Category Archives: health

Covid before cancer. Or maybe not.

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The Northern Ireland Health minister was interviewed on the BBC here.  After first saying that he didn’t want anyone in the health service to be put in a position of making ethical decisions to deny essential medical treatment the interviewer told him that the Chief Executive of the Belfast Health Service Trust has said that they are already being made, and are life and death decisions.  Does Swann deny this or say he will investigate?  No.  He immediately and without hesitation attempts to justify something he said he didn’t want to happen, as if it hadn’t been happening.

He says that these decisions have to be made – “the ethical decision is could we turn a Covid patient away?  The answer is no.”  For other patients, “sorry your operation, your scope your diagnosis is going to have to be put off.”

When it is put to him that what he is saying is that a Covid patient won’t be turned away but that the result of this is that a cancer patient may die his answer is “yes, that’s as black and white as it is.”

So how is this ‘black and white’?  There has been no medical assessment provided that this blanket prioritisation is justified, in fact it is presented as if its justification is self-evident, an obvious ethical decision.  Except it’s not obvious and it is without justification, in both senses of that term – it has not been justified and any attempt to justify it would be wrong.

Swann says that we ‘cannot turn a Covid patient away’ but we already know that while over 50,000 people in the UK and over 3,000 in Ireland have died with Covid it is not at all clear how many of these have died of Covid.  So how can this particular disease be prioritised?

More people die of cancer than Covid-19.  There are around 165,000 deaths from cancer in the UK – that’s every year.  In 2018 over 4,000 people died of cancer in Northern Ireland.  In the Irish state over 9,000 die every year.

It cannot be because of the severity of the disease: cancer kills cancer patients because of their condition, while for most sufferers of Covid the disease is so mild they may not even know that they have had it.   If someone with Covid has a serious underlying condition making them vulnerable to death compared to a relatively healthy person with the same disease, what is it that makes the difference between survival and death?  Covid may be the proximate cause of death but Covid may not be the underlying condition without which death would not occur. If this is not considered an important distinction then presumably the health service and whole swathes of the economy will close down during the next flu season. A report from the Health Information Quality and Quality Authority shows that not all ‘Covid deaths’ should really be counted as such (see below).*

There is little that can be done to avoid many cancers; even those who don’t smoke, eat healthily and exercise fall prey to it.  Hospital treatment is necessary but can sometimes require less serious intervention if caught earlier, although this is precisely what is being deprioritised. Those most vulnerable to Covid on the other hand can take many of the measures we have all become accustomed to including social distancing etc.  The most vulnerable received shielding letters informing them of their vulnerability and measures they might want to take to limit exposure to infection.  Swann and his chief medical advisor have decided that these letters aren’t necessary this time but provided no real explanation why.  What has changed from the first lockdown?

Why is the protection of those most likely to suffer fatalities from Covid not the major focus of protection, support and prevention from these political leaders and bureaucrats?  Is it not really that, what both measures have in common – prioritisation of Covid patients within hospital and lack of focus on those most vulnerable – and what is being protected, as they have made clear repeatedly, is the NHS?   Protected from doing a job they know it will fail? And by their association, responsibility and accountability for it, protection of themselves?

The NHS in the North of Ireland is the worst in the UK.  There are, for example, more than 2,500 nursing vacancies.  As I have said before, Covid-19 may overwhelm the resources of the health service but is in itself not overwhelming.  It is only so because the NHS is already in crisis, and what we are asked to do is also to accept that we must collude in covering up this permanent crisis, including through regular speeches telling us how difficult it has been for the staff.

This message is all the more powerful, and successful, because it is largely true – many health service staff have been under enormous strain but this should not be an alibi for failure of the bureaucracy that is the NHS as an organisation.  As I have said before, the demand to protect the NHS, when it is supposed to be there to protect us, is an admission that this responsibility of the NHS will not be met.

The unjustified blanket prioritisation of Covid patients in hospital and the failure to issue shielding letters to the vulnerable are political decisions and have been successful because of a political campaign to justify lockdowns.  This has involved not only politicians but also senior health figures, who have given legitimacy to their decisions.  One such figure has been Gabriel Scally who has regularly intervened to argue that policies in the North and the South should be the same, as if two wrongs make a right.  He has stated that ‘the figures speak for themselves’ when it is well know that they don’t, and has stated that over 50,000 have died of the disease without recognition that dying with it is not the same as dying of it.  That such basic errors are repeated by a respected public health doctor illustrates the scope of the group think that has developed.

