firstly, Indian capital had to
develop under the tight control of British imperialism.
In its confrontation with foreign capital and imperial
policies, it was but natural that a tendency developed
towards developing stronger economic and political
organisations of its own. Moreover, Indian Capital
did not develop through "free competition." Due to
several intrinsic factors specific to India, and due to
the fact that World Capital was already at the
monopolistic stage, there was naturally a tendency
for Indian industral capital to take monopolistic
forms. This situation helped it to organise its various
groups with much more ease and also made it more
shrewd and alert in extending right political
patronage.
At the same time, in the turbulent 1940s the
Indian bourgeoisie feared the militancy of the work
ing masses. It should be noted that from the later
half of 1930s, the mass unrest had attained serious
proportion. On the industrial front, the number of
strikes in 1937 reached 379, the highest since 1921.
Between 1942 and 45, the cost of living went up by
200 percent. The year 1940 saw another strike wave,
in which workers of cotton textile, jute, oil, coal,
iron, and steer and many other industries partici
pated. The number of trade unions went up from
66‘J/ie Indian bourgeoisie opted
{or a model o{ health care
service in which health care
could be transformed into a
commodity-^
Secondly, the Indian bourgeoisie was politi
cally shrewd enough to understand the importance
of Gandhi’s ideology of harmony between capital
and labour. During the 1918 textile workers' strike
in Ahmedabad the newly formed Bombay Mill
owners' Association utilised this opportunity to
establish contacts with Gandhi. Subsequently in
1921, with the launching of the Swadeshi movements
they found in Gandhi a representative leader and in
the Congress their representative Party. It is impor
tant to note that from this point onwards, the
bourgeoisie never lost its political leadership of the
nationalist movement. Thus, at the time of indepen
dence,the party of the Indian bourgeoisie, thelndian
National Congress maintained its leadership of the
nationalist movement and very meticulously imple
mented the strategy of the Indian bourgeoisie for the
post independence growth of capitalism in India.
188 in 1938 to 515 in 1944 with the membership
rising from 3,65,450 to 5,09,084 (Dutt, 1983).
At the same time, the All India Kisan Sabha,
which took a leading role in fighting against govern
ment repression and had helped organise self-help
movements for food and funds, quadrupled its mem
bership between 1942 and '45. (Dutt, 1983,
p. 279). The end of the war saw two significant
peasant movements - the Tebhaga movement between
'46 and '47 in what is now Bangladesh and the
Telangana struggle in '46 and '51 in Andhra. These
were the most outstanding indicators of peasant
ferment brewing al! over the country.
The political ferment also spread to the armed
forces in'46. The RIN mutiny and the support it
gained in Bombay from the working class and
middle classes shook the Indian bourgeoisie. Thus
although, the Indian left, because of many reasons
into which we cannot go in in this article, could
not destabilise the bourgeoisie nor have a perspective
b) The political and economic strategy ado
pted by the Indian bourgeoisie forstrengthening
its class rule: The Indian independence was not a
social revolution in which, one class through violent
means seizes political and socio-economic power from
another. In fact, independence was just transfer of
political power from British imperialism into the
33
existing bourgeoise forces leading ultimately to the
modernisation of agriculture on a capitalistic basis.
to take control of the national movement, the latter
was forced to recognise the explosive potential for
militancy among the labouring masses. The reali
sation that the mass pressure the bourgeoisie had
so far used to their advantage could get out of
hand, forced them into granting concessions in the
overall plan of development at independence.
c) The health care strategy adopted as a
part of the development perspective : At the time
of independence, three major reports concerning the
health system in the new nation saw the light of the
day. In 1939 the national planning committee had
set up a subcommittee to prepare a plan for health.
In 1940, the Chopra Committee was constituted at
the first health minister's conference. And the Bhore
committee began work in 1943, and was charged
with the task of conducting a survey of the entire
field of public health and medical relief on which to
base plans for post-war development in the health
field. (Bhore, 1 946). It advocated a doctor-centered
system of health care and urged the creation of a
vast health infrastructure. Its main inspiration were
the Flexner report (which consolidated the establish
ment of 'scientific' medicine in the US) and the
Goodenough Committee (which had been a more
recent report restructuring medical education in
U.K.). Briefly, the Bhore committee recommended
(i) the main focus of all health measures should be
to enable people to enjoy life to the fullest extent
and to help the individual reach his maximum level
of productive capacity; (ii) the future health care
system should be a doctor-based, hospital-centered
system with a proliferation of health institutions;
(iii) a salaried service should be preferred over
private practice although "any apprehension that
private practitioner will be seriously affected to their
detriment by our proposals for a state health service
is unfounded." (Bhore, 1949 p. 1 6); (iv) occupation
al and industrial health was an important aspect
of health services; (v) maternal and child health
was to be given a high priority; and (vi) consequent
on the development of a health infrastructure, the
pharmaceuticals and the surgical goods industries
would have to be encouraged to expand.
In the context of the above, the bourgeois
strategy that developed after independence . was
twofold. Parliamentary democracy was accepted
because it would widen the mass base of the
regime, to give room to the contending socio-econo
mic forces in the governmental block and to
provide a safety valve for mass discontent. This
method of bourgeois rule granted universal fran
chise, formal political democracy, equality before
the law and so on all at one stroke. In the Constitu
tion, it gave the State Power a clear bourgeois
impress by making the right to private property a
fundamental right. The right to work, the right to
receive free health care, education and so on were not
included in the list of fundamental rights but were
^7/ie expansion of capitalism is
dependent on a politically
stable and healthy labour force
relegated to being directive principles. Also, for the
future socio-economic development of India, plan
ning with the active intervention of the State in the
economy was adopted as the best way for industrial
development and for the transformation of back
ward agriculture.
Briefly, the aims of planning with the active State
intervention in the economy were the following: (i)
To develop an infrastructure of the heavy industry,
transport, communication, and energy, so vitally
necessary to overcome the most glaring weaknesses
of industry or the under-developed capital intensive
industries. This development required.huge invest
ment and a long gestational period for invested capi
tal, the private sector was not yet ready for this,
(ii) To aid the process of capital accumulation in the
private sector. This was to be done providing private
capital with easy access to the infrastructure, by em
ploying private'contractors in the operation of public
sector, by enriching individuals or groups of indi
vidual bureaucrats and so on, and (iii) To carry out
limited agrarian reforms, to provide facilities for agri
cultural development and strengthen and expand
The Chopra committee (the committee on
Indigenous System of Medicine) report was publi
shed in 1948 and made recommendations which,
had they been implemented at that time, would
have resulted in a drastically different system of
medicine. It saw an urgent necessity for evolving
one unified system'. It pointed out that the Bhore
Committee had been rather silent on the question of
indigenous systems in their grand plan for the
development of health services in India. The
Chopra Committee, in fact, had drawn up a plan for
health services where the primary levels would
mostly use indigenous system and the taluk hospital
and beyond would practise 'synthesised' medicine.
Almost all the recommendations were rejected It
34
was decided that a full course in modern scientific
medicine was to be the basis on which other systems
were to be engrafted.
production of food grains recorded a much smaller
growth than that of cash/industrial crops. The
rise in grain production did not outstrip or even
equal the rise in population. The sectoral allocations
in the first plan gave first priority to agriculture,
community development and irrigation which
together accounted for 35.8 percent of the outlay.
After that, the percentage share of the outlay in
these areas consistently decreased.
The Indian bourgeoisie opted for a model of
health care service in which health care could be
transformed into a commodity. Even in adopting
the recommendations of the Bhore committee, it
selectively incorporated those recommendations
which contributed to the growth of the health
infrastructure and the consolidation of bourgeoisie
and its concomitant organisation. The development
and consolidation of allopathic 'scientific' medicine
was also a deliberate choice which offered several
advantages which we will elaborate in a later sec
tion. For the moment, it is sufficient to state the
supposed resolve of the Indian bourgeoisie to
develop indigenous systems did not get translated
into any meaningful programmes and India was
well set on the way to enlarging the world base for
the practice of 'scientific medicine'.
