28.11.2024

Your health, comrade

Physical and mental health is central to the communist project. Not only would people be healthier in a communist society, writes Ian Spencer, but such health would help deliver the full realisation of human potential

Marx and Engels wrote extensively on health. Engel’s The condition of the working class in England contains numerous references to the way in which capitalism in general, and industrialisation and urbanisation in particular, ruins the health of the working class. If one adds to this Marx’s discussion of alienation in the 1844 manuscripts, it is easy to see that health is at the heart of Marx’s ontological project.

Volume 1 of Capital is replete with quotes from Her Majesty’s Inspectorate of Factories, from which Marx draws attention to the way the health of workers is destroyed by capitalism. In some factory districts average life expectancy had dropped to just 15 years. The working class was not living long enough to reproduce itself. Of course, this can be misleading, since the low average life expectancy reflected high rates of infant mortality. If you lived to be 5, you would probably reach the age of 55. Also, industrialisation did not falter, because the urban population was constantly replenished by people displaced from the land (in particular, in Ireland).

More than this, the emphasis by Marx and Engels on communism being the full realisation of what it is to be human gives a richness to the concept of health, which does not exist in the bourgeois sociology of health and illness. The latter tends to focus on a deviation from a statistical norm or the presence or otherwise of a disease process. Furthermore, sociology obfuscates class relations and makes the consideration of health and illness one of relative inequality, rather than the realisation of human potential, which will only come into being with the abolition of class society.

Sociology plays as important an ideological role as does Keynesian economics in providing an intellectual prop for reformism. However, just as Marx was not squeamish about making good use of empirical data, neither should we be afraid of the empirical insight sociology offers. After all, with few exceptions, it shows class as being the most important social determinant of longevity, morbidity and general wellbeing. But, as with all data it needs a critical eye, something which has not always been applied by many on the left, especially when it comes to a discussion of mental health or the nature of the National Health Service. This has effectively left the field open to those who would provide a justification for the attack on the free universal provision of healthcare.

Moreover, such explanation as is provided tends to focus on ‘lifestyle choices’, such as diet and the consumption of alcohol and tobacco, as crucial in determining health inequalities. The victims of health inequalities get the blame for their apparently feckless choices, rather than those choices being the product of class society. In the coming years this will be a key battleground for the working class, as our standard of living is attacked to increase expenditure on a war economy.

There is every reason to believe that the Labour government intends to move closer to a US-style system of private health insurance, with a Medicare/Medicaid type of backstop for those of us who cannot afford the premiums (as we have already seen with NHS dentistry).

Inequality

Britain is unusually well provided with an extensive literature on inequalities in health. What is interesting is that it has started to reveal some of the mechanisms by which class society disproportionately kills the poor.

The Whitehall Studies, beginning in 1967-87, with a cohort study of 17,500 male civil servants, showed that civil service rank was the best predictor of health outcomes. This was followed up with Whitehall Two (1985-88), which studied 10,308 civil servants of both sexes and confirmed that status seems to exert an influence independent of poverty.¹

The endocrinology of stress gives us a clue to why there is a class gradient in health and illness, and the mechanism by which low status and poverty lead to high rates of type-two diabetes, hypertension and cancer. Stress hormones, such as cortisol, are essential for life. They act as part of the ‘fight or flight’ response, to increase blood sugar and aid in the metabolism of calories, which, when facing an immediate threat from a predator, can make the difference between life and death. Having escaped, naturally, cortisol levels return to normal. However, under conditions where the threat is constant, such as in a work environment, where subordination is unceasing and control over one’s life is limited, then raised cortisol leads to not only higher blood sugar, but the suppression of the immune system - essential, among other things, for controlling the incidence of cancer. It also reduces the sensitivity of peripheral tissue to insulin - a key feature of type two diabetes.

Moreover, a similar pattern is also observable in other primates. Robert Sapolsky’s work, looking at baboons in Africa,² shows how blood profiles relating to stress between high- and low-status primates are remarkably similar to high- and low-status civil servants in England. Interestingly, he was also able to show how being social can mitigate some of the worst effects of low status, supporting the view that high levels of social cohesion and cooperation can mitigate the adverse effects of low status.

Further support for this can be seen in a study of Roseto, Pennsylvania,³ the population of which was unusually healthy, compared to the surrounding populations of relatively more affluent towns. They, on average lived longer and had in the mid-1960s no incidents of coronary artery disease requiring surgery. The population of Roseto consisted mostly of poor Italian immigrants. Early speculation that their exceptionally good health was due to diet was quickly refuted. Most people had a higher fat content than more affluent towns and many smoked. We now know that dietary fat is not the culprit once assumed, but it was a revelation at the time. The researchers, John Bruhn and Stewart Wolf, concluded that the adverse effects of poverty were more than ameliorated by a strong sense of social cohesion. The fact that the society was hierarchically flat also produced a culture of mutual aid and interdependence. Tellingly, as the standard of living of Roseto rose to closer to the standard of the USA, then levels of heart disease also rose, as levels of social cohesion declined.