So egregious was the Health minister’s statement that the Department of Health put out a tweet entitled ‘Myth Buster’ with ‘myth number 1′ being “are Covid-19 patients being prioritised over other patients?” To which the answer was “No, they are not.  Patients are treated according to clinical priority.” Swann pitched in with “it is untrue and offensive for anyone to accuse frontline staff of prioritising one condition over another.”

Since it was Swann who said that prioritising was ‘black and white’ perhaps it is himself he is referring to as being offensive.  So who is right – the Department or the minister, and which version of the minister?

It would be difficult to deny that senior health staff would not be so stupid to as to admit such crass medical practice but easy to understand how Stormont politicians could grandstand with this level of idiocy and ineptitude.

The real problem is not that some politician has instructed hospital doctors to relegate individual cancer patients in order to prioritise Covid patients but that this is what has and will continue to happen by political decisions on allocation of resources that constrain individual medical assessments.  These individual decisions rely on higher level decisions on allocation of staff, wards and beds to deal with Covid that in the first wave witnessed empty Covid beds in the Nightingale hospital while other treatments were stopped.

Lockdown is a political decision involving an analysis not only of the disease but the potential impact of the response.  It is not a question of medical expertise determining the correct approach, even if one were naïve enough to believe that the medical profession is a paragon of virtue and wisdom.  The advocates of lockdown refer regularly to the number of cases, hospitalisation cases, numbers in ICU and deaths but rarely to the costs incurred by lockdown.  To do so would invite a critical debate they are ill prepared to have.  Swann’s mistake was to take soundbites to their logical conclusion and blurt it out.  It denotes the logic of the current approach but too crudely expresses its effects.

It is tempting to see in Swann’s first statement the chaos and breakdown of the functioning of the Stormont Executive that because of its reaction to the pandemic was seen for a while as an example of the political arrangements working.  No one is pretending they’re working now. However, the real political weakness lies not in the political primitiveness of Stormont but that such crass political interventions elicit no popular opposition. Unfortunately on this score looking for the left to offer one would be a complete waste of time, as we shall look at in the next post.

* HIQA: ‘The officially reported COVID-19 deaths may overestimate the true burden of excess mortality specifically caused by COVID-19. This may be due to the likely inclusion within official COVID-19 figures of people who were known to be infected with SARS-CoV-2 (coronavirus) at the time of death who were at or close to end-of–life independently of COVID-19 or whose cause of death may have been predominantly due to other factors.’

https://www.hiqa.ie/sites/default/files/2020-07/Analysis-of-excess-all-cause-mortality-in-Ireland-during-the-COVID-19-epidemic_0.pdf

 

 

Karl Marx’s alternative to capitalism part 7 – crises and contradictions i

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white-america-1-e1448033371744Last year an academic paper noticed that there has been a marked increase in mortality among white middle aged men and women in the United States between 1999 and 2013.  The effect of this has been dramatic: if the previous decline in mortality among this group of people had continued as before there would have been almost half a million fewer deaths during these years.

There has also been an increase in morbidity among this section of the population, reflected in increased self-reporting of poor health, pain and psychological stress.  Nor can this be put down to the well-known increase in obesity among some sections of the American population because this decline in the health of middle-aged men and women has affected both the obese and non-obese, with the former accounting for only a small fraction of the overall deterioration in health.  This worsening has particularly hit those with a poorer education, those with only a high school degree or less, and is primarily the result of increases in the rates of suicide, drug and alcohol poisoning and chronic liver disease and cirrhosis.

fd2a8a276c172deed75f43e23ef7b229The significance of this is even more noteworthy because this segment of the US working class was part of the embodiment in the middle of the twentieth century of the American dream and therefore of the capitalist vision epitomised during the American century.  Visions of white families in suburbs, owning automobiles and domestic appliances, in new homes with pretty gardens and white picket fences were a domestic ambition so strong it fired the imagination not only of American workers but millions of the poor across the world who wished to become American.  An ambition millions succeeded in achieving.

