On August 28, with the pronouncement, “INEQUALITIES ARE KILLING PEOPLE ON A GRAND SCALE,” the World Health Organization’s Commission on the Social Determinants of Health released its report, Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health.
The Commission confirmed previous reports of health inequities between nations as well as “health gradients” within them. It confirmed that the poor are worse off than those less deprived, the less deprived are worse off than those with average incomes, and so on, up the social hierarchy. It confirmed that this health gradient exists in all nations, including the richest. It also confirmed that health equality cannot be achieved by medical systems alone.
Water-borne diseases are not caused by a lack of antibiotics but by dirty water, and by the political, social, and economic forces that fail to make clean water available to all; heart disease is caused not by a lack of coronary care units but by the lives people lead, which are shaped by the environments in which they live; obesity is not caused by moral failure on the part of individuals but by the excess availability of high-fat and high-sugar foods.
None of these findings is new. Studies of health inequity date back to the Industrial Revolution of the 19th century and spurred the development of the public health movement.
The founder of Social Medicine is generally considered to be Rudolf Virchow (1821-1902), a liberal physician and public health activist. However, I think that title properly belongs to Frederick Engels (1820-1895), Karl Marx’s comrade and collaborator. Engels was the first to connect a broad number of medical and social problems to the way capitalism is organized.
Between September 1844 and March 1845, Engels documented the human impact of the industrial revolution in England. He published his findings in The Condition of The Working Class in England: From Personal Observation and Authentic Sources.
Over the past 163 years, much has changed. The United States has replaced England as the center of the industrial world. Higher living standards have lengthened life-spans and lowered child death rates in many nations. Yet much remains the same, and some things are worse.
As the WHO report documents, health inequities continue to follow income inequities, and both are increasing. In 1980, the richest countries had a gross national income 60 times that of the poorest countries. By 2005, this difference had more than doubled. The global population now suffers many of the same health and social problems that Engels documented in England: extreme poverty, environmental pollution, lack of sanitation, contaminated food, preventable diseases and premature deaths.
As I read the WHO report, I wondered what Engels would think of it. So I constructed a fictional interview for the purpose of comparing his findings with current conditions. His words (taken from his book) are in italics. I am responsible for the rest of this imaginary conversation.
Class and Health
SR: Your book documents a strong link between class and health in, what was in your time, the wealthiest nation in the world.
Engels: Yes. In Liverpool, in 1840, the average longevity of the upper classes, gentry, professional men, etc., was 35 years; that of the business men and better-placed handicraftsmen, 22 years; and that of the operatives, day-laborers, and serviceable class in general, only 15 years.
SR: In the United States, currently the world’s richest nation, death rates are not recorded by class. However, the nation’s poorest adults are nearly five times more likely to be in “poor or fair” health than the richest, and at every income level the wealthier group is healthier than the one below it. This health gradient exists in all racial groupings.
Engels: There is a heavy mortality among young children in the working-class. The tender frame of a child is least able to withstand the unfavorable influences of an inferior lot in life; the neglect to which they are often subjected, when both parents work or one is dead, avenges itself promptly, and no one need wonder that, in Manchester, more than 57 per cent of the children of the working-class perish before the fifth year, while but 20 per cent of the children of the higher classes, and not quite 32 per cent of the children of all classes in the country die under five years of age.
SR: America’s infant deaths are recorded by location and race, which are loosely related to class. In poorer states, like Mississippi, infant death rates are more than double what they are in richer states like Vermont. And the overall death rate for Black babies is two-and-a-half times higher than it is for White babies.
You found a report of differing mortality rates on different streets.
Engels: Yes. Dr. P. H. Holland studied a suburb of Manchester. He divided the houses and streets into three classes each, and found that the mortality in the streets of the second class is 18 per cent greater, and in the streets of the third class 68 per cent greater than in those of the first class; that the mortality in the houses of the second class is 31 per cent greater, and in the third class 78 per cent greater than in those of the first class; that the mortality in those bad streets which were improved, decreased 25 per cent. Holland concluded his report with this unusually frank remark.