In 1976, a young Richard Wilkinson wrote an open letter to the Labour Health Secretary, David Ennals, which was published in New Society.⁴ He pointed out that notwithstanding the existence of the NHS, there was a class gradient in virtually all categories of mortality and morbidity. Sticking to the registrar general’s classification of social class, derived as it was from Weberian sociology, the lower the social class, the higher the mortality and morbidity rates.

One of the outcomes of this letter was that the government established, in 1977, a royal commission on inequalities in health, under the then president of the Royal College of Physicians, Sir Douglas Black. By the time the commission reported, Labour was out of office and the incoming government of Margaret Thatcher was largely indifferent to its findings. Nevertheless, it was legally required to publish them, which it did in the fewest numbers consistent with satisfying its legal obligations: that is, one for the copyright libraries, the House of Commons library and so on. However, in 1982, it became something of a best seller, when it was published as Inequalities in health by sociologists Peter Townsend and Nick Davidson.

Relative inequalities in health and death rates have real consequences in absolute terms. To take the example published in the Black Report⁵ in 1980:

If the mortality rates of occupational class I (professional workers and members of their families) during 1970-72 (the dates of the latest review of mortality experience) had applied to classes IV and V (partly skilled and unskilled manual workers and members of their families), 74,000 lives of people aged under 75 would not have been lost. This estimate includes nearly 10,000 children and 32,000 men aged 15 to 64.⁶

While the health of the UK population has improved significantly since the 1980s, the class gradient in health inequality remains a constant feature and has been supported in study after study ever since - as has the apparent inability of social policy measures to mitigate it.

Richard Wilkinson, with Kate Pickett, went on to make their own distinctive contribution to the debate with a wealth of research, which made international comparisons and supported the idea that inequality exerts an influence on health independently of poverty.⁷ Put simply, the wider the gap between rich and poor, the worse the health outcomes for society. Drawing on a wide range of social indicators, such as rates of imprisonment, obesity, life expectancy, use of narcotics, teenage pregnancy and levels of social mobility, Wilkinson and Pickett made comparisons with a range of different countries.

Typically, the Scandinavian countries tended to do well, and the USA was almost always among the worst, notwithstanding the fact that it spends more on ‘health’ as a proportion of GDP than any other country in the world. Similar patterns were also seen in each of the states of the USA. The more unequal the state, the worse was a basket of different social indicators.

They followed up this research with a later study focusing on aspects of mental health, such as anxiety and depression, which revealed a remarkably similar picture.⁸

Inequality, it seems, is bad for us all, even the rich. This naturally fits very well with the reformist political perspective, which can also been seen in the online publications of the Equality Trust, which seeks to persuade politicians of the imperative of shifting social policy in the direction of the redistribution of wealth and income.⁹ Every indication, so far, is that the Labour government has no intention of reducing inequality across British society, and inequalities between different countries is also likely to widen.

Mental health

The consequences of leaving the field open to the enemy is particularly glaring in the case of mental health.

There were very few who defended the old asylums, when their intended closure was announced in 1961 by the then Conservative health minister, Enoch Powell, in his ‘water tower’ speech. Yet the ‘crisis of social care’ has its historical origins with the privatisation of dementia care. Dementia, almost alone amongst neuro-degenerative disorders, has been removed from the care of the NHS and now must be paid for, typically by the sale of the sufferer’s house. If the estate of the patient is over £23,250, it must be paid for in full. After that, a proportion is paid until their estate is down to £14,250, at which point it is the statutory responsibility of the local authority. This has played an important part in increasing the crisis of local government funding.

It is not accidental that in the same year that Powell announced the decision to close the psychiatric hospitals Erving Goffman published his book Asylums. Goffman’s critique was pushing at an open door. Bourgeois sociologists often provide the ideological justification for social policy measures, often with the superficial appearance of a critique from the left. In fact, Goffman’s book makes facile comparisons with other ‘total institutions’, including the armed forces, concentration camps, monastic orders and prisons, as if there were not rather more important distinctions between them!

Other critics of psychiatry were explicitly of the libertarian right, such as Thomas Szasz in his The myth of mental illness in 1961, but it was a refrain that was taken up by many on the left in one form or another. At the time, the absence of any evidence of pathology for the ‘functional’ mental disorders seemed to support critical perspectives that asserted that mental illness was a ‘social construct’ and by implication less ‘real’ than disorders with a discoverable causal organism. Psychiatry was lumped together with the state and assumed to be repressive, part of an apparatus of control over the working class.