In the twenty first century this dream is collapsing amid widening inequality, stagnant wages, deindustrialisation and an increase in economic insecurity, with precarious employment and pensions reliant on the vagaries of the stock market.  It is reflected in large increases in disability; falling participation in the labour market, particularly among women and addiction to prescription painkillers where for every death in 2008 due to addiction there were 10 admissions for abuse, 32 emergency department visits, 130 people who were abusers or dependent and 825 non-medical users of the drugs.

I remember seeing a programme on the collapse of the Soviet Union which noted that a French researcher had predicted its fall due to an increase in infant mortality.  No one is predicting the collapse of US capitalism but things are really bad when people stop living longer and start dying earlier.

In my previous posts in this series on Marx’s alternative to capitalism I have noted the prodigious development of the capitalist system across the globe and its achievement of what Marx called its ‘civilising mission’.  This, I showed, was evidenced by increasing life expectancy, better health, higher levels of education, higher living standards and the sheer increase in numbers of the working class and the world’s population. In fact five out of six of my posts were an attempt to substantiate the argument that the civilising mission of capitalism continues into the twenty first century.

But surely this is now blown apart by this example of the death of the American dream, something inconceivable 60 years ago?

A few years ago I met an American socialist who I believe was from Detroit who was not so much arguing but simply incredulous that anyone could believe other than that capitalism was in crisis and failing badly

But world capitalism is not Detroit.

Accepting this point however, is it not the case that socialists should be pointing out the failures of capitalism, its crises and its contradictions?  After all, if capitalism is to be overthrown and replaced it must be because in some way it has failed.  Surely a capitalism that keeps on developing and retains a ‘civilising mission’ is not one that will suffer this fate? 

Should socialists not criticise capitalism and certainly not heap praise on it and its achievements?

Marx himself, although he praised capitalism’s prodigious development of the productive forces and the human capacities it had unleashed, hardly spared it his condemnation. Development brings industrialisation and the goods and services that change peoples’ lives for the better but it is built on exploitation of humanity and degradation of the planet’s resources and ecosystem.  Capitalist industrialisation brings the capitalist phenomenon of periodic or partial unemployment on a massive scale – “it makes an accumulation of misery a necessary condition, corresponding to the accumulation of wealth.” (Marx)

So the International Labour Organisation estimated that there were 218 million unemployed workers in 2009 and that of the 1.4 billion wage workers in 2011 many are only employed part time or precariously employed and a further 1.7 billion are “vulnerably employed”, being “own-account” workers (including street workers in poorer countries or those engaged in subsistence agriculture) and “contributing family workers” (those who worked unpaid in the home).  “In most of the world, open unemployment is not an option; there is no safety net of unemployment compensation and other social welfare programmes.  Unemployment means death, so people must find work, no matter how onerous the conditions” (Michael Yates, all quoted in ‘The Global Reserve Army of Labour and the New Imperialism’)

So why the series of posts on capitalism’s ‘civilising mission’?

The short answer is that the arguments set out above are mistaken.  The slightly longer answer is that they are wrong because they are one-sided.  The longer response again is that the whole answer is not simply an addition of capitalism’s achievements and its failures, of its successes and crises, or more simply of its good bits and its bad bits.  Even to understand its contradictions is not to think of a good side and a bad side in opposition.

To seek simply to condemn capitalism requires a standard by which it should be judged to have failed – it must have failed against some criteria.  Even if there were ‘good bits’ to capitalism to weigh in the balance against its ‘bad bits’, which together would allow one to make a judgement, some measuring criteria would be required by which to determine the relative weight and importance of its good and bad aspects.

But what would these criteria be?  They could be derived from what capitalism itself claims to defend, uphold and promote – economic growth, political equality, equality of opportunity, individual freedom, efficiency, modernisation and progress.  It would then be possible to, indeed socialist regularly do, expose these claims as hypocritical, false, misleading, one-sided and often simply untrue.  But this would be to limit one’s case to the criteria that capitalism’s defenders themselves identify as important and socialists usually find themselves making arguments that go beyond what capitalism can accommodate and what its supporters will consider legitimate.