Throughout this period agrarian legislation
strengthened the position of the rural upper classes.
The richer peasantry were able to gain greater free
dom from their landlords and were able to increase
their holdings. The big landlords were being trans
formed into capitalist farmers. The conditions of the
poorer peasantary considerably worsened during
these years. On the whole there was a slow develop
ment of rural capitalism. (Betteleheim, 1968).
Agrarian reforms were in this period directed
not so much at transforming the modes of produc
tion in agriculture, as adapting the colonial agrarian
structure to fit the pattern of growth envisaged by
First fifteen years of Planning
(a) Growth of industries hastening captial
accumulation : The public expenditure on develop
ment in the first three five years plan period was
as shown in Appendix 1.
66‘JAc programmes like malaria
control must be seen as death
control programmes preceding
the birth control programmes
of a later period.^
From the second plan, Industry and mining
started receiving the attention of the planners and
in the third plan it got the first priority. The major
investment in this branch was in heavy industry. By
1965, substantial changes took place in the in
dustrial structure. The gross value of output of light
industry increased from Rs. 17,100 million in 1951
to 35,900 million in 1965, i. e. itmore than doubled
in 15 years. In this period, theoutput value increased
by 8.5 times in the heavy industry. The share of
heavy industry in the total output of manufacturing
industries went up from 22 to 52 percent. The
investment in heavy industry went up from 43.4
percent of the total investments in the manufacturing
industriesin 1951 to 79.8 percentin 1965. (Shirokov,
1980).
Thus, at the end of third plan period, the public
sector had set up productive plants mainly in the
sphere of heavy industry. It could do this by recei
ving soft-term loans from the Soviet and other
'Socialist' countries.
the bourgeoisie. They were directed at eliminating
the intermediaries and middle men and reducing the
effect of feudal and semi-feudal relations. Agricul
tural policies and programmes favoured those land
lords who had undertaken cultivation on their own,
rather than rentier landlords (Joshi, 1969). The
non-implementation or failure of those portions or
land reforms or the 'failure of land reforms' was not
surprising, considering as Davey remarks aptly, that
the state assemblies were dominated by landlords
and kulaks. Likewise, land ceiling legislation was
easily circumvented. The Failure to ensure security
of tenure has resulted in evictions. In the Punjab
alone, the number of tenancies fell from 583,400
in 1955 to 80,520 in 1960 (Davy, 1975).
Even while developing the industrial infrastruc
ture, in this period a slow but steady transformation
of the Indian agrarian sector, was also begun.
The Community Development Programme, laun
ched with US aid in the first plan, further strength
ened the economically and politically dominant
classes. Later evaluations showed that 70 percent
of the benefits from agricultural extension went to
(b) The Transformation of Indian agriculture
The progress in the agricultural sector in the first
fifteen years can at best be termed modest. The
35
There were four factors, one may call them
constraints, which limited the bourgeoisie's options
in the health sector. Firstly, they functioned in an
economy linked to and subservient to World
capitalism. Secondly, they were committed to
planned development. Thirdly, they had to function
within the garb of a 'welfare State' and fourthly,
in the beginning at least, they had to counterpoise
and diffuse working class demands and tensions.
What were the health plans and programmes of the
period and how did they advance bourgeois aims
and ideology?
the elite groups, the more affluent and influential
agriculturists" (Dubey, 1969). The CD projects
worked through existing village institutions which
were more often than not, dominated by landown
ing groups. The 'Shramdan' drive which was sup
posed to encourage people's participation, in terms
of free labour on road construction and repair,
was usually contributed by the poor who had
nothing to gain from roads; while those who benefitted from the roads, the large landholders who
needed to transport goods out, got away by merely
supervising. The CD programmes not only streng
thened the rural elite but also created bureacratic institutions which acted as a link between
the rural elite and the government.
In 1951, the population of India was 361 mil
lion. Nearly 38% of the working, population were
wage-earners (Bettelheim, 1968). The economic
growth envisaged required a healthy and pro
ductive labour.
However, the recent series of
famines and droughts, increased exploitation of war,
further deterioration of the abysmal public health
and sanitary services, the post partition exodus had
resulted in a labour which obviously could not con
tribute its best in terms of productivity. The situation
also favoured political instability. The expansion of
capitalism is dependent on a politically stable and
healthy labour force and these called for measures
to reduce mortality and morbidity in the Country.
Moreover, the unhampered bourgeois hegemony
of the national movement had been paid for by
making promises to the working class and its leaders
as well as the progressive educated elite, in response
to the growing mass discontent the bourgeoisie had
to make visible gestures which could demonstrate
their concern and their intention of fulfilling promi
ses. The creation of large health institutions, and
building of medical colleges and research establish
ments was a most appropriate strategy.
After 1960, agrarian policies and programmes
became openly favourable to rich peasants. The
Ford Foundation sponsored Intensive Areas Develop
ment Programmes with its packages of credit,
modern inputs, marketing facilities and technical
(tCBourgeois radicalism cither in
the form of reports or
legislations or programmes can
best be viewed as concessions
gained by working class
militancy
advice was one such. This meant also the increas
ing use of high yielding varieties and fertilisers.
Between 1960 and 1966 the consumption of fer
tilisers more than doubled (Davev, 1975). The two
disastrous droughts in '65 and '67 upset bourgeois
plans of strengthening and developing rural
captitalism.
At the same time it was recognised that the
reinforcing of capitalist ideology and reproduction of
bourgeois class relations was necessary to the
growth and development of capitalism. 'Scientific'
medicine which had evolved and matured under
capitalism was obviously the most appropriate cho
ice. In this sense, the adoption of modern medicine
as the dominant system of medicine and the creation
of hospital infrastructures where it could be practised
was an ideological as well as political necessity.
(c) Health Care in a Planned economy; The
evaluation of health services and the growth
of medicine in India can only be analysed in the
background of the development strategies employed
by the Indian bourgeoisie. As we have seen the
primary aim of Indian capitalism at independence
was the consolidation and expansion of capitalist
relations and the transformation and integration of
pre-capitalist mode of production. Accordingly, the
health strategies that were chosen directly or in
directly supported and strengthened the drive for
capital accumulation.
1) Reduction in Morbidity and Mortality: At
the time of independence 50 percent of all deaths
were estimated to be from epidemic diseases. The
expectation of life at birth was 32.45 years for males
and 31.66 for females (Health Statistics, 1982).
Cholera, Malaria, tuberculosis and smallpox were
major killers. In 1 950 malaria killed 75 million and
36
it was estimated that 156 million work days were
l0SS Of Rs' 75 million- PAC Report1-83-8 ). Moreover, "aggregation of labour in
irrigation, hydroelectric and industrial projects is
attended with severe outbreaks of malaria". (First
F. Y. Plan, 1 952, p. 500-501). Tuberculsois was the
other major killer which claimed fives lakhs lives
annually and rendered 25 lakh people ill. It was
estimated that SOO to 1000 million mandays were lost
because of the disease. (First F. Y. plan 1952).
early spectacular results also aided the legitimation
of the 'welfare state".
By the '60s increasing urbanisation with a 40
percent increase of urban population, inadequate
housing and living conditions, low availability of
food and impoverishment and unemployment had
pushed up disease incidence rates. The health
impact of new industrial processes that were being
introduced went unrecorded. In industry, intensifi
cation of labour coupled with chronic malnutrition
accounted for a rise in industrial injuries which rose
by 30 percent between 1961 and 1966 while work
force rose only by 16 percent (Ajit Roy, 1973)
The Malaria control programme co-ordinated all
Malaria control activities and consisted of DDT
spraying, treatment with antimalarial drugs and pro
viding malaria engineering services wherever there
were developmental irrigation and hydroelectric
projects.
