6/18/2019 ‘Health Care Under the Knife: Moving Beyond Capitalism for Our Health’ by Howard Waitzkin and

kin and Working Group on Health Beyond …

Howard Waitzkin and Working Group on Health

Beyond Capitalism
Health Care Under the Knife: Moving Beyond Capitalism for
Our Health

Monthly Review Press, New York, 2018. 336pp., $27.00 pb.

ISBN 9781583676745

Reviewed by Mirjam Pot

Most scholars at the intersection of medicine,

health care and the social sciences agree that
About the reviewer
health and disease are, in a relevant dimension,
Mirjam Pot is a Political Science
also social and political phenomena. Health Care
graduate studying for a PhD at the
under the Knife, edited by Howard Waitzkin and
University of Vienna. She …
 More the Working Group on Health Beyond Capitalism,
however, goes further by relating persisting and
more recent problems in health care with the
developments and workings of capitalism. Providing detailed descriptions in the
single chapters, the book not only claims that health care systems in profit-
oriented societies are unable to sufficiently alleviate the most pressing health
issues: The authors also show how health care systems in capitalism contribute
to some of the conditions they are supposedly meant to counteract, as health
care itself is an important domain of capital accumulation.

The book is organised in five parts. Part one discusses the changes in the social
class position of doctors and how the advancing corporate organisation of
medical labour as well as the ever-increasing importance of (digital)
technologies in health care is affecting the everyday work practices of medical
professionals. The use of medical health records, quality assessment via metrics,
and the widespread replacement of relationship-based care with high-tech
interventions are just a few of the changes that contribute to doctors’ growing
subordination to management and their alienation from their own work and
patients.
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Part two
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interwovenness of industry, academia and the state in producing profits in
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health care, which is argued to blur the differences among for-profit, non-profit
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6/18/2019 ‘Health Care Under the Knife: Moving Beyond Capitalism for Our Health’ by Howard Waitzkin and Working Group on Health Beyond …

and state actors. The prime example is the funding of drug trials by
pharmaceutical companies and the companies’ exertion of influence on
governmental regulations and procedures of approval.

Following a critique of the Affordable Care Act (‘Obamacare’), at the beginning of

part three, the book for the first time also draws on examples from South
America and Europe to address how under the neoliberal paradigm, austerity
and privatisation have shaped health care reforms in Colombia, Greece, Spain
and the United Kingdom. By pointing to the retreat from universalism and
increasing cost sharing in these countries, the book reminds us that the
movement towards universal health care is far from being a linear progression.

Part four then moves to the global scale (keyword ‘imperialism’) by first
discussing the role of international organisations like the WTO and the WHO in
global health care, followed by a historical comparison between the Rockefeller
and the Gates foundation and the impact of their philanthropic engagement in
particular in the Global South. Although the amount of money allocated to health
initiatives by these foundations has been appreciable, their focus on specific
diseases and the underlying idea of a technological fix has prevented substantive
and sustainable improvements of public health infrastructures in these
countries.

Finally, in the fifth and most extensive part, the book outlines a number of
examples of how and where future struggles for better health and health care
could or should take place. Popular protest movements in Bolivia and Mexico are
consulted to inspire resistance against the privatisation of health care and other
health-related infrastructures. Furthermore, the authors draw on these
movements to motivate political action in favour of universal health care
systems that could overcome the structural inequities produced by the
commodification of care. Especially the case of the Affordable Care Act, its
benefits but also its shortcomings, and the struggle for a single-payer national
health programme in the U.S. are discussed at length. Challenging other writings’
often overly positive evaluation of the Act, makes the chapters on this example a
particularly interesting read. However, the authors also remind us that the
influence of the health care system on our health is rather modest in comparison
to the impact of environmental and social factors like access to clean water and
unpolluted air or the provision of healthy foods. Not to mention, for example,
racial and gender relations, housing quality and working conditions. In short,
capitalism does not only affect our health via the commodification of care but
more importantly through
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Health Care under the Knife profits in particular from the diverse backgrounds
and experiences of its authors. Many of them, like Howard Waitzkin himself, are
established researchers in the social or medical sciences, health care
professionals and social activists. Above all, however, the strength of the book is
the detailed studies on the economic dimension of health care, be it how the
insurance and pharmaceutical industry’s interests are catered for in the design
and reform of national health care systems and global public health, or the
changing class position (‘proletarianisation’) of doctors. Depicting these
processes in their development over time and relating current trends (as for
example the philanthropic engagement in public health) to their historical
predecessors, is another merit of the book.

