In November’s Lancet, editor Dr Richard Horton has liberated his esteemed medical journal from the shackles of science by inviting us to resurrect Karl Marx as the saviour of medicine. His paean to Marx is a confusing blancmange of naïve romanticism and sophomoric cliché. Marxism, he pleads un-ironically, offers a ‘critique of society’, a ‘method of analysis’, a ‘call to engage’, and more than a legacy of famine, genocide and failed states.
This is not satire. Like many physicians in positions of influence, Horton still believes that capitalism is the stubborn obstacle to fairer and healthier societies, and that, (quoting Howard Waitzkin) ‘fundamental changes in the broad social order’ are necessary. Whilst he notes that many young people are sceptical of the influence of free markets on society, he ignores the fact that a majority of these critics live at home on parental largesse. Thanks to a feelings-based educational system born of the Frankfurt School, youngsters of Western democracies have little knowledge of the murderer’s row of socialists who successfully ‘changed the social order’. Pol Pot, Mao and Lenin are names largely absent from contemporary history curricula. Horton chooses NZ’s very green PM Jacinda Ardern to paraphrase in support of his thesis. That the millennial Ms Ardern should be considered a ‘go-to’ authority on such matters should trouble Kiwis and Marxists alike.
Socialists make the category error of viewing capitalism as a system; an evil inversion of their own utopian ideal. Capitalism is simply the emergent result of individuals freely exchanging goods. It is neither inherently virtuous nor wicked. It makes no grandiose claims about perfecting society. Horton ignores the necessary contributions of the free market to healthcare. Everything from surgical masks to antibiotics, IT systems, and even Apple Macs used by Lancet editors is the happy result of profiteering. Competition insures that these goods are affordable and high quality. Whilst capitalism permits competition for production, Socialism promotes competition for consumption. If Horton wants less Big Pharma, the solution isn’t more government; it’s to allow lots of little Pharmas to flourish. The UK’s National Health Service is both an exemplar of the failures of socialised medicine and one of the greatest marketing successes in history. Britain’s relationship with the NHS has something of the Stockholm syndrome about it. Britons defend their health service in the same tones as a wife making excuses for an abusive spouse. A structural flaw of limited supply and infinite demand condemns the NHS to perpetually inadequate resourcing. Despite its mediocrity, the NHS does experience considerable health tourism, but patients are more likely to be from Nigeria than from, say Switzerland. That there can never be enough money is a feature, not a bug. For the evangelical socialist there is no limiting principle, and hence there is always a justification for revolution.Meanwhile, individual patients passively endure queues, hospital-acquired infections, poor cancer outcomes and lack of physician choice. Incidentally, the greatest barriers to satisfactory healthcare in the developing (Marxist) world include cronyism, lack of political and trade freedoms, aid diversion and corruption. Rather than focussing on those, Horton frets about ‘techno-optimism’, ‘philanthrocapitalism’, ‘multimorbidities’, ‘neoimperialism’, and other scary portmanteaux.
Horton’s boast that Marxists refuse to accept the fixity of human nature is also absurd; Marxists eschew the very existence of human nature in favour of the idea of the tabula rasa. The dogma that health is socially determined stems from this fallacy. For the socialist, inequality is considered the Holy Grail of health determinants. Readers may remember activist researchers Richard Wilkinson and Kate Pickett. Their 2009 book The Spirit Level caused a stir, purporting to show that the steeper the social gradient within a society, the more likely all citizens experience poor health outcomes. They argue it isn’t absolute poverty, but the gap between rich and poor that matters most. Sadly for the true believers, this field of research is prone to cause and effect substitution, cherry-picking of data, and the minimising of cultural factors.
Unsurprisingly the biological mechanisms mediating the supposed Spirit Level phenomenon remain elusive. One fashionable idea is that harmful hormones and inflammatory cells attack our bodies if we are exposed to very specific micro-traumas. Examples might include the stress of being an employee rather than a boss, or discovering that your neighbour has a newer Lexus than you (a condition previously known as envy). So not only is capitalism exploitative, but unhealthy too. A big dose of taxation will cure this ill.
Horton’s assertion that public health is the ‘midwife’ of Marxism depends on how public health is defined. If he means what Richard Epstein terms the ‘old’ public health i.e the development of epidemiology, sanitation and vaccination, then he is drawing a long bow. Advances in longevity, reductions in infant mortality and the treatment of communicable diseases began with scientific explosion of the Enlightenment and emerged as one of the fruits of Western Civilisation. It was the spirit of Victorianism that gave us the public health innovations of Snow, Bazalgette and Chadwick. But Horton’s version of ‘public health’ is more ominously totalitarian. His airily vague aspiration for ‘public participation in shaping collective choices’ means in reality an ever-expanding list of paternalistic impositions aimed to protecting people from themselves without their consent.
Christopher Snowdon’s recent book Killjoys: A Critique of Paternalism surgically dissects many of these illiberal preoccupations; from the banning of alcohol to the mandatory restriction of restaurant portion sizes. In this world, the cost of a theoretically marginal rise in life expectancy at a population level is offset by forbidding everything save for cycling and literary criticism. In a free society, consequences of bad choices are borne primarily by the individual. Socialism achieves a double whammy; simultaneously encouraging the intemperate to disavow personal responsibility whilst forcing the prudent to underwrite the cost. Let’s please consign Marx to the annals of history.