2) Institution Building : Both the Bhore
committee and the First Plan took serious and anxi
ous note of the lack of medical facilities. Low health
status was seen as being primarily because of
lack of medical facilities. The major emphasis in the
first fifteen years was an increase of hospitals, beds
and dispensaries and the numbers of doctors,
nurses and other health personnel. (Appendix 2).
The Tuberculosis Control Programme included
vaccination with BCG, clinicsand domiciliary services,
and aftercare. The emphasis was on prevention
with BCG. Both these programmes depended on
international agencies like the UNICEF and WHO for
supplies of necessary chemicals and vaccines.
Both these programmes, especially Malaria
Control Programme, achieved spectacular results in
the beginning, after which their success levelled off.
By 1956 the mortality due to malaria had declined to
19.3 million and in the first year of the programme
tne number of workdays saved was estimated to be
116 million.
667/ic faitJtfal implementation ofi
recommendations is
contradictory to the interests
o§ capital and can be brought
about only by continued
struggled
These programmes, especially the malaria pro
gramme conducted like a military campaign were
conceived in such a manner that they were bound
to fail. Cleaver (1976) points out that programmes
like malaria control must be seen as death control
programmes preceding the birth control programmes
of a later period. Together they constitute "the
means for obtaining control over populatian growth
and thus over the supply of labour". These have
been the strategies sought by business whenever
they have sought to invest — in US, South, SW Asia
or China.
The first plan envisaged an increase of 24 per
cent in the number of hospitals, a similar increase in
the number of urban dispensaries, a 11 percent
increase in the number of rural dispensaries and a
10 percent increase in hospital beds. The number
of maternity and child health centres both in urban
and rural areas was also to be increased. More than
fifty percent of the budget for medical schemes was
allocated to the establishment of hospitals and
dispensaries.
These programmes have also been used to divert
attention from the real causes of ill-health by equa
ting disease eradication to 'technical' measures such
as DDT spraying in the case of malaria or BCG
vaccination in the case of TB. Both eradication and
immunisation programmes constitute the 'medicalisation' of socially and economically determined
problems of health. By introducing disease control
and later eradication programmes, the Indian bour
geoisie was ensuring control over labour supply. Its
Public health expenditure went into the provi
sion of water supply and health sanitation, the
major share going to Madras and Bombay. Since
training of personnel of all kinds was so important,
institutions and facilities for training were given
high priority. The establishment of the-All Indian
Institute for standardising and co-ordinating" post
graduate medical education was also initiated (First
37
F. Y. Plan). This venture, as well as others, such as
the setting up of the Virus Research Centre in Pune,
and the expansion of the All Indian Institute of
Hygiene and Public Health was assisted by the
Rockfeller Foundation. This trend for incieasing the
medical infrastructure continued throughout the
fifties and the early sixties.
The Mudliar committee which published its
report in 1961, recommended a strengthening of
the district hospitals as against any expansion of
primary health centres, in its opinion, the resources
in regard to personnel, finance were not available
sufficiently for any further expansion of PHCs.
It must be pointed out that most of the expan
sion in facilities took place in urban areas and a
majority of the medical graduates set up practice in
cities. Together with this, the pharmaceutical
industry which had made small beginnings after the
first world war had expanded a little during second
world war. By the beginning of the'50s, India was
self-sufficient in all the galenical preparations, most
of the vaccines and alkaloids. But medicines like
Pencillin, Streptomycin and sulphas were largely im-
medicine and the growing array of drugs and asso
ciated products. Also, these institutions were an
emphatic and 'visible' assertion of the State's conc
ern in fulfilling its 'Welfare' goals and in keeping
with the 'leap frogging' approach to catch up with
developed countries that was being advocated.
This is not to deny that the increase in the
numbers of health personnel and institutions was
not necessary or useful. That would be patently
untrue. But arguments which place blame for the
current crisis on
the non-implementation of
'radical' recommendations of the Bhore committee
are inadequate. Given the path of development
chosen by the bourgeoisie, the alternative offered in,
say the Bhore report or the Community Development
Programme could never have been implemented.
Bourgeois radicalism either in the form of reports or
legislations or programmes can best be viewed as
concessions gained by working class militancy. The
faithful implementation of recommendations is con
tradictory to the interests of capital and can be
brought about only by continued struggle.
3) Reproduction
of
bourgeois social
relations and social control : The bourgeoisie
always adopts policies and strategies which will re
produce and reinforce bourgeois social relations.
rationale otf the Indian
bourgeoisie in adopting massive
family planning drive was a
means ofi controlling labour.^
(i) The adoption of allopathic medicine as the
dominant medical system : From the outset, it was
clear that the western allopathic system was to be
the medicine of choice. In the period between 1948
and 1960 four committees Chopra, Pandit, Dave
and Udupa) were constituted to plan for the deve
lopment of indigenous systems of medicine in the
country. By and large the only recommendations
which were implemented were those which helped
to suppress or discourage the growth of indigenous
systems. We have already noted what happened to
the Chopra Committee report. Later reports increa
singly emphasised the need to examine indigenous
medicine 'scientifically'. Further, it was generally
agreed that the only area where indigenous medicine
could play a role in the health system was in area
of drugs and remedies.
ported. After 1956, many foreign subsidiaries which
had begun as trading operations went into the prod ac
tion of formulations, and public enterprises such as
Hindustan Antibiotics and Hindustan Organic Chem
icals were started in the late '50s mainly with the
help of Soviet aid and technical know-how. But the
major expansion of production was of the foreign
subsidiaries. By '68-'69 the average profits for
pharmaceuticals was 20.3 percent (Rangarao, 1977.)
In short, the health care system being-developed
was a doctor oriented, hospital centered, curative
system largely dependent on modern pharmaceutics
with its locus in urban areas. For the Indian bourge
oisie, such a health system created a large base for
consumer durables which were manufactured in the
private sector. It also motivated the growth of the
pharmaceutical and chemical industry. Increase in
the number of hospitals and medical institutions
also meant many more 'converts' to both 'scientific'
Why was the adoption of allopathic system as
the dominant system of medicine so important to the
bourgeoisie? Firstly, the class and sex biased, posi
tivist individualist ideology of modern medicine
reflected bourgeois ideology. The hospital system
reproduces the social structures of bourgeois
society and by doing so reinforces and authenticates
it. Modern medicine with its dependence on myssterious sounding drugs and its array of task specific
38
mononnl
^familiar language facilitated the
comes thl
n of knowled9e and skills. From this
XT ? power and influence t° those who have '
access to this knowledge viz; the doctor and to a
sser extent other health professionals. These
Profess'°nals, mainly doctors, who shared the same
, th fck9round as the bourgeoisie were necessary
tor the legitimation, strengthening and maintenance
, . e capitalist order. In recognising and locating
scientific' medicine as the dominant system, the
bourgeoisie were also acknowledging and encoura9ln9 the role of the educated elite.
(11) The development of maternal and child
health services : Concern for the health of women,
as mothers, has a long history in India. At the time
of independence, the sex ratio (women to 1000
women) had already started declining. But none of
the health plans nor policy statements were ever
concerned with this. However, investment in the
health of the child (and incidentally its mother) were
seen as an investment “for building a sound and
healthy nation" (First F. Y. Plan). These facilities
were seen as facilities through which women could
fulfil their socially determined primary role as
mothers. In consequence, women's health needs
became subordinate to the needs of the family. The
deterioration of women s health and women's status
through the '60s is to a large extent the result of the
policies and programmes that have been adopted by
the Indian bourgeoisie.
