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Most discussions assessing the effects of racism on health attempt to suggest solutions, ranging from combatting provider bias, to changing the insurance system, to reducing income inequality. However, we should start by asking a fundamental question: Is it possible to erase the inequalities and deficiencies in health and health care in our capitalist system? Is it possible to create an equitable and excellent health care system in America?

The Needs of Capitalism

Capitalism exists to make profits. This is not a moral statement, but the underlying mechanism of the system, for a business must be successful at not only making, but maximizing profits, or it will lose out to competitors. Profits are derived from the difference between the value of goods produced and the investment in the means of production, ie labor, machinery, advertising, etc. It is the cost of labor where the major flexibility lies, and wages depend on the costs of maintaining the worker in working condition, providing training, and replacing workers lost to disability or retirement. Thus a low-skilled worker in a time of high unemployment, when he or she can be easily replaced, is much less valuable and is paid less than a highly trained one with scarce skills.

In addition, there is the factor of what workers demand above the owner’s minimum, via strikes or other struggles. In fact, Medicare and Medicaid, which cover the poor, elderly and disabled in the U.S., were created in 1965 in response to the massive unrest of that time, the civil rights and the burgeoning anti-Vietnam War movements. Medicaid, however, which covers care for the poor and disproportionately enrolls non-white patients, has been chronically underfunded. Reimbursements are so low that many doctors and facilities will not accept it, and it is now threatened with massive cuts under Trump. The undocumented still remain without any coverage whatsoever. Obama care, flawed and reactionary as it is, is under deep threat.

Services that are necessary to maintain workers in general, such as public schools, sanitation, and health care, are general expenses to the capitalist system, a large part of which is recouped via taxes paid by workers themselves. Of course, capitalists also want to guarantee their own disease-free survival, so the control of conditions that might adversely affect them, such as epidemics, is also a consideration in understanding the history of public health. They also want to have a general level of health care infrastructure and scientific advancement so that they can live long and comfortably.

Keeping Workers Productive

Within capitalist nations, where industrialized production requires the well-being of a large number of workers and the availability of healthy young workers for the military, the level of health and health care must be ample to maintain this productive force. In 19th century England, as factory production flourished, workers lived in filthy crowded hovels, ate very poor diets, worked 15-hour days, suffered exposure to filthy air and toxins, and had frequent crippling accidents. As Edwin Chadwick, chief author of the Sanitary Acts, noted, the “depressing effect of adverse sanitary circumstances on the laboring strength of the population …is to be viewed with the greatest concern….The pecuniary cost of noxious agencies is measured by with data within the province of the actuary, by the changes attendant on the reduced duration of life, and the reduction of the periods of working or production by sickness.”

Within the U.S. at this time, the same sort of calculation was going on. The economist CEA Winslow wrote in 1908 that improved factory ventilation would pay for itself by decreasing absences and preventing workers from being stupefied by late afternoon. Another economist, Irving Fisher, wrote a report using a cost-benefit analysis of disease pointing out the loss of work years by early death. Stacy May, a WWII era Rockefeller-linked economist, summed up the capitalist view of health: “Where mass diseases are brought under control, productivity tends to increase – through increasing the percentage of adult workers as a proportion of the total population, and through augmenting their strength and ambition to work….”

One example of a corporation’s attack on disease for its own ends is hookworm. Hookworm, which still flourishes in Africa, was brought to U.S. by the slave trade beginning in the 17th century. By 1910, the Rockefeller Sanitation Commission for the Eradication of Hookworm Disease documented that nearly 40% of Southerners were infected, the cause of the so-called “laziness” of workers(due to the resulting anemia) which affected the agricultural productivity and economic development of the region. They therefore initiated a program of sanitation, education and medication dispensaries that significantly mitigated the problem. In each area where the program was instituted, productivity increased.