Appeals to loftier ideals such as justice or fairness beg the question of how such things are to be defined and how realistic or practical any definition is, given the real world we live in.  A definition of justice that cannot possibly exist in the real world is not just because these criteria must apply to a world which is possible.  A just and fair world that cannot exist is neither just nor fair.  The civilising mission of capitalism is therefore not one of the ‘good’ sides of capitalism against which the bad must be weighed.  This civilising role of capitalism is itself grounds on which the alternative to capitalism rests.

I have tried to make this easier to appreciate by pointing out that the amazing economic growth of capitalism has produced an ever larger world working class without which, obviously, there can be no socialism.  And without a working class that has developed a relatively high cultural level we cannot expect socialism either.  The civilising mission of capitalism has created both.

This is generally understood among some Marxists only in the sense that unless the productive forces have developed sufficiently there will not be the level of resources necessary to ensure that inequality will not breed class divisions after any successful socialist revolution.  If society cannot develop sufficient levels of consumption to satisfy the needs of everyone then class divisions will re-emerge.  Society’s productive powers will be distributed so that these are owned by a separate class because society as a whole cannot address the needs of everyone. 

Leon Trotsky explained how this laid the foundation for the development of Stalinism after socialist revolution in Russia in 1917:

“The basis of bureaucratic rule is the poverty of society in objects of consumption, with the resulting struggle of each against all. When there is enough goods in a store, the purchasers can come whenever they want to. When there is little goods, the purchasers are compelled to stand in line. When the lines are very long, it is necessary to appoint a policeman to keep order. Such is the starting point of the power of the Soviet bureaucracy. It “knows” who is to get something and who has to wait.

A raising of the material and cultural level ought, at first glance, to lessen the necessity of privileges, narrow the sphere of application of “bourgeois law”, and thereby undermine the standing ground of its defenders, the bureaucracy. In reality the opposite thing has happened: the growth of the productive forces has been so far accompanied by an extreme development of all forms of inequality, privilege and advantage, and therewith of bureaucratism. That too is not accidental.

In its first period, the Soviet regime was undoubtedly far more equalitarian and less bureaucratic than now. But that was an equality of general poverty. The resources of the country were so scant that there was no opportunity to separate out from the masses of the population any broad privileged strata. At the same time the “equalizing” character of wages, destroying personal interestedness, became a brake upon the development of the productive forces. Soviet economy had to lift itself from its poverty to a somewhat higher level before fat deposits of privilege became possible. The present state of production is still far from guaranteeing all necessities to everybody. But it is already adequate to give significant privileges to a minority, and convert inequality into a whip for the spurring on of the majority. That is the first reason why the growth of production has so far strengthened not the socialist, but the bourgeois features of the state.” (The Revolution Betrayed)

So there are two reasons why socialists in particular should welcome the development of the productive forces that capitalism is responsible for – the material foundations for socialism in terms of sufficient consumption for everyone in society and the growth of the working class that develops as these productive forces develop.

To these are added the civilising mission of capitalism through the productive forces developing new and higher needs that lead to a higher cultural level among the working class, on which basis it becomes more and more fit to become the ruling class of a new society.

The development of the productive forces must also be welcomed for other reasons which we shall come to in future posts.  What is important for the argument here is that the development of capitalism’s productive forces is necessary for the future of socialism.  As Marx explained in a letter written two years before his death:

“The doctrinaire and necessarily fantastic anticipations of the programme of action for a revolution of the future only divert us from the struggle of the present.  . . . Scientific insight into the inevitable disintegration of the dominant order of society continually proceeding before our eyes, and the ever-growing passion into which the masses are scourged by the old ghosts of government – while at the same time the positive development of the means of production advances with gigantic strides – all this is a sufficient guarantee that with the moment of the outbreak of a real proletarian revolution there will also be given the conditions (though these are certain not to be idyllic) of its next immediate modus operandi [form of action].”

In this quote Marx does not seek to place class struggle and the development of the productive forces, which can only mean the development of capitalism, as opposites but welcomes both as positive factors leading to socialist revolution.  Yet many socialists cannot think how the development of capitalism assists its eventual overthrow and can only conceive that capitalism must be in perpetual crisis, feeling that without this not only is there no prospect for socialism but no rationale for it either.  But if this were true then the prodigious development of capitalism over the last two centuries or so would have proved the advent of socialism impossible.