’70s in the context of socio-political and
developments.
economic
The two consecutive droughts in the mid
sixties had brought impoverishment and ruin to the
rural landless and agricultural labourers. The pro
portion of rural population below poverty line
reached a new hight of 57.9 percent (Shah). The
nett per capita daily availability of food-grains was
around 402 grams the lowest since 1952. It was in
this situation that the Green revolution was laun
ched. The concept itself, according to Davey was a
part of America s post war strategies and was an
extension of the agricultural research of the Rock
feller and Ford Foundations. The Green revolution
also coincided with the glut in the world fertilizer
market.
In the arease where the green revolution took
root the crop yields shot up and also altered the
^‘Reduction of state inputs in
health care and a great
involvement of the private
sector were the outstanding
features of the national health
policy and is in keeping with
the objectives of the new
bourgeois strategy for health
care.yy
The provision ofMCH service,however relevant,
in the absence of primary care accessible to women
indirectly perpetuates 'the myth of motherood' and
the social location of women under capitalism mai
nly as 'reproducers of labour.'
agrarian structure. There was an increase in the
numbers of agricultural labourers and despite
mechanisation, the demand for labour also went up
In time the landless labour gained in strengh and
emerged as a distinct class (Bhalla, 1983). Most of
these also belonged to the deprived sections_ the
scheduled castes and scheduled tribes. At the
same time the introduction of new technology and
easier credit facilities had strengthened the small
and marginal farmers and increased their staying
power. Rich farmers were unable to buy them out
However there were no basic contradictions between
the large and marginal/small farmers. These hold
ings constituted two-thirds of the cultivating house
holds. In such a situation agrarian struggle was
inevitable. Agitations for better wages were also
in reality struggles against caste oppression.
(iii) Health
Education. One of the most
important component of 'preventive' services
was and has been health education, which
mainly reinforces the victim-blaming ideology of
modern medicine. It also helps to mask the social
roots of illness and disease. The emphasis on chang
ing life styles rather than on changing the socio
political environment which endanger such lifestyles
protects the existing power structures in society and
the exploitative mechanisms of capitalism.
Changes in Health Policy after 1965
In the health sector the trends which were
discernible in the first decade after independence
continued to be prominent until about the '70s. In
this sectionjwe will analyse the seemingly drastic
change in health policy and programmes in the mid
In areas outside the green revolution area, such
as M.P., Rajasthan, Gujarat, parts of Bihar and
39
Orissa and West Bengal, it was the srnali end
middle farmers w ho gained most by the introduc
tion of new technology. They soon began to chall
enge the economic and political power of the land
lords, most of whom were absentee landlords. The
interests of these new rich small and marginal
farmers were contradictory to both that of the
landless as well as that of the politically influential
landlord. Having gained economically this section
of the peasantry, the middle farmers who were
usually from the middle castes, began to develop
political clout both on the regional and the national
scene. They also began to demand development
inputs which would enable them to gain a qualita
tively better standard of living... electrification,
consumer goods and health services.
By the beginning of the '70s, industrial produc
tion had stagnated, the rise in national income
being only 4 percent in 1971-72. The population
went on rising, hence the labour force had con'
tinuedto expand. The total work force was 184
million, 8 percent or 15 million were unemployed.
While wages had remained stagnant the average
product per worker had increased. So, the employ
ing class had benefitted, thus polarising income
(Davey- 1975).
conflicts, strikes, peasant agitations, tribal move
ments, student and mass movements most of which
were directly or indirectly concerned with economic
grievances. The Gujrat and the JP movement were
against price rise initially but later made political
demands The Naxalite movement and the revolt of
the tribals in Srikakulam, were more broad based
and directly challenged class oppression. That
brutal repressive measure were used to break and
suppress them was an indication of the insecurity
of the Indian bourgeoisie. The world economic situ
ation had also changed by the mid '70s. Many
advanced capitalist countries were on the brink of a
third technological revolution. The national bour
geoisie realised that if they weie to forge a new
relationship with the world capitalist economy they
had to re-structure the industrial sector by reducing
state intervention and increasing opportunities for
foreign investment. This also meant disciplining and
controlling labour and stabilising the political
climate.
Inputs into rural development therefore served
two purposes—firstly, they facilitated the further
penetration of capital and secondly, 'visible' efforts
such as provision of health care, educational facilities, .
electricity, low capital intensive 'appropriate' tech
nologies would not only nullify the growing dis
content and political influence of the new rich
'middle' peasants and capitalist farmers but also
strengthen them as a class who would associate with
the industrial bourgeoisie in opposing and suppress
ing working class struggles. Moreover, these efforts
would also mean an expanded market for the new
technological consumer products.
The Fourth Plan's emphasis was on rural and
agrarian programmes and the enormous emphasis
on family planning. This was an attempt to postpone
and forestall the crisis and also a recognition of the
new and growing political influence of the middle
peasantry. In the health sector almost half of the
allocation went to family planning.
There have been a number of analyses of why
there was an emphasis on family planning. The
most obvious explanation is of course, the enormous
spurt in numbers in the previous decade, which was
mainly because of decrease in death rates. Even
though epidemic diseases had not been eliminated
there was a decrease in the number of death in each
of these epidemics. Another less obvious reason
was that given the high rates of unemploymenl and
impoverishment, the sheer numbers presented a
threat to the stability of the system. That there was
imperialist pressure, through the use of conditional
international loans and such, cannot of course be
denied. But the rationale of the Indian bourgeoisie
in adopting a massive family planning drive was a
means of controlling labour supply to suit the expan
sion of more capital intensive modern industries.
The Fifth Plans' Minimum Needs Programme is
justonesuch strategy. In the health sectors it was
being realised that a hospital based health system
supported by vertical programmes such as Malaria
Eradication and Family Planning no longer performed
either this ideological role or achieved their sociopolitcal objectives. There had not been any large scale
improvements in health indicators in the past years.
Their role as advertisements for the bourgeoisie's
concern for 'welfare' had long outlived its usefulness.
Moreover, it was no longer a good economic option.
The amount spent for welfare of the working class
comes out of the surplus value being created. If
this no longer achieves the purpose of either
maintaining and reproducing labourer of strengthen
ing class relations by reproducing and legitimating
the capitalist order, the loss in surplus value cannot
be justified. The only answer was a change in stra
tegy. 'Scientific' medicine gave way to a 'community'
Throughout the first half of the '70s there was
a marked increase in the number of industrial
40
conscious science-based medicine which was accom
modating enough to allow the operation of other
systems under its hegemony.
reluctant and antagonistic professional bodies to
co-operate.
In 1980, the new strategy for rural health was
formalised and integrated into overall bourgeois
strategy in the form of a national health plan,
proposed by the ICMR-ICSSR committee. This
report, a good indicator of the bourgeois radicalism,
in the '80s, proposed a pyramid model of health
care, based on a diffused primary health care
programme relying on limited, cheap, labour-inten
sive techniques and technology and a smaller,
capital-intensive, mainly curative, referral and speci
alist service using sophisticated, modern, high tech
resources, and the hospital system. Both the termi
nology and the spirit of the report was greatly
influenced by lllich. It saw the organising of primary
health care on a community basis as an essentially
'political experience' which would enable people to
fight other battles and this in turn would set in
motion a 'process to strengthen a decentralised,
democratic and participatory social order'. (HFA,
1981). The major recommendations of the HFA
were incorporated into the Sixth Plan.