When we find the rate of mortality four times as high in some streets as in others, and twice as high in whole classes of streets as in other classes, and further find that it is all but invariably high in those streets which are in bad condition, and almost invariably low in those whose condition is good, we cannot resist the conclusion that multitudes of our fellow-creatures, hundreds of our immediate neighbors, are annually destroyed for want of the most evident precautions.
SR: Such detailed studies are rarely done here, but I suspect the results would be comparable.
SR: You document the poor quality of food consumed by the working class.
Engels: In the great towns of England the best food can be found, but it costs money; and the workman, who must keep house on a couple of pence, cannot afford much expense. The potatoes which the workers buy are usually poor, the vegetables wilted, the cheese old and of poor quality, the bacon rancid, the meat lean, tough, taken from old, often diseased, cattle, or such as have died a natural death, and not fresh even then, often half decayed.
On the 6th of January, 1844 (if I am not greatly mistaken) in Manchester, eleven meat-sellers were fined for having sold tainted meat. Each of them had a whole ox or pig, or several sheep, or from fifty to sixty pounds of meat, which were all confiscated in a tainted condition. In one case, fifty-four stuffed Christmas geese were seized which had proved unsaleable in Liverpool, and had been forwarded to Manchester, where they were brought to market foul and rotten. But these are by no means all the cases; they do not even form a fair average.
SR: We continue to suffer from contaminated meat and vegetable produce. In Britain in 1986, a deadly brain disease (BSE) was caused by feeding diseased animal parts to cows that were later consumed by human beings. Over a hundred people died and many more were infected. The victims were mostly workers who ate cheap ground beef, which is mass produced by pooling many carcasses.
Today, food is produced and distributed on a much larger scale than it was in your time, which makes the problem of contamination much more serious. In 2003, the first infected cow surfaced in the U.S., and before the diagnosis could be confirmed, meat from the infected animal had been distributed to more than eight states, and the cow’s infected spinal cord had been incorporated into food for pets, pigs, and poultry.
Engels: And when one reflects upon the many cases that escape detection under the slender supervision of the market inspectors — when one considers how great the temptation must be, in view of the incomprehensibly small fines mentioned in the foregoing cases; when one reflects what condition a piece of meat must have reached to be seized by the inspectors, it is impossible to believe that the workers obtain good and nourishing meat as a usual thing.
SR: We have many more regulations to protect the food supply, but they are poorly enforced. Companies are “trusted” to regulate themselves. When problems arise, the government’s first concern is to protect industry profits. After the first infected cow was found, the Department of Agriculture reassured us that ” the food supply is fully protected and consumers should feel fully confident that the beef supply in this country is very safe to eat.” When more diseased cows were identified, the DA announced that it was reducing testing for BSE. Less testing lowers the risk of identifying sick animals.
Engels: The capitalists have made progress in the art of hiding the distress of the working-class.
SR: You also describe extensive food adulteration.
Engels: Dealers and manufacturers adulterate all kinds of provisions in an atrocious manner, and without the slightest regard to the health of the consumers. But don’t take my word for it. Let us hear from the Liverpool Mercury (I delight in the testimony of my opponents):
Salt butter is molded into the form of pounds of fresh butter, and cased over with fresh. In other instances a pound of fresh is conspicuously placed to be tasted; but that pound is not sold; and in other instances salt butter, washed, is molded and sold as fresh…. Pounded rice and other cheap materials are mixed in sugar, and sold at full monopoly price. A chemical substance – the refuse of the soap factories – is also mixed with other substances and sold as sugar…. Cocoa is extensively adulterated with fine brown earth, wrought up with mutton fat….Nasty things of all sorts are mixed with tobacco in all its manufactured forms.