There should be no doubt that the calculation of benefits to the employer from a healthy work force has not decreased with time. In 2011, an oft quoted paper

by Hymel et al reiterates the claim that: The two factors, personal health and personal safety— [are] each essential to a productive worker and to a productive workplace. Just last week, the NY Times (7/25/17) described a new program in Britain to provide widespread talk therapy for common mental health problems like anxiety and depression. The justification was, of course, “just on lost work alone, the program would pay for itself.”

Racist Inequality in Health Care is an International Problem

Worldwide, the comparison between the health status of the darker-skinned countries of the southern hemisphere and the wealthier more Caucasian northern countries is shocking. One out of eight people in the world do not have enough food, 98% of whom live in developing countries. The case of cholera provides some interesting insights. Although cholera most likely originated in India around 500 BC, it did not cause epidemics until the early 1800s, when increased urban congestion, commerce and migration facilitated its spread. By 1860, millions had died around the world in various epidemics. Now that clean water is readily available in the developed world, cholera is virtually unknown. The disease, however, continues to flourish in underdeveloped countries and is endemic in Africa and South and Southeast Asia. Although two vaccines, rehydration solutions, antibiotics, and means of achieving safe water are well known, the number of cholera cases continues to rise, with almost 600,000 being reported worldwide in 2011. In all of the endemic areas, there is a disparity between illness rates of the rich and the poor, among whom poor sanitation, overcrowding, and lack of safe drinking water promote disease A major epidemic was imported to Haiti in 2011 by Bangladeshi UN peacekeepers, and another epidemic has erupted in Yemen as American supported Saudi bombing has destroyed the sanitation infrastructure.

It is clear that the health and survival of the poorest people of the world, away from capitalist centers of production, is not of enough concern to the wealthy and powerful to mitigate the plagues of cholera and the many other infectious diseases that plague only the destitute poor of the less developed world or those whose well-being is less important than a military objective

It is not uncommon for American liberals, in highlighting the injustice and inequality in colonized or militarized societies, to point out the striking differences in health and longevity between the rich and poor, the rulers and the ruled, the white and the non-white populations. In Israel/Palestine, there is a ten year gap in life expectancy between Jews and Palestinians, and a five fold difference in infant mortality. In South Africa, based on data from 2012, black men had an 18 year shorter life expectancy than white men, 17 years after the end of apartheid. We use such statistics to bolster our diatribes against the horrors of occupation or apartheid, but sometimes we forget that racial disparities of a large degree persist and exist in our own supposedly democratic society, free of internal armed conflict, walls, enforced segregation or occupation.

Racism and Health in the U.S.

The difference in wages alone in the U.S., between white men on the one hand and women, minorities, and immigrants on the other, adds up to $3-4 trillion a year, almost 25% of the gross national product. (This can be calculated up from the Bureau of Labor Statistics wage figures.) Some of this is due to different wages paid for the same work and some to the fact that different work is available to women and non-whites with less education and opportunity. In any case, it is not a figure that the economy could afford to erase or even substantially decrease. In addition, one must consider the enormous savings in inferior housing, schools, health facilities and many other services that characterize black, Latin and immigrant neighborhoods.

A century ago, W.E.B. Dubois said “The Negro death rate and sickness are largely matters of [social and economic] condition and not due to racial traits and tendencies” This year, in a TED talk, the renowned Harvard sociologist David R. Williams noted that every 7 minutes, a black American dies prematurely, over 200 people each day who would not die if their health were the same as their white counterparts. He presented evidence that these racial differences cannot simply be accounted for by unequal economics and education, because even within groups of equal income and education, racial gaps persist. Only racism can be the answer. Even among college graduates, there is a 4.2 year black/white gap in life expectancy, and it rises for each lower rung of achievement.