Through the '70s a number of voluntary agen
cies funded by industrial houses, Christian missions
or foreign development agencies, and individual
professionals frustrated and disgruntled with the
existing system began to 'experiment' with alter
native health strategies following essentially the
'health-by-the people'approach. The rising cost of
health care, of medicines and equipment provided a
further impetus to many. Naturally enough this app
roach had an instant appeal to a mass of sociallyconscious urban and rural youth, plagued by the
threat of unemployment and sensitive to the increa
sing deprivation of the masses. Many of these
projects achieved initial success in improving health
indicators such as infant mortality or maternal deaths,
epidemic deaths and achieving high immunisation
rates.
In 1975, the Srivastava Committee was the first
official document which put forward a proposal for
health care which created a new health functionary.,
the community health worker. Based on the premi
ses that most of the commonest health problems are
of the easily preventable kind and may be easily
looked after at the village level, the committee pro
posed the training of selected villagers as the first
contact in the new rural health care structure. It
suggested a well organised and graded structure of
dispensaries, hospitals and referal services.
In 1982, the government of India published a
Statement on National Health Policy. Itenunciated an
integrated, comprehensive approach toward the
future development of medical education, research
and health services. Broadly it followed and repeated
the recommendations of the HFA. But in doing it
re-emphasised certain trends which had been barely
discernible in the HFA and the Sixth Plan. For
instance, it focussed greater attention on reducing
governmental expenditure and utilising untapped
resources to encourage the establishment by private
practice professionals .... and financial and tech
nical support to voluntary agencies (NHP 1982-).
More importantly, it focussed on the need to
establish a referral system which could provide
speciality and super speciality services. Again, to
reduce governmental expenditure private investment
in such fields was to be encouraged. In providing
water supply and sanitation too, appropriate tech
nologies were to be used 'to reduce expenditures'.
The 'involvement of community' in the implementa
tion was also seen as a means of reducing costs.
Thus, reduction state of inputs in health care and a
great involvement of the private sector are the
outstanding features of the national health policy
and are in keeping with objectives of the new
bourgeois strategy for health care.
The alacrity and the speed with which these
proposals were accepted and implemented by the
government is a measure of how appropriate and
urgent they were to those in power. By then, in
1977 the Janata Party, a configuration albeit tempo
rary, of the commercial bourgeoisie and capitalist
farmers had dislodged the Congress, which then
represented
mostly the industrial bourgeoisie.
The Janata Party saw the provision of rural
health care as a means of fulfilling election promi
ses. Moreover, they were the representatives of just
those sections who would be benefitted most... the
rural rich and middle peasantry. Democratic selec
tion processes notwithstanding, the community
health workers were certainly not to come from
among the poor.
Around this time several countries, met under
UN auspices at Alma Ata and signed the Declara
tion which proposed just such a strategy. The
international move conferred on the programme a
high status which would play a part in persuading
We will examine briefly how the alternative
strategy fits into the overall strategies adopted by
the bourgeoisie since last quarter of 1970.
41
(1) The growing mass of rural poor has little
access to any kind of health care. Diseases which
could be easily prevented were still claiming lives.
Maternal and infant mortality rates were still pretty
high. Community health workers, however in
efficient orinappropriately selected would ameliorate
sickness conditions to some extent. The credit for this
in turn, would accrue to the party in power.
modern medicine. The introduction of CAT scans,
linear accelerators, laproscopy and so on in the last
few years must be viewed in this context. The new
'medical leasing' companies which have started to
function will facilitate the introduction of new
technology and instruments in health institutions.
(2) More importantly the new alternative is
demystifying medicine just sufficiently for people to
learn to use and to become
dependent on
modern drugs. If until now injections had a 'magic'
value, soon metronidazole or B-Complex which the
CHVs use will become familiar enough for people to
ask for and demand them. This expands the base of
operation for pharmaceutical companies.
Medicine is not a socially independent activity.
The evolution of medicine and the development of
health care can only be understood within the larger
perspective of the overall development of the
Indian economy and the changes in the relation of
production that came about.
Conclusion
The choice of 'scientific' medicine and a
hospital-centred structure through which it can be
practised was a deliberate choice on the part of the
Indian bourgeoisie and was a necessary component
in achieving the objective of a capitalistic transfor
mation of India. This also had a profound impact
on the traditional practices in India, not simply in
terms of making their techniques less effective, but
more so by changing the social relationship that
such practices of those techinques embodied.
Such transformation has further strengthened the
domination of bourgeois medicine.
(3) As we have noted earlier, the medicine
practised by the community health worker was no
different from the medicine practised by a hospitallocated health functionary. Its content was the same
but its garb was different. Therefore, the dominant/
dominated relations that it embodied are strengthen
ed and reproduced. Since the outreach of these
rural health alternatives is so much larger, bourgeois
ideology is being strengthened. It is possible that
these programmes are hastening the degeneration of
indigenous practices and local healers.
The community health approach so lauded
since the late '70s initially gave an illusion that
radical changes were being brought about in
health care. We have argued here that this approach
was never intended to bring about any radical
changes but on the contrary, it was very much a
part of a strategy to expand the hosptial-centred
health care structure at the primary and secondary
level in the rural areas. Not only. The strategy also
involves inviting private investment and collabora
tion in the health care system with state gradually
reducing its inputs in health. The community health
approach also helps the pharmaceutical and surgical
goods industry (which is largely in the domain of
the private sector) to expand their domestic market.
As the main disseminators of health education
messages, the village health workers are also sprea
ding the ideology of 'victim blaming' shifting atten
tion from socio-political roots of illness and masking
class contradictions. In locating the main focus of
health care in the family, programmes determine and
lend support to the oppressive institutions which
are so necessary to the maintenance of capitalist
order.
Moreover, the village health workers have gene
rally been from among the rich and middle peasants
and middle castes. The acquisition of new techniques
and knowledge has led to a different level of mono
polisation strengthening the power base of this class.
The existing selection process does not cut across
existing power relations in society, including that
of man and woman, and so reinforces them.
Lastly India with her vast area and dense popu
lation divided into class, caste, sex, cultural, ethnic
and a host of other differences is probably the most
complex of socio-economic formations rendering
attempts to properly comprehend it a most difficult
task for the social scientists. There is always the
danger of making sweeping generalisations and
over-simplifications in providing an
analytical
outline of the development of health care in the
context of the dynamics of socio-economic changes
in India. We have not taken into consideration in
(4) This separation of primary and referrel
facilitated the modernisation and development of
productive forces of modern medicine on the one
hand, while at the same time appearing to cater to
the needs of the masses. The new strategy attempted
to resolve the growing contradictions between the
relations of production and production forces in
42
this analysis the regional differences and the uneven
ness of socio-economic development. But we have
identified the dominant trend of development at the
general level and analysed how the development
of health care services is integrated with it. We are
also aware that we have not included in our ana
lysis the relative strength and political influence of
medical organisations like the Medical Council of
India nor their relationship with the pharmaceutical
and surgical goods industry.
Bettelheim Charles, India Independent, 56-59 pp
Monthly Review Press, New York, 1968
16. Dutt, R. P. India Today, p. 434, Mahnisha
Granthalaya, Calcutta, 1983
17. Dutt, R. P. Same as in 16, p. 279
18. Desai, A. R. Recent Trends in Indian Nationalism,
pp 40-41, Popular Prakashan Bombay, 1973.
19. Report of the Health Survey and Development Commi
ttee, Vol. I, Manager of Publication, Delhi.
20. National Planning Committee, Report of the
Sub-committee, National Health Vora and Co.
Publishers Ltd., Bombay, 1948.
21. Committee on Indigenous Systems of Medicine,
Government of India, Ministry of Health, New
Delhi, 1948.
22. Report of the Health Survey and Development Com
mittee, Vol L, Manager of Publications, Delhi,
1946.
23. Report of the Health Survey and Development
Committee.