It is enough to recognise that such a viewpoint, which leads to denying capitalism’s continuing growth, divorces socialists from some of the concerns of workers who experience its reality, its ‘good’ and ‘bad’ sides, without ideological blinkers. If it were indeed true that only capitalism’s failures or crises were grounds for socialism then we would have to recognise that those grounds are not enough.

So, the marked increase in mortality among white middle aged men and women in the United States between 1999 and 2013 is all the more remarkable because it contrasts sharply with the experience of other demographic groups.  Mortality declines among Hispanics and black non-Hispanics continued to decline, as they did for this segment of the population in France, Germany, UK, Canada, Australia and Sweden.

mortality

All-cause mortality, ages 45–54 for US White non-Hispanics (USW), US Hispanics (USH), and six comparison countries: France (FRA), Germany (GER), the United Kingdom (UK), Canada (CAN), Australia (AUS), and Sweden (SWE).

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Karl Marx’s alternative to capitalism part 5: capitalism’s achievements

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classroom-19th-century-1140x684One comment on an earlier post on the blog relating to the situation in Greece included the following: “So I think the task at hand is not to solve Greece’s economic crisis, this will certainly take years. Rather it is to add some political organisation and direction on to the instinct to fight. I believe that you are thinking too far ahead, overly concerned with what socialism should be in the future, and not really catching the fire of the present.”

Leaving aside whether this was true of this particular post on Greece or even of other posts; a point I have made is that the Marxist movement is too concerned with attempting to “catch the fire of the present”.  This has usually meant jumping on whatever bandwagon it thinks might propel it along in some opportunist direction.  This is informed by the view that socialism will arrive through a capitalist crisis that precipitates political revolution that will destroy the existing state and then introduce the new society.  All of which it will lead through “catching the fire” in some sort of eschatological conflagration.

Missing is the development of the alternative, evolving within capitalism in advance of any crisis, that creates and develops workers’ power in the present and most of all creates the conditions that means workers actually seek a socialist alternative long before any crisis.  Missing is the building of a working class movement that fights for an alternative society now, sees such a new society as its answer to its problems and does not limit itself to the necessarily defensive struggles against capitalist attacks.

This understanding of the working class movement, as embodying the future alternative within itself, is now more or less completely lost but would have been the foundation of workers’ socialist consciousness during most of the first century of the movement’s existence.  So, the building of mass workers’ parties, trade unions, friendly societies, educational organisations and cooperatives were all seen to be the visible rise of the more or less inevitable final victory of socialism.

No such confidence now pervades the socialist movement and part of this impoverished outlook is the perspective of fighting for and relying on the state to deliver the goods.  This and/or the view that some future, but always more or less near, political crisis will quickly precipitate a struggle and a consciousness adequate for a successful political revolution.   A view that forgets that socialist revolution is distinguished by it being primarily a social one and the Marxist view that social being determines consciousness: that is the development of consciousness is based on the development of capitalism, including what workers do over many decades to develop their own power and organisation within it. There is no exception in such a view for small groups propagandising for revolution, crisis or no crisis.

The patient building of workers organisations, such as cooperatives, is viewed by some as simply reform of capitalism when in fact no successful revolution will be possible without them.  Opposition to what has been termed the stages theory of revolution, that every workers struggle is inevitably limited to certain non-socialist goals, is confused with rejection of the truth that the working class will go through stages of development and that earlier stages that do not immediately threaten the system are also just as necessary because they are expressions of the workers own activity and power.

That this has been more or less forgotten is both a product and producer of the decline of the socialist movement.

That is why I started to write a series of posts on Marx’s alternative to capitalism, because without such an alternative there will be no, well to state the obvious – alternative!  It’s why this series is now continued.

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In the last post on Marx’s alternative I said I would look at the evidence that the development of capitalism continues to provide the grounds for socialism as an alternative.  By this I mean the contradictory nature of capitalism is still creating on an increasing scale its gravediggers, the working class, and that even “with all the miseries it imposes upon them, the present system simultaneously engenders the material conditions and the social forms necessary for an economical reconstruction of society.” Marx.