SR: It’s no different today. The better-off can afford a wholesome, organic diet, while the workers’ food continues to be adulterated. It’s almost impossible to find cheap food that does not contain a long list of additives to enhance color, flavor, texture and shelf-life. Many of these additives are indigestible or harmful, but they make cheap food very profitable. These adulterated foods fill the bellies of the working class, generating digestive disorders, malnutrition, obesity and diabetes.
SR: You condemn “the custom of giving young children spirits, and even opium” to keep them quiet.
Engels: One of the most injurious patent medicines is a drink prepared with opiates, chiefly laudanum, under the name Godfrey’s Cordial. Women who work at home, and have their own and other people’s children to take care of, give them this drink to keep them quiet, and, as many believe, to strengthen them. They often begin to give this medicine to newly born children, and continue, without knowing the effects of this “heart’s-ease”, until the children die. The less susceptible the child’s system to the action of the opium, the greater the quantities administered. When the cordial ceases to act, laudanum alone is given, often to the extent of fifteen to twenty drops at a dose. The effects upon the children so treated may be readily imagined. They are pale, feeble, wilted, and usually die before completing the second year. The use of this cordial is very extensive in all great towns and industrial districts in the kingdom.
SR: Today, child drugging has reached epidemic proportions, with millions of youngsters being prescribed addictive substances to keep them quiet and compliant.
Despite the many parallels, conditions for workers in the industrial nations are generally better then they were in your time. You acknowledge this in the 1892 preface to your book when you wrote, “the most crying abuses described in this book have either disappeared or have been made less conspicuous.”
Engels: The state of things described in my book belongs, in many respects, to the past, as far as England is concerned. Repeated visitations of cholera, typhus, small-pox, and other epidemics have shown the British bourgeois the urgent necessity of sanitation in his towns and cities, if he wishes to save himself and family from falling victims to such diseases. Moreover, the capitalists were learning, more and more, that they could never obtain full social and political power over the nation except by the help of the working-class. So they accepted reforms that raised the workers’ standard of living.
SR: The worst problems you describe can now be found in the poorer nations. Even so, contaminated air, food and water continue to plague even the richest ones. We have the science and technology required to protect health, but the drive for profit prevents us from using it effectively.
Your book covers much more ground, and there’s so much more we could discuss, but let’s proceed to the matter of solutions.
What Must Be Done?
SR: To reduce health inequality, the WHO report recommends improving living and working conditions; and distributing power, money, and resources more equitably. And in a series of “What Must Be Done” boxes, it makes specific suggestions, including:
Invest in early childhood development and in the education of women.
Remove the barriers to girls and boys enrolling and staying in school
Provide clean water, sanitation systems and electricity for all.
Ensure safe, secure, and fairly-paid work, year-round work opportunities, and healthy work–life balance for all.
Ensure a healthy standard of living below which nobody should fall due to circumstances beyond his or her control
Provide universal access to quality health-care services.
Engels: How will they implement these measures?
SR: The Commission emphasizes “the primary role of the state in the provision of basic services essential to health (such as water/sanitation) and the regulation of goods and services with a major impact on health (such as tobacco, alcohol, and food).”
Engels: Has the capitalist class ever paid any serious attention to social grievances? Have they done more than pay the expenses of half-a-dozen commissions of inquiry, whose voluminous reports are damned to everlasting slumber among heaps of waste paper on government shelves? Have they even done as much as to compile from those rotting blue-books a single readable book from which everybody might easily get some information on the condition of the great majority. No indeed, those are things they do not like to speak of.
SR: As you said, the capitalists need the cooperation of the working class to stay in power, and health inequity has become so serious and so global that it cannot be ignored. We now have a mountain of reports on the condition of the working class, but none indict capitalism for the problems they document. All call for the State to curb the greed of the capitalist class through regulation.
Engels: Regulations are as plentiful as blackberries; but they only contain the distress of the workers, they cannot remove it. Must I remind you that the capitalist class can exist only by depriving the working class of what it creates? That is the basis of the system which tends more and more to split society into a few Rothschilds and Vanderbilts, the owners of all the means of production and subsistence, on the one hand, and an immense number of wage-workers, the owners of nothing but their labor-force, on the other. So that inequality of all kinds is caused, not by this or that secondary grievance, but by the system itself — this fact has been brought out in bold relief by the development of capitalism.