24. Shirokov, G. K Industrialisation of India, People's
Publishing House, New Delhi, 1980, pp
201-203
25. Bettelheim, Same as in 15, p 199.
26. Joshi, P. C. Land Reforms in India, in Desai
A. R. (Ed) Rural Sociology in India Popular Pra
kashan, Bombay 1969
27. Davey, Brian. The Economic Development of India,
p. 168, Spokesman Books Nottingham, 1978.
28. Dubey S. C. Community Development - A
Critical Review in Desai, A. R. (Ed) Rural
Sociology in India p. 624 Popular Prakashan.
Bombay, 1969.
29. Davey, Brian same as in 27, p. 188
30 Bettelheim, Same as in 1 5, p. 5.
31. Health Statistics of India, p. 35 Central Bureau
of Health Intelligence, New Delhi 1982.
32. Public Accounts Committee (1983-84) Hundred
and Sixty-first Report. National Malaria Eradica
tion Programme, p. 1, Ministry of Health and
Family Welfare, New Delhi, 1983.
33. The First Five Year Plan, pp. 500-501 Government
of India, Planning Commission, New Delhi
1952.
34. First Five Year Plan As in 33, pp. 502.
35. Cleaver, Harry, Political Economy of Malaria
De-control, Economic and Political Weekly. 9(36):
14. 1976.
36. Roy, Ajit Economics and Politics of Garibi Hatao,
p. 81 Naya Prakashan, Calcutta, 1973.
37. First Five Year Plan As in 33 p. 513.
38. Report of the Health Survey and Planning Committee,
Government of India Ministry of Health. New
Delhi, 1961
15.
Given the vastness of the subject it was only
natural that all aspects could not be covered. But
the article, we hope, will generate enough interest
in this subject so that the analysis can be deepened
and broadened.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Marx, Karl. A Contribution to the Critique of Poli
tical Economy. p. 20 Progress Publishers Moscow,
1977.
Lukacs, George. The Ontology of Social Being —
Marx. P.9, Merlin Press, London, 1978
Turshen, Merdeth. The Political Ecology of
Disease. Review of Radical Political Economics
9(1) : 48,1977.
Doyal, Lesley with Pannel, Imogen The Political
Economy of Health, Pluto Press, London, 1981.
Schatzkin, Arthur. Health and Labour power
A theoretical investigation. International Jour
nal of Health Services 8 (2) : 213-234. 1978.
Rodeberg, Leonard and Stevenson, Gelvin.
The Health Care Industry in Advanced Capita
lism. Review of Radical Political Economics 9 (1):
104-115. 1977.
Marx, Karl Capita! Vol 1, P. 644, Penguin Books,
1976.
Navarro, Vincent. Radicalism, Marxism and
Medicine. International Journal of Health Services
13 (2) : 179-202. 1983
Crawford, D. G. A History of the Indian Medical
Service Mo\. 1. p. 240, W. Thacker & Co., 1914.
Tesh, Sylvia. Political Ideology and public
health in the 19th century International Journal of
Health Services 12 (2) : 321-342. 198.
Turshen, Meredeth. As in 3.
Ramasubban, Radhika. Public Health and Me
dical Recearch in India, Sarec Report R 4: 1982.
Billington, Mary Frances. Women in India p.
86-110. Amarko Book Agency, New Delhi.
1973 (Reprinted)
Banerji, D. Social and Cultural Foundations of
Health Service Systems Economic and Political
Weekly. 9 : (32-34) 1974.
43
39.
Bhalla, C.S. Peasant Movement and Agrarian
Change in India. Social Scientist 11 (8) : 47-^8
45.
Rangarao, B. V. and Ramachandran, P. K.
The Pharmaceutical Industry in India in Rahman
et al (Ed) Imperialism in the Modern Phase, p.
146 People's Publishing House. New Delhi,
August, 1983.
Davey, Brian Same as in 27 p. 198-199.
Fourth Five Year Plan, Government of India,
Planning Commission.
Fifth Five Year Plan, Government of India, Plan
ning Commission
Alma Ata Dede ration, International Conference
on Primary Health Care, September, 1978.
ICMR-ICSSR Committee Health for AH : An
Alternative Strategy, Indian Institute of Education,
Pune, 1981.
Health for AH Same as in 50 p. 20
Statement on National Health Policy, Government
of India. Ministry of Health and Family Plan
ning, New Delhi, 1982 Services 1 <1) January
1984
National Health Policy, same as in 52 p.34.
46.
47.
1977.
,, ,.
Pandit Committee Report, Government or India,
Ministry of Health, New Delhi.
41. A committee to study and report on the question of
establishing standards in respect of education and
regulation of the practice of indigenous systems of
medicine, Government of India, Ministry o
Health, New Delhi, 1956.
42 Udupa Committee The Committee to assess and
evaluate the present status of Ayurvedic system of
Medicine. Government of India, Ministry of
Health, New Delhi, 1960.
43 First Five Year Plan Same as in 33 pp.
44. Shah, Narottam Standard of Living Centre for
Monitoring Indian Economy, Bombay.
40.
48.
49.
50.
51.
52.
53.
Appendix 1
First Plan’
in per
Rs. in
cent.
thousand
million.
Agriculture and
community
Development
Irrigation and
Major projects
Electricity
Second Plan
Third Plan
Rs. in
thousand
million
in per
cent
Rs. in
thousand
million
in per
cent
2.9
14.4
5.7
11.8
10.68
14
4.3
21.4
5.3
11.1
6.5
9
1.5
7.4
3.8
7.9
10.12
13
8.9
18.6
17.84
24
Industry and
Mining.
Other Industries
1.0
5.0
Transport and
Communication.
5.3
26.4
13.8
28.9
14.86
20
Social and other
services.
5.1
25.4
10.5
21.7
13.0
17
—
—
2.0
3
48.0
100
75.00
100
Stocks
Total
20.1
100
♦Actual result.
(Compiled from, Bettelheim, 1968, p. 157, 161 and 163)
44
(Appendix 2 contd. on page 48)
REVIEW ARTICLE
A CULTURAL CRITIQUE OF MODERN MEDICINE
anant phadke
The Cultural Crisis of Modern Medicine, John Ehrenreich (Edited),
Monthly Review Press, New York and London, 1978, 300 pages, $7.50
It is quite often alleged that marxism is inte
rested only in the economic aspects of society or a
part of it. But this view is at best a misunderstand
ing. Marxism does attach primary importance to the
analysis of the process of social production ("econo
mic aspect") of any society but it is also quite con
cerned with a concrete analysis of the superstruc
ture! aspects. In the field of analysis of Health
(determinants and dynamics of health status of the
people) and Medicine (as science and technology
and as system of professionals geared to interven
tion based on this science and technology) marxists
have given due primary importance to the political
economy of health. But the ideological/cultural
aspects of health and medicine have also been
analysed by Marxists. The Cultural Crisis of Modern
Medicine is one of the most important contributions
in this field. What follows is more of an introduc
tion to this book than a critical review.
minorities who pointed out that in their experience,
medicine was not so much a helpful measure as a
tool of ideological, and cultural domination. Along
with the radical community movements, the other
sources of cultural critique were some critical health
analysts (Dubos, Mckeown, Powls, lllich) who
showed that modern medicine has not at all been as
effective and beneficial as it is made out to be. Most
of the infectious diseases in Europe were well on the
way out before the era of antibiotics. When antibio
tics came, the West had by then acquired the socalled diseases of industrialisation, cardio-vascular
diseases, accidents, cancer, psychological and
geriatric problems, and so on for which medicine
has not much to offer in real terms.
Ehrenreich in his introduction also points out the
problems of a cultural critique. For example when
one says that the existing system of Medicine is not
very effective, or helpful, this gives a ground for
conservatives and reactionaries to argue for a re
duction in the subsidised, social medical-care-programmes. In backward, developing societies, even a
rise in the availability of conventional medicine can
help to improve the health status of the population.
