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Book Review

(Assignment for course 632: Political Economy of Health) The Political Economy of Health by Lesley Doyal with Imogen Pennell Pluto Press Limited, London, 1979 The author attempts to understand medicine and health from the standpoint of the labour process that constitutes the capitalist mode of industrial production. Theoretically she takes a position in contrast to the one adopted by Ivan Illich and in fact critiques it. She argues that there is little point in making a case for de-industrialisation and debureaucratisation of society as Illich suggests. Further, there is no meaning in saying that medicine is particularly strategic in the struggle to move from an industrialised to autonomous mode of production (p 19). Doyal suggests that it is not appropriate to assume, as Illich does, that any industrialised society must be organised on an authoritarian, bureaucratic and hierarchical basis. She argues that there are problems inherent in bureaucracy as a mode of organisation, but the functioning of bureaucracies basically reflects the nature of society within which they have been created. Hence, the functions of modern medical organisations and the mode of production of modern health care are to a very large extent determined outside the health sector. In large part they are a reflection of the need of a capitalist system to sustain a particular set of social and economic relationships within the spheres of production and consumption; and the disappearance of a particular system of medical care would not change this (pp. 19-20). The perspective developed by Doyal has the following features: The relationship between the biological and the social is determined by the laws of development of capitalism. While on the one hand capitalism may facilitate an improvement in general health of the population the health needs of the mass of population on the other hand continue to come into frequent conflict with the requirements of continued capital accumulation (p 23). The physical process of commodity production itself will affect health in a variety of ways. The imperatives of capital accumulation condition, the nature of labour process, and the need for shift work, de-skilling, overtime or the use of dangerous chemicals will all be reflected in the health or ill health of workers (p 25). The direction of the argument is that to sustain and enable the reproduction of the labour power and process is the first parameter for understanding health and medicine. Linked to this is the second parameter, that is, the social conditions created by capitalism. These conditions contribute to public health. The first parameter defines the clinical aspect and the second parameter defines the preventive. Both these together determine the institutional arrangements for medicine and health. From this perspective she describes health, illness and the development of capitalism. Chapter two describes the process in a developed situation in Britain and chapter three described the process in Third World situations of underdevelopment. She does not focus

on the clinical aspect that deals with the knowledge system of modern capitalism. In other words, she does not explore the implications of the fact that modern medical knowledge not only is produced and reproduced by the capitalist system, it also produces and reproduces the conditions necessary for the continuation of this system. Instead, she concerns herself with link between public health system, medicine and the development of British capitalism (chapter 4). Chapter four continues the discussion raised in chapter two. Corresponding to chapter three she concerns herself with medicine and imperialism in chapter seven. In chapter six, she deals with the system of control inbuilt into the national health system which is a component of the public health system. In the last chapter she raises some questions with regard to the struggle for a healthier society. In chapter two she shows that patterns of illness and health standards are linked directly to the working conditions on factory floors and other work places, to labour migration, to environmental pollution, to the stress of coping with the demands of industrial production. For instance, she points out that the mixture of exhaustion, unhealthy working conditions, damp and insanitary housing, and inadequate nutrition meant that working class families became especially susceptible to infectious diseases (p 53). Different industries added to the generally debilitating effects of work, though producing their own specific health problems (p 52). One of the standards for judgement was in terms of life expectancy. She points out that there can be no doubt that capitalist development made possible a dramatic reduction in mortality rates and increase in the life expectancy for the entire British population. Indeed, she argues, the change in life styles that accompanied this added to disease and illness to the list. The level of comfort at home and the level of safety at the work place increased. All this was made possible by the national health system. Equally, the process of industrial development specific to the Third World countries determined the pattern of illness, disease and the health system. There were two kinds of disease and illness those that were infectious and those that were caused by malnutrition. The early effect of colonial expansion has been the spread of infectious diseases. Throughout history of the extension of world trade and travel has involved not just economic and cultural contacts, but also the dissemination of new infections. According to Doyal, this makes clear the objective significance of this process of capitalist development. She suggests that there is a close relationship between economic and physical health, so that the ability of a population to maintain a given standard of health is always directly related to its capacity to maintain and control material means of production. Colonial expansion in bringing about the destruction of the vital social and ecological relationship which enabled people to feed themselves, also destroyed the health of local populations on an unprecedented scale (p 107). The need for a public health system in Britain arose from the concern for conditions of the working class. Their ill health posed an immediate threat to the inhabitants of the wealthier parts of the town (p141). More fundamentally, chronic ill health appeared to present a serious obstacle to economic and military expansion. Attempts by the expanding central and local state apparatus to solve these problems were concentrated on public health measures. This included control of disease through the provision of clean

water, sewage disposal and some slum clearance. In the early 19th century curative medicine was still very limited both in its availability and its effectiveness (p 141). Throughout the nineteenth century, medicine and biology played a central part in the process of change. Scientists began increasingly to take over from priests the task of defining and upholding the moral order (p 148). According to Doyal, this is no where more clear than in the sphere of sexuality. For instance, the organisation of medical care reflected very clearly the class divisions in the Victorian society. Science became a metaphor within which the existing social and sexual division of labour was justified and reinforced. During the 18th and 19th century, work at home and work at outside were separated and work done by women at home was denied social recognition. This was strongly reinforced by the idea of female domesticity and medical knowledge emphasised the difference between men and women by arguing that the status and capacities of women were entirely pre-determined by the nature of their reproductive organs (p 152). Further, the impact of medical precepts on the lives of middle class women came most clearly into perspective when women were beginning to prefer for birth controls. In this collective effervescence, strong forces were pushing towards an extension of the state in the provision of medical care for individuals. As a result, the split between preventive and curative approaches to health care widened (p 160). Alongside working class demand for social reform began to be echoed by enlightened sections of the ruling class and the attention of reformers during this period was therefore focused mainly on the expansion of health measures directed towards individuals and on the introduction of a minimum level of social security. These themes are discussed in greater detail in chapters 4, 5 and 6. The thrust of argument is that this was the paradigm that was developed in the womb of capitalist industrial development and then extended to third world countries and formed a part of the imperialist package. In chapter seven, she outlines the dissemination and replication of this paradigm. In her terminology there was visible a consolidation of the western medical practice. For instance, the first task to ensure the health of Europeans was also the beginning of the introduction of the medical system. It introduced medicine as a commodity and internationalised the public health system such that standards universally valid were used to access and intervene in Third World situations. The most important dimension, according to Doyal, is the reproduction of a cheap labour force that was a necessary condition for industrial production. This was visible ironically in the emphasis on population control which is indeed necessary for such reproduction.