SR: The WHO report disagrees, assuring us that “the private sector has much to offer that could enhance health and well-being,” in particular, by improving working conditions. It also recommends that “private sector activities and services (such as production and patenting of life-saving medicines, provision of health insurance schemes) contribute to and do not undermine health equity.” Yet none of these measures is profitable. On the contrary, they would all cut into profits. This is like asking the fox not to eat the chicken, but to safeguard its health instead.
Engels: When one individual inflicts bodily injury upon another such injury that death results, we call the deed manslaughter; when the assailant knew in advance that the injury would be fatal, we call his deed murder.
When society places workers in such a position that they inevitably meet a too early and an unnatural death, one which is quite as much a death by violence as that by the sword or bullet; when it deprives thousands of the necessaries of life, places them under conditions in which they cannot live – forces them, through the strong arm of the law, to remain in such conditions until that death ensues which is the inevitable consequence – knows that these thousands of victims must perish, and yet permits these conditions to remain, its deed is murder just as surely as the deed of the single individual; disguised, malicious murder, murder against which none can defend himself, which does not seem what it is, because no man sees the murderer, because the death of the victim seems a natural one, since the offence is more one of omission than of commission. But murder it remains.
Capitalism daily and hourly commits social murder. It has placed the workers under conditions in which they can neither retain health nor live long; it undermines the vital force of these workers gradually, little by little, and so hurries them to the grave before their time. The capitalist class knows how injurious such conditions are to the health and the life of the workers, and yet does nothing to improve these conditions.
SR: Your book calls on the capitalist class “either to continue its rule under the unanswerable charge of murder and in spite of this charge, or to abdicate in favor of the laboring-class. Hitherto it has chosen the former course.” Did you really expect them to abdicate their rule?
Engels: I confess that I was only 24 when I wrote the book and politically immature when I stressed that socialism is a question of humanity and not of the workers alone. This is true enough in the abstract, but absolutely useless, and sometimes worse, in practice. So long as the wealthy classes not only do not feel the want of any emancipation, but strenuously oppose the self-emancipation of the working-class, so long the social revolution will have to be prepared and fought out by the working-class alone.
And today, those who, from the “impartiality” of their superior standpoint, preach to the workers a Socialism soaring high above their class interests and class struggles, and tending to reconcile in a higher humanity the interests of both the contending classes — these people are either naive, with much to learn, or they are the worst enemies of the workers — wolves in sheep’s clothing. I explain this more fully in Socialism, Utopian and Scientific.
SR: I can see why the capitalists don’t want to acknowledge you as the founder Social Medicine. They still recoil at your insistence that the only way to improve health and eliminate health inequity is to abolish class divisions. And yet, the evidence continues to prove you right.
A 1998 study of American cities found that the greater the difference in income, the more the death rate rose for all income levels, not just for the poor. Reducing income inequality to the lowest level found in the United States would save as many lives as would be saved by eradicating heart disease or preventing all deaths from lung cancer, diabetes, motor vehicle crashes, HIV infection, suicide and homicide combined
Moreover, the WHO report calculated that, if racism were abolished so that mortality rates between White and Black Americans were the same, 886,202 deaths would have been avoided between 1991 and 2000. Over the same period, only 176,633 lives were saved by medical advances. And many millions would be saved by raising living standards in the poorer nations.
Engels: Clearly, the need is greater than ever. But until workers fight back as a class, there can be no progress.
SR: That’s so true. The WHO report starts with a bang — INEQUALITIES ARE KILLING PEOPLE ON A GRAND SCALE — and ends with a whimper, with a plea for the “political will” to make change.
Thank you for taking the time to talk with us.
Engels: Don’t thank me. Organize!