In such countries a cultural critique is not a priority,
though it is still relevant in such situations. In such
situations what is needed is more medical care and
also a better one, a helpful one and not as a tool of
domination. He points out other problems such
as dependency, professionalism, problems of tech
nology. Capitalism has given a particular shape to
these problems. We should reject their capitalist
form but the problems in Ehrenreich's view do not
end there and hence concrete socialist alternatives
need to be worked out.
The book is a collection of a dozen essays
abridged, and edited by John Ehrenreich. In his
lengthy introduction, John Ehrenreich first traces
the historical and political origins of the "cultural
critique” of modern medicine. Ehrenreich alleges
that the political, economic critique concentrates
its fire on the inequitable distribution of health
services, on the problems of organisation of medical
care, and is not much concerned with the nature of
medicine itself. Ehrenreich is not entirely correct in
his assertion. There are marxist analysts who
analyse the political economy of health not pri
marily from the standpoint of distribution of medical
services. For example. The Political Economy of Health'oy
Lesly Doyal and Imogeh Pennel is primarily concer
ned with showing the relationship between phases
in the bourgeois economic development in Britain
with the development of Medicine and it shows the
ideological/political role of medicine at different
historical junctures in England. It is however true
that traditional marxist analysts have almost exclu
sively focussed on the lack of proper medical
facilities to the poor ancf on medicine as a money
making industry.
Medicine and Social Control : The Book is
divided into three parts. The first Section consists of
three essays which deal with how modern bourgeois
medicine acts as one of the mechanisms of Social
Control, of perpetuating and consolidating bourgeois
social norms and ideology. Medicine and social control
by Barbara and John Ehrenreich makes a critique of
Talcot Parson's (the famous bourgeois sociologist)
concept of'sick-role' which governs the understand
ing of the relations between the sick-person and
'
Ehrenreich points out that the question of the
purpose and nature of medicine was brought forward
by the women's movement, and movements of
45
profession, even after the advent of modern
medicine, has played a very small role in the improve
ment in the health of the people. He quotes impor
tant authorities to back-up his statements. Hethen
shows how, by their very nature, the incidence and
effects of the so-called diseases of industrialisation
(for example, cardio-vascular diseases) are not ame
nable to curative services. So long as the profit-seek
ing giant corporations continue to decide what we
eat, what work we do and how we live and travel,
which consumer goods we shall use, ill health is
going to continue. The state allows this basic mech
anism of production of illness on a social scale
unaffected. It also allows the commodification of
medical-care. All it does is rationalise the access
to medical care and make it less costly. But the drug
industry and the health-industry in general, would
continue to live happily. The manufacturers of
ill health would then continue to accumulate profits
as before. The bourgeois state is not prepared to
stop the production of surplus-value even if it
threatens the health status of the people; it cannot
stop the commodity character of medical care. This
is the limit of state intervention in bourgeois society.
Renauds analysis is a good concrete case study of
the limitations of state intervention in bourgeois
society and a solid indictment of the limitations of
medical care in this society.
the society in bourgeois society. The medical pro
fession decides as to who is sick and how a sick
person should behave. A particular person may be
pronounced as below normal, or neurotic even if
he/she is just different from or rebelling against
what the doctor and the bourgeois ideology
regards as normal. A worker may be ill, but the
doctor may deciare him to be normal and fit for
work so that the employer does not have to give
any concessions to the worker during his illness.
Like law or religion, these medical verdicts cannot
be challenged. This power of the medical profession
is one of the mechanisms through which people are
made to behave in the way in which bourgeois
society wants them to behave. The authors show
that the medical social control could be either
disciplinary or cooptive. Disciplinary control mainly
directed against the poor, discourages people from
saying that they are sick by making sickness an
unpleasant, painful episode-— long waits at the
doctor's clinic, unpleasant reception by the medical
profession, costly, painful treatment and so on.
Cooptive control, on the other hand coopts the reci
pient of medical care (mostly well-to-do, rich
people) into the dominant mainstream of socialcultural life by creating, and reinforcing a certain
stereotyped understanding of what constitutes
proper social behaviour. There has been a tremendous
increase in the jurisdiction of the medical profession
(from brith to marriage to old age), in the availability
of medical services, and through these two, in the
dependency of the people on the medical profession.
The authors show how the situation of interaction
between the highly trained, higher-middle-class
doctor and a patient from a poorer or a minority
community or a woman is a fertile situation for
conveying ideological messages and cultural values;
and how this is done in the U. S. today. This frame
work is a good starting point for us here in India to
explore our own situation here.
Women, Illness and Medicine ; The second
section of the book consists of five concrete case
studies which demonstrate how medicine in bourgeois
society acts as one of the mechanisms of social
control over women. In Sick women of the upper classes
Barbara Ehrenreich and Deirde English show how
medicine in 19th century Britain reinforced stereo
typed images of women that they are inherntly
prone to illness, and that they ought to be frail, and
engaged only in "feminine pursuits" like deco
ration, courtship, motherhood. If a woman were to
engage herself in social, intellectual activity, she
would be regarded as being abnormal and inviting
illness. By "women" the medical profession meant
only upper-class women since it had a vested
interest in the cult of female invalidism among its
upper-class clients. Medicine gave a " scientific
basis" to the male-chauvinistic ideas by proposing
"scientific" theories which had no real scientific
basis. Scientific knowledge of how sexual, and
reproductive organs function did not exist then.
This opened a wide door for the male prejudices
amongst medical men to be propagated as scienti
fic opinions, medical treatment was more of a
punishment.lt is quite a shock to read about the
barbaric methods of treatment empolyed by doctors
Irving Kenneth Zola in Medicine as an Institution
of Social Control continues with the same theme
and further unravels the ramifications of this
mechanism. Her analysis however, focuses exclusi
vely on the domination of the medical profession
without linking it with the capitalist character of
today's medicine and today's society. It reads more
like a radical attack on modern medicine as such,
and not on its capitalist character. Nowhere does
Zola make a distinction between the capitalist
limitations of modern medicine and the potentialities
created by it which can be used in a socialist society.
Marc Renaud in Structural constraints to state
intervention in Health first shows how the medical
46
to treat women including the application of leeches,
blister-producing counter-irritants to genitalia,
removal of the ovaries (for "conditions" like trouble
some menses, eating like a ploughman, erotic
tendencies, dysmenorrhoea...!) and others. The
account of hysteria by the author is also extremely
revealing. This short essay is one of the most
damning indictment of medicine in the 19th century.
outranked by 14 other nations in the low rate of
infant mortality although the U. S. is the most pro
sperous and advanced nation in the world. The U. S.
leads all other developed countries in the rate of
infant deaths due to birth injury and respiratory
distress such as postnatal asphyxia and atelectasis.
The reason ? - monopolisation by doctors of mid
wifery (unlikein Europe) and their overintervention
list strategy. One cannot disagree with Doris Haire.
One may add that even in countries like Britain with
a long history of legal, expert, trained midwifery,
doctors more or less decide the strategy of interven
tion and the midwives have to follow it. The
midwives are fighting this out and are putting for
ward a series of arguments, facts, figures, and
alternative practices. This disease of monopolisation
and overintervention is no longer unique to the U. S.
It is quite a surprise to learn that doctors were
opposed to the birth-control movement as late as
the 1920s. Linda Gordon in her piece on The politics
of birth-control documents this opposition and the
reasons for it. She also shows the connection bet
ween the left, the feminist and the birth-control
movement, and how later, due to the problems
created by World War I, the birth-control movement
lost the leftist political edge. Later, the medical profes
sion instead of oppossing birth control, decided to
co-opt and monopolise it. With their entry and with
the decline of the role of the left, the birth-control
movement no more remained a people's movement.