The scene was then set for the closure of hospitals, which were an important part of the trade union base for the NHS. Very few nurses in mental health were members of the Royal College of Nursing. Almost all staff there were members of the National Union of Public Employees or the Confederation of Health Service Employees and campaigning for a 12% pay rise for all NHS staff. More importantly, health workers were widely supported by solidarity action by rail, mining, post, print and other workers - one of the last times that the TUC organised such action.

Unsurprisingly then, after the defeat of the 1982 health workers dispute, the programme of closures of mental health hospitals accelerated. More than that, the 1982 health workers dispute was the government’s dress rehearsal for the crushing of the miners’ strike. Most of the legislation that was used to outlaw ‘secondary’ picketing and other solidarity action by workers during the miners’ strike was tried out first in 1982 against health workers. The government knew in advance that to defeat the health workers they would first have to come to a settlement with the Royal Colleges of Nursing and Midwifery, which settled for a pay rise above the 4% offered to other staff in exchange for a pay review body that subsequently delivered a significant rise for qualified nurses and midwives only. The longer-term consequences of the loss of that trade union base have been seen by the relative weakness in strike action in the NHS since.

I am not suggesting that there are no political aspects to psychiatry. A great deal of psychological distress has its origins in class society, but is regarded as an individual disorder and the growth of diagnostic categories illustrates the point. For example, post-traumatic disorder came into being in the Diagnostic and Statistical Manual III, partly in response to the needs of the US Veteran’s Administration to have a diagnosis for the treatment of those who suffered mentally because of the Vietnam war.¹⁰ This does not mean that all psychiatric disorder would vanish with communism, but, as we have seen, there is well-established evidence for a class gradient in poor mental health and as consistent materialists we would not draw a distinction between somatic and psychiatric disorders.

For those of us who have worked in mental health for many years the reality of people’s distress is readily observable and, with the development of medical imaging, demonstrable. Positron emission tomography, for example, can demonstrate areas of the substrate of the brain which are relatively inactive, such as the frontal lobes, in people with some mental health diagnoses.¹¹ This is not to fall back on a simplistic biological determinism, which is a criticism which could be levelled at Sapolsky, for example. There is a growing body of evidence about the complex interrelationship between biology, genetics, epigenetics and environment, which has a distinctively dialectical feel to it.

Anti-psychiatry

The difficulty with what is sometimes referred to as the ‘anti-psychiatry movement’ is that, while there were writers such as RD Laing, who had insights into the nature of mental health and illness, they were unable to theorise the question in a way that could provide any explanatory capacity.

Laing, for example, did not regard himself as ‘anti-psychiatry’. In fact, in his training, he was a highly orthodox psychiatrist and psychoanalyst, even if his practice in subsequent years became somewhat less so. The term was coined by David Cooper in his forward to the publication of the proceedings of the Dialectics of Liberation conference held in London’s Roundhouse in 1967. This featured a galaxy of stars of the ‘new left’, such as Herbert Marcuse and Paul Sweezy.¹² The reason Laing did not object to the term, ‘anti-psychiatry’, was simply because he did not read the proofs prior to publication!¹³ Laing’s son and biographer described his father as “a reactionary, against the status quo” and said that, when talking to Marxists, Laing senior spoke ‘fluent Marxese’ and spoke to Buddhists in a way that showed his understanding of Buddhism.¹⁴ Laing had undoubtedly studied Marx. His copy of volume one of Capital, currently held in the special collection of Glasgow University, is annotated throughout. Volumes two and three are, however, pristine.

‘Anti-psychiatry’, then, is a term applied to a disparate array of thinkers, many of whom had little in common except for writing at a time when ideas were in a state of flux and mental health, like so much else, was open to question.

What is also true of RD Laing is that he did much to popularise the questionable historiography of Michel Foucault, when he wrote a glowing review of Histoire de Follie, in the New Left Review. Foucault’s 1961 book was published in English as Madness and civilisation, thereby setting a trend among sociologists and historians to use the term ‘madness’ to refer to ‘mental ill health’ - supposedly to distance themselves from the stigmatising positivism of medical diagnoses. If you think ‘mentally ill’ is stigmatising, try ‘madness’ on your sicknote from the doctor!

Foucault has powerful insights in his work, but no explanatory theory, not least because he would probably deny that such a theory could exist. Laing was on very friendly terms with Foucault, as he had been previously with Jean-Paul Sartre, and their correspondence is again currently held in the special collections at Glasgow University.

