By Natalya Dinat
ANC, South Africa and the world in crisis, where to?
I will be focusing on the crises in healthcare as a facet of the capitalist crisis. Characterised by the commodification of health care services, a result is poor quality, inefficient, expensive and often inappropriate health care. Firstly, I will provide some examples of how increasing marketisation has adversely affected health outcomes. Then I will ask whether an equitable healthcare system is possible in a market driven environment and can current ANC policy take us there, if healthcare remains a for-profit commodity.
Healthcare is a key area for struggle, since everyone is directly and immediately affected, also because it has an obvious link with food and water safety and sovereignty; climate and environmental crises; gender equity; and adequate housing. I will end by inviting a discussion on the need for a rigorous Marxist analysis of healthcare terrain to guide a response on a way forward for an equitable health service.
Commodification of healthcare
In recent times healthcare has emerged as an area where mega profits may be made for little risk. Mckee and Stickler argue that the healthcare industry has taken a cue from the military-industrial complex. They describe the formation of the military-industrial complex as “…A powerful coalition of general and chief executives talking up the threat from the then Soviet Union exaggerating the so called missile gap and seeing threats where none existed. The goal was not to protect the USA, but to transfer vast sums of money from the federal budget to the coffers of the corporations and ultimately to those generals”. They go on to show that “this model has been emulated widely. For example, the security- industrial complex” – where corporations like G4S are beneficiaries of billions of dollars and euros on ineffective airport security, Olympic security and prison security.
Mckee et al, find that healthcare goals have been redefined by moving priorities away from those most in need, such as those with infectious diseases, (TB, malaria), away from the ageing with chronic diseases and away from the mentally ill toward those who’re essentially well.
In South Africa, a stark example is in the private sector where there is an upward of 85% Caesarian section rate. A surgical operation which when performed for healthy pregnancies carries a 2.3-4.8x increased risk of death of the mother, and a significantly increased morbidity for mother and child (including increased blood loss, wound infection, post- partum depression, failed breast feeding – and its sequelae). The World Health Organisation recommends a CS rate of 10-15% in a healthy population. They state that upward of that can only incur more harm. Although detrimental to the health of women, the 85% CS rates does produce more profit for the medical industrial complex than vaginal deliveries.
Market driven healthcare misdirects research priorities and resources. For example, pharmaceutical companies spend more on marketing than on research, and more on diseases of the wealthy than diseases which kill poor people. Redefining normal is another marketing ploy, for example, The recent redefinition of “normal” surrogate markers of lipid (cholesterol), has increased the sale of cholesterol lowering drugs, but not deaths from heart disease, also a recent attempt to change the normal for vitamin D levels has made an ‘epidemic of vitamin D deficiency’ .
The sugar industry together with the US government (via the all- powerful lobbies) have hidden research findings on sugar and promoted poorly conducted research blaming fats as the cause of heart disease. An increase in sugar intake has resulted in a rise in obesity, type two diabetes and heart disease. Over-prescribing antibiotics has led to the emergence of multi- drug resistant infections.
The proponents of market deregulation are turning their attention tothe health medical industry as their next opportunity to make a huge profit, and they will use all means to defend this obscene profit, by blaming the individual for their own health problems, as in 1850s the poor were told that they were of low morals and lazy, and that is why they remain poor. By keeping people sick, weak and in debt they are less likely to assert their democratic rights and also the democratic spaces close down.
Low and middle income people suffer
The poorer households pay disproportionally more for health care. Lower income earners or the unemployed are also more sick and more frequently sick than wealthier incomes. Those with medical aids are also affected as they often face a co-payment pay for useless, expensive imaging tests, and non-proven treatments.
According to the World Health Organisation (WHO), (2014) the total amount spent on healthcare in SA wasn’t very different to other countries:
SA: 8.8% of the country’s GDP;
UK: 9.12%of the country’s GDP.
However the differences become apparent when looking at the ratio of private spending on health versus government spending.
Private spending is 51.76% of the total amount spent in 16% of the population.
Government spending is 48.24% (including funding of public hospitals and government medical workers);
Medical aids account for 82.8% of private healthcare spending.
This is a stark contrast to countries like the UK.
83.14% of medical spending comes from government;
Only 16.86% is spent by private citizens;
Medical aids only make up 20.41% of private spending on healthcare.
I would argue that no matter how well regulated the medical industrial complex is, it cannot serve two masters, whose needs are often in conflict with one another. It cannot serve the health of the individual and population, and at the same time make super profits. The BBC reported in 2016 “outrage” when Forbes reported on enormous profits made by the pharmaceutical industry.