A look at the long term development of capitalism illustrates what Marx called its civilising mission, a product not just of the growing requirements of capitalist production for an educated and relatively healthy workforce but of the needs of the capitalist state itself that provides most of this education.  By 1985 mass education was compulsory in 80 per cent of the countries of the world and over 90 per cent of the world’s children spent some time enrolled in school.

Estimates for the year 1900 put participation rates in primary education at under 40 per cent in most parts of the world outside North America, northwest Europe and English speaking areas of the Pacific, where it was over 70 per cent.  By the beginning of the twenty-first century every part of the world had achieved the minimum of the most industrialised countries at the start of the 20th century and most had exceeded it.

The picture of course is far from universally rosy and a 2007 UNESCO report estimated that in 2004 781 million adults did not have minimum literacy skills and close to 77 million children of school age were not enrolled in school.  Nevertheless the twentieth century was the first in human history in which the majority of the world’s population learned to read and write.

The development of higher level education has been just as dramatic.  In 1900 roughly half a million were enrolled in higher education institutions across the world.  By 2000 the number had grown two-hundredfold to 100 million people.  Growth in higher education has not slowed but accelerated in the latter part of the twentieth century; particularly after about 1960, with enrolment rates climbing rapidly, especially of women.  This growth has created what amounts to a global higher education system with “the same subjects . . . taught with the same perspectives leading to very similar degrees . .” (The Worldwide Expansion of Higher Education in the Twentieth Century)

If we look at population and health we can see the capacity of the productive system to support a growing population and improved health.  “Since 1800, global population size has already increased by a factor of six and by 2010 will have risen by a factor of ten. . . . The length of life, which has already more than doubled, will have tripled . . In 1800, women spent about 70 percent of their adult years bearing and rearing young children, but that fraction has decreased in many parts of the world to only about 14 percent, due to lower fertility and longer life.” (The Demographic transition: Three centuries of Fundamental Change)

Global life expectancy (years at birth) in 1700 was 27, still 27 in 1800, 30 by 1900 47 by 1950 and 65 by 2000, while population was 0.68 billion, 0.98, 1.65, 2.52 and 6.07 billion in the same years.  This decline in mortality began about 1800 in northwest Europe, and in many lower income countries at the beginning of the twentieth century, accelerating after the Second World War.

“The first stage of mortality decline is due to reductions in contagious and infectious diseases that are spread by air or water. Starting with the development of the smallpox vaccine in the late eighteenth century, preventive medicine played a role in mortality decline in Europe. However, public health measures played an important role from the late nineteenth century, and some quarantine measures may have been effective in earlier centuries. Improved personal hygiene also helped as income rose and as the germ theory of disease became more widely known and accepted. Another major factor in the early phases of growing life expectancy is improvements in nutrition. Famine mortality was reduced by improvements in storage and transportation that permitted integration of regional and international food markets . . .”

“In recent decades, the continuing reduction in mortality is due to reductions in chronic and degenerative diseases, notably heart disease and cancer (Riley, 2001). In the later part of the century, publicly organized and funded biomedical research has played an increasingly important part, and the human genome project and stem cell research promise future gains.”

“Many low-income populations did not begin the mortality transition until some time in the twentieth century. However, they then made gains in life expectancy quite rapidly by historical standards. In India, life expectancy rose from around 24 years in 1920 to 62 years today, a gain of .48 years per calendar year over 80 years. In China, life expectancy rose from 41 in 1950–1955 to 70 in 1995–1999, a gain of .65 years per year over 45 years.” (The Demographic transition: Three centuries of Fundamental Change)

Again however the gains in life expectancy are not uniform and the productive advances of capitalism, some of which are reflected in public health and medical advances, are subordinated to the accumulation of profit.  This is most clearly seen in the two significant exceptions noted in the article quoted above – the stagnation in mortality gains and increased mortality from HIV/AIDS in sub-Saharan Africa and the decline in life expectancy in Eastern Europe and the former Soviet Union arising from their transition to capitalism.  The article quotes the UN in 2002 noting that male life expectancy in the Russian Federation was 60, similar to that of India.

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