Along with the feminist birth-control movement,
there was the tendency in the U.S. of new eugenics.
The essential argument of this eugenics was that
unfit people such as criminals, and paupers, were
genetically inferior. They were therefore, interested
in the compulsory birth-control for these "enemies
of civilisation." Because of the lack of strong anti
racist traditions in the U.S., even the feminist used
the eugenics arguments for the propagation of the
birth-control movement. This, together with the
lack of interest of the leadership in "reformist,
peripheral" issues like birth-control, resulted in the
decline of the paople's birth-control movement
and made it into one dominated by conservatives,
reactionaries, racists and the ilk. In the 1930's
however, eugenics fell into disrepute because
Hitler's Nazi Germany took it over. This zigzag
movement of the status of birth control makes very
interesting reading.
7he other two essays in this section focus on
the sexist biases in the medical textbooks. Mary
Howell exposes the paediatricians whereas Dianna
Scully and Pauline Bart pin down the gynaecologists
for their sexist bias and their ignorance about female
sexuality. Like other articles in this book, these are
also made up of quite concrete stuff.
The third section of this book deals with Medi
cine and imperialism. Frantz Fanon in his Medicine
and Colonialism depicts the hatred, distrust, and
alienation felt by the Algerian people towards their
colonial masters and their doctors. Most of the
doctors owned land or some business and were
directly a part of the exploiting system, even of
political oppression and torture. This explains the
ill-feeling of the Algerian people about these doctors.
As opposed to this, the Algerian people were extre
mely cooperative, helpful to the health programmes
and to the doctors of the National Army of Liberation.
It is difficult to fully appreciate the situation in a
colonial country for those of us from the younger
generation who have never experienced it. But
Fanon has made his point clearly.
The next three articles show how the ideology
of sexist or of scienticist, commercial professionalism
affects clinical practice even today. Doris Haire in
her Culturul warping of child birth makes a point by
point critique of the various technical measures
employed by American obstetricians for conduc
ting deliveries from confining the normal woman to
bed, to shaving the birth area, to Routine Electronic
Foetal Monitoring. She argues that ail these
interventions
are
not really indicated and
that they
are
not beneficial to patients
but to doctors and to
commercial interests.
It is because of these unnecessary and potentially
hazardous medical interventions that the U. S. is
E. Richard Brown in his Public Health in Impe
rialism shows how the Western interest in tropical
diseases and public health in tropical countries was
motivated by their imperialist interests. The American
imperialists wanted an overall penetration into South
America for higher profits. But the productivity of
these people was low. The reason for their "laziness"
was found to be diseases like hook-wom. Hence
the Rockfeller Foundation's first act after its incep
tion in 1913 was to create an International Health
Commission to extend worldwide the hook-worm
and public health programmes initiated in the U.S.
The programme against hookworn in Costa Rica
47
succeeded and resulted in a 50 percent rise in
labour productivity. The Rockfeller Foundation had
quite clearly expressed why it put a priority on the
hookworm programme. "On account of the direct
physical and economic benefits resulting from the
eradication of the disease and also on account of the
usefulness of this work as a means of creating and
promoting influences." This latter element was as
important as the first one. Brown convincingly
shows how. Brown clearly welcomes the better
ment of the health status of the population but
shows that the chief aim of these programmes was
to prepare better conditions for the accumulation of
imperialist capital, and people’s health was subser
vient to this aim. He shows that Health was defined
as the capacity to work and other aspects of health
were neglected.
James Paul in his short essay Medicine and Impe
rialism puts forth an overall picture of the relation
ship between the two. He considers five “principal
features of medical imperial politics— (1) physicians
as covert diplomats; (2) physicians as propagandists
and spies among colonial people; (3) medicine as
a vehicle for imperialist propaganda in the metropo
litan centre; (4) colonies as territories for medical
sales and medical experimentation; (5) Medicine as
a vehicle for establishing and maintaining the exploi
tative social relations." His analysis is, however,
exclusively based on the colonial experience and it
has to be seen as to whether and how many of these
five features continue in post-colonial imperialism
and whether any new features are added. (For
example : the question of brain-drain ) The distinctly
new phase of imperialism after the World War II must
be borne in mind. Many marxists mistake colonial
imperialism in general and hence generalise from the
colonial experience. James Paul's analysis tilts
towards such misinterpretation. He however points
out that the contradictions of "imperialist medicine”
and hence the possibilities of revolutionary change.
(Contd. from page 44/
Appendix 2 _________________
Year
1951
1965
Doctors
59, 338
(1950)
99,779
It would be worthwhile to study the relationship
between imperialism and medicine in India, keeping
in mind the five features discussed by James Paul.
The last article in this section traces the relation
ship between the military and medicine. It shows
how medicine has on many occasions not been
above nations, and how it has directly, and indirect
ly helped war-efforts. This much is not surprising.
What is more startling is the conscious effort of in
vaders to use medical work to boost up the image of
the conquering nation Howard Levy has success
fully shown with the help of quotations from military
men how this occured in the case of the American
Army in the fifties and the sixties, especially in the
Vietnam War.
On the whole, the book is rich and wide-ranging
in the historical material it contains which exposes
the ideological role played by medicine in bourgeois
society. It does not, however, show the corres
pondence between the different stages of the develop
ment of capitalist economy and the development of
health and medicine. This is partly because of its
character as a collection of essays. But that in
itself cannot explain this weakness. Secondly, the
contradictions in medicine in bourgeois society are
no where posited clearly, emphatically. The analysis
therefore can be misunderstood as an attack on
medicine as such and not on its bourgeois form.
Morever the possibility and necessity of revolutionary
change does not emerge because of this failure
to point out the contradictions in today's medicine.
Though not a very systematic account in this sense,
this collection of incisive and very absorbing pieces
of historical analyses is one of the most important
and useful additions to the marxist analysis of medi
cine in bourgeois society. It is essential reading for
anybody wanting to understand the nature of medi
cine in capitalist society.
DEVELOPMENT OF HEALTH INFRASTRUCTURE IN INDIA
Sub
Centres
Hospitals
Beds
('000)
Dispensaries
PHCs-
2694
117
6515
3900
295
9486
725
(1951-56)
4793
(1967)
5293
5951 1
Pharmaceutical
Production
Rs. in Crores
Formula- Bulk
tions
10
17,521
(1967)
33,616
51,192
150
18
130
560
11295
404
4023
1,97,650
1975
289
28312
1,430
6805
477
2,68,712
1981
Health Statistics of India, 1971-75 and 1982 Central Bureau of Health intelligence, Government of
India, 1971-75 and 1982.
Health for AH ; An alternative Strategy, Indian Institute of Education, Pune. 1980.
OPP Bulletin, July-August, 1983.
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A Worker's Speech to a Doctor
We know what makes us ill
When we are ill we are told
That it's you who will heal us.
For ten years, we are told
You learned healing in fine schools
Built at the people's expense
And to get your knowledge
Spent a fortune.
So you must be able to heal.
Are you able to heal ?
When we come to you
Our rags are torn off us
And you listen all over our naked body.
One glance at our rags would
Tell you more. It is the same cause that wears
Our bodies and our clothes.
The pain in our shoulder comes
You say, from the damp; and this is also the reason
So tell us ;
Where does the damp come from ?
Too much work and too little food
Make us feeble and thin
Your prescription says :
Put on more weight
You might as well tell a bullrush
Not to get wet
How much time can you give us ?
We see : one carpet in your flat costs
The fees you earn from
Five thousand consultations.
You'll no doubt say
You are innocent. The damp patch
On the walls of our flats
Tells th^,same story.
— Bertolt Brecht
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