Last year, US Pfizer, the world’s largest drug company by pharmaceutical revenue, made an eye-watering 42% profit margin. Pharmaceutical companies have the largest profit margin of all industries.
Stakes are very high in this area, with powerful political lobbies prepared to go to extreme lengths to protect this cash cow. It may explain why many battles in this arena seem to have David and Goliath characteristics. But history shows us that workers in particular, once organised, have won significant advances.
Is a ‘good’ healthcare policy in the current funding framework in SA enough to withstand effects of commodification?
The horrors heard during the Life Esidemeni Public Arbitration hearings is a stark but unsurprising example what can happen in healthcare. Policy, the PFMA, even well-meaning Boards, and other fail-safe measures became inadequate when up against the lure of profits and the need to serve two masters.
Whilst Chief Justice Moseneke’s findings are important and need to be implemented, as are those of the Health Ombudsman and the Premier of Gauteng’s task team. Can they adequatelyprevent such a disaster? Should we be fighting for more? Even in the UK, profit motive is largely understood to be behind the Grenfell fire murders.
A health report commissioned from another time and place found that loss of lives, are not the result of a few rotten apples, but will happen again and again as long as healthcare is commodified, the findings ask:
‘and what of an army of well-trained civil servants… the law existed, the civil servants were there – and the people died in their thousands from starvation and disease’
These words were written by Virchow in his report in the Typhus epidemic in Upper Silesia in 1848. Virchow is widely regarded as an early proponent of social medicine.
He states “I later had no qualms in making known these conclusions… they can be summarised briefly in three words: full and unlimited democracy” 
Healthcare services to mobilise communities
It would be useful to examine whether provision of various worker/ community led healthcare services contributed to the strengthening of the left/ or national health services. The example of Tredegar in Wales was in some ways the progenitor of the NHS. In the late 19th century, workers began to form their own medical societies. The most successful of which was in Wales, in a mining town – the Tredegar Workmen’s Medical Aid Society. By 1945 they had clinics, dental care, a hospital, and 23,800 members of a population of 24,000. Paid for by contributions based on income, care was free to men, women and children at the point of delivery. Aneurin Bevan, a miner and a socialist, was intimately involved in the project and so it heavily influenced the formation of the NHS when Bevan was minister for health the Attlee’s Labour government.
In the 1970s in California the Black Panther Party started free clinics in communities. Inspired by the Freedom Charter they declared:
WE WANT COMPLETELY FREE HEALTH CARE FOR ALL BLACK AND OPPRESSED PEOPLE
We believe that the government must provide, free of charge, for the people, health facilities which will not only treat our illnesses, most of which have come about as a result of our oppression, but which will also develop preventive medical programs to guarantee our future survival.
The clinics were successful in that they filled a gap for neglected diseases prevalent in those communities, such as sickle cell anaemia. They were able to recruit and raise political awareness in the community, but not to go any further. Comparing ideological stances of the two examples above perhaps give us pause for thought for today.
The struggle for a national health service in UK
Prior to 1946, in Britain, healthcare was provided for by churches and charities. Opposition to the NHS was led by the British Medical Association, a conservative organisation which had lifted the status of some barbers and physicians from below an apprentice to a professional class. They were closely allied to the emerging capitalist class and had systematically hounded women with folk knowledge and knowledge of midwifery, making it illegal for them to continue their practices. Bevan was forced to make compromises; the GPs refused to be employed and were privately contracted in. The starting price tag was twice that originally envisaged, but within 10 years, being sick was not a source of worry for working class men and women. However, in 1980’s under Thatcher’s free market onslaught, the NHS started to be sold off to Biscuit manufacturers and record company moguls. Once again vast sums of money were being transferred from state coffers to private hands, on an almost risk free enterprise. These Government/confectionary bosses then find that there is no money (i.e. no profit) to pay for the elderly, dying but will pay for expensive treatments of diabetes of too much sugar found in biscuits. The Left was not able to fight these changes after the systematic destruction of the trade unions by Thatcher and later Blair, but now a new Labour manifesto promises to return the NHS to its former state-owned glory.
A common misperception is that the much admired universal healthcare and free education just occurred naturally within a capitalist system in the Scandinavian countries. The truth is that only after bitter fought battles by strong trade unions and socialist parties had insisted on equitable healthcare (in Finland from as early as 1909), that healthcare system was won, through labour strikes, street battles and a strong parliamentary left. To succeed in the fight for healthcare, requires a robust ideological