The fact is, few Marxists have extensively researched or theorised mental ill health. Peter Sedgwick, once part of the editorial board of Critique, made a worthy attempt to begin the process but, sadly, died young.¹⁵ His book Psychopolitics is, however, a useful corrective to those who take Szasz, Goffman, Laing and Foucault too seriously. Andrew Scull in his earlier histories of psychiatry employs a Marxian language in a good empirical history. His insight that the asylums grew out of the custodial provision of poor relief in workhouses is convincing. It was necessary to separate those who were too sick to work and a disruptive influence in the workhouse. It is out of this need that the expansion of the asylums increased.¹⁶

Scull’s thesis on decarceration¹⁷ has, however, been disproven by subsequent events. In fact, what we have seen is recarceration. As the number of mental health beds have declined, the number of people in prison has risen. While we cannot infer a direct causal relationship, it is demonstrable that many currently in prison have diagnosable mental disorders. In the meantime, the care of organic mental disorders, which once took up a large proportion of mental health beds, has now been privatised to thousands of non-NHS care homes.

The establishment of the NHS saw the nationalisation and rationalisation of Poor Law infirmaries, charitable hospitals and county asylums, paid for out of the local taxation. The hotchpotch of provision before 1948 was failing. The creation of the NHS was a concession made at a time when the USSR was considered by the ruling class to be a viable pole of opposition. Its demise has now rendered that concession obsolete in the eyes of many.

Ironically, the one proven case of the political abuse of psychiatry by the state was in the USSR, where in the period after the death of Stalin psychiatry was used as an ameliorated form of labour camp against a dissident intelligentsia. Psychiatry was not abused under Stalin. Why would they bother? Opponents would just be killed or sent to a labour camp. In fact, there is evidence that psychiatrists may have saved lives by diagnosing mental illness in someone who might otherwise have been executed for, say, telling a joke about Stalin. The patient would then be discharged, apparently cured, sometime later.

The peak of the political abuse by the Soviet state was in the period after the uprising in Czechoslovakia in 1968.¹⁸ The Soviet elite needed a way of incorporating the intelligentsia to achieve its ends. Terrorising and imprisoning philosophers may have few immediate consequences, but it is hard to have a space programme by terrorising physicists.¹⁹ Members of the working class would be sent to a labour camp, but the intelligentsia could be subjected to psychiatric harassment, while negating their pronouncements as evidence of psychopathology, and appearing to show solicitude for their welfare. RD Laing was fully aware of this. The book by Sidney Bloch and Peter Reddaway, Russia’s political hospitals, is in his Glasgow collection.

It is not that psychiatry has never been used in this way in the west. Siegfried Sassoon was sent for a psychiatric assessment at Craiglockhart, a former spa, outside Edinburgh, after beginning to oppose the war in 1917, which probably saved Sassoon from having to face a court martial. However, it is very much the exception that proves the rule.

The proletariat is controlled in the first instance by commodity fetishism, furthermore by the reserve army of labour and only as a last result by the threat of violence by the state. Psychiatry has little to do with it. The mental distress suffered by millions of people, at least some of which is attributable to class society, is as real as the incidence and prevalence of heart disease.

Our task as communists is to eliminate both as part of our maximum programme, but also oppose further privatisation and the further implementation of a US-type system of healthcare, which has been so unsuccessful - except for those who can afford the premiums, of course.

1. M Marmot Status syndrome New York 2009.↩︎

2. R Sapolsky Behave: the biology of humans at our best and worst London 2017.↩︎

3. J Bruhn and S Wolf The Roseto story Norman OK 1979.↩︎

4. sochealth.co.uk/national-health-service/public-health-and-wellbeing/poverty-and-inequality/income-and-health.↩︎

5. pubmed.ncbi.nlm.nih.gov/7118327.↩︎

6. P Townsend and N Davidson Inequalities in health: the Black Report Harmondsworth 1982.↩︎

7. R Wilkinson and K Pickett The spirit level London 2009.↩︎

8. R Wilkinson and K Pickett The inner level London 2018.↩︎

9. equalitytrust.org.uk.↩︎

10. B Shephard A war of nerves: soldiers and psychiatrists 1914-1994 London 2000.↩︎

11. B Van Der Kolk The body keeps the score London 2014.↩︎

12. D Cooper To free a generation: the dialectics of liberation Harmondsworth 1968↩︎

13. A Laing RD Laing: a life London 1997.↩︎

14. Adrian Laing’s unpublished personal communication, October 1997.↩︎

15. P Sedgewick Psychopolitics London 1982.↩︎

16. A Scull Museums of madness Harmondsworth 1979.↩︎

17. A Scull Decarceration: community treatment and the deviant - a radical view London 1977.↩︎

18. I Spencer The relationship of Soviet psychiatry to the state unpublished PhD thesis, 1997.↩︎

19. H Ticktin Origins of the crisis in the USSR London 1992.↩︎