Obviously, these two aspects are essential for understanding health care in
contemporary profit-oriented societies. Yet I want to argue that they are not
sufficient for a thorough analysis of health care in capitalism. The limitations of
the book in explaining health care in capitalism are related to the rather narrow
notion of capitalism the book draws on, understanding it merely as an economic
but entirely deterministic system (or even equating capitalism with the activities
of large companies). Social philosopher Rahel Jaeggi, whose work is situated in
the tradition of the Frankfurt School, has suggested to think of capitalism as a
‘way of life’. In such an understanding, the free-market economy is just one
component of capitalism. I consider this a valuable approach, because reducing
capitalism to an economic system, in which a couple of companies and
organisations run the world, does not help to understand why we still live in
capitalist societies. In other words, such a reductionist understanding of
capitalism impedes (rather than contributes) to understand why resistance is not
much more common and why we still play by capitalist rules. Instead, such a
notion of capitalism conceptualises us as ideologically blinded and stripped of
any agency as well as denies our own role in the maintenance of capitalism. In
this sense, conceptualising capitalism as a way of life, and health care as part of
it, makes it also necessary to consider how we are ourselves, as patients and
maybe doctors, entangled in capitalist health care. It is particularly striking that
patients are almost entirely missing from the analyses in Health Care under the
Knife.

I want to illustrate the argument about our own entanglements with the
example of over-diagnosis and over-treatment. Over-diagnosis is the diagnosis of
anomalies that would never result in symptoms and over-treatment denotes the
resulting medically unnecessary and often harmful treatment of patients. Both
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are particularly connected to the availability of new diagnostic and therapeutic
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possibilities, like high-resolution imaging technology or the diversification of
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available drugs. The introduction of new technologies in health care resulting in
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6/18/2019 ‘Health Care Under the Knife: Moving Beyond Capitalism for Our Health’ by Howard Waitzkin and Working Group on Health Beyond …

over-diagnosis and over-treatment can in part be understood as consequences of

the creation of new health markets. (Although Health Care under the Knife does
not refer to this example, it is specifically this economic dimension that is
addressed throughout the book.)

However, the unnecessary and/or harmful use of diagnostic and therapeutic

interventions cannot be fully understood without understanding doctors and
patients’ role in it. Doctors, for example, who have little time, consider it more
comfortable to prescribe a patient with lower back pain an MRI scan instead of
listening to her talk about her currently stressful life. Or take doctors, who
prescribe antibiotics, not primarily because it would be medically necessary, but
to sooth a patient. Often enough patients themselves expect quick solutions for
their ailments and demand medically unnecessary interventions themselves,
sometimes also against the advice of their doctors. In this respect, to understand
over-diagnosis and over-treatment one also has to understand how imaginations
and expectations about salutary medical interventions are mobilised and
reinforced, how patients’ desires and hopes are appealed to, or how patients are
increasingly addressed as being responsible for their own health and ‘proper
functioning’.

We have to understand doctors’ and patients’ role in capitalist health care to

understand why there is a growing market for medical products, which cannot
only be explained by the continued existence of diseases. Of course, part of such
an analysis is among others to address structural aspects, as the reasons why
doctors have less and less time for patients, and why patients demand quick
solutions. Looking at the specificities of health care and the problems
encountered by doctors and patients ‘on the ground’, in turn also contributes to a
better understanding of health care in capitalism and maybe even to a better
understanding of contemporary capitalism itself. Health Care under the Knife,
however, misses this opportunity. The reader learns interesting details about
health care reforms, the insurance industry and so on. Yet on an analytical level,
a book about other fields like education or housing in capitalism would have
resulted in similar conclusions. The book is based on and reaffirms an economic
reductionism and determinism that both have already been challenged in
various strands of Marxist theorising. In this sense, the analytical concepts it
draws on are of limited value to fully understand the dynamics of capitalism but
in particular to fully understand the specific dynamics of health care in
capitalism.

This last
Wepoint is also
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particularly in the chapters on contemporary forms of ‘imperialism’ in health
care. The creation of markets in the Global South for medical products
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6/18/2019 ‘Health Care Under the Knife: Moving Beyond Capitalism for Our Health’ by Howard Waitzkin and Working Group on Health Beyond …

manufactured in the Global North is mentioned as an example of this

phenomenon. What is not mentioned, however, is the lack of even basic drugs in
many poorer countries because pharmaceutical companies do not consider the
production of such drugs profitable. It would be a worthwhile endeavour,
besides stressing continuity, to also consider where it is more fruitful to think in
terms of discontinuity. For capitalism to be a stable arrangement, it constantly
has to change. Consequentially, if we want to grasp the current relationship
between capitalism and health (care), we also have to update and refine our
analytical tools to do so. Not just for theoretical reasons, but to move beyond
capitalism for our health.

Health Care under the Knife is an informative reading for an audience interested
in detailed descriptions about how economic interests shape, particularly in the
U.S. health care system. Readers with an interest in learning more about the
specificities of health care in capitalism or readers interested in a productive
engagement of empirical data on health care with Marxist theory, however,
might find the book somewhat shallow.

3 June 2019

URL: https://marxandphilosophy.org.uk/reviews/16955_health-care-under-the-knife-moving-beyond-
capitalism-for-our-health-by-howard-waitzkin-and-working-group-on-health-beyond-capitalism-
reviewed-by-mirjam-pot/

This review is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 3.0

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