Racism, he said, can be measured both in the gross insults like excess stops by the police, and in the small effects of everyday slights. These may include less courteous treatment in a restaurant, poorer service at a store, or expressions of fear by fellow pedestrians, High blood pressure, obesity, cancer, heart disease and premature death have all been shown to correlate with the experience of everyday racism. Another factor is different access to medical care, which reflects housing and employment discrimination. In addition to these institutional factors, implicit bias, or unconscious racism, occurs amongst many health care providers, even well intentioned ones.

Structural Racism

The Lancet, the major British medical journal, has recently published a new issue devoted to the inequities in American health and health care, and “In the nearly 3 years since the first Series was published, health in the USA has changed and not for the better”. The article on structural racism, that not dependent on the actions of individuals, focuses on the experience of black Americans and reiterates the history of the creation of racism to justify slavery and the later use of eugenics and genetic “science” to perpetuate white supremacy. Despite the passage of civil rights legislation in the 1960s, structural racism persists in residential, occupational, educational, and judicial differences determined by discrimination in, rental policies, job training and wages, school variations and discrepancies in arrests and sentencing.

According to the 2010 census, the average white American lives in a neighborhood that is 75% white, and the neighborhood of a typical black American is 65% non-white, figures unchanged since 1940. Poorer neighborhoods with high black populations are characterized by lower quality housing, more pollutants and toxins, less availability of healthy food and less access to quality health care. These conditions lead to higher neonatal morbidity, a lower life expectancy and an increased risk of chronic disease, such as cancer and diabetes.

*Economic data and data on self-reported health and psychological distress are for Asians only; all other health data reported combine Asians and Pacific Islanders

†Wealth, poverty, and potential life lost before the age of 75 years are reported for the black population only; all other data are for the black non-Hispanic population.

‡Serious psychological distress in the past 30 days among adults aged 18 years and older is measured using the Kessler 6 scale (range=0–24; serious psychological distress: ≥13). Sources: wealth data taken from the US Census; 1 x 1 US Census Bureau. Detailed tables on wealth and ownership assets: 2011. http://www.census.gov/people/wealth/data/dtables.html. (Accessed Jan 25, 2017).)

As pointed out in a recent review article published by the National Institutes of Health, segregation in the workplace often creates different levels of risk. For example, at a federal nuclear power plant, black workers had a greater level of radiation exposure. Minority workers often work in more dangerous environments, such as buildings without fire exits or less secure scaffolding. They also often encounter conditions that lead to increased stress, such as lack of breaks or late or underpayment of wages. Such stress, exclusive of physical hazards, is related to an increased incidence of heart disease.

Overall, the U.S. ranks last or near last among developed nations in nearly all measures of health outcomes, health equity, and systems of delivery. Even health outcomes for the well insured with access to the “best” care lose in comparison to similar groups in European countries, despite the U.S. being the highest spender. This reflects the emphasis on expensive high-technology procedures, unregulated drug pricing, and high insurance company profits. It also reflects the lack of emphasis on prevention, including healthy food, a safe environment and working conditions, minimizing stress, and exercise facilities. A sharply divided society by class and race hinders everyone from attaining a healthy and long life.

In sum, some health services for workers, from the unskilled to the professional, are necessary under capitalism to provide a dependable workforce, in order to maximize profits. Care for the unemployed, unemployable or less skilled and easily replaceable workers is not a priority. To admit this is in no way seen as a dark matter to be couched in euphemisms, but is proudly touted with all sorts of cost-benefit analyses. For example, during medical student and resident training the introduction to every lecture on a condition starts with a statement that cost in loss of time from work is XXX million/year and the expenditure in medical cost is XXX million or billion/year. Thus young doctors are inculcated with the ethic of measuring treatment or prevention benefits on the basis of profitability to capitalism, as opposed to the well-being of patients. Thus it is unlikely – indeed , economically unfeasible — that any political administration will usher in a health care system that provides excellent preventive, chronic or acute care to all segments of the population. Only a mass movement which includes millions, employed and unemployed, old and young, and of all ethnicities can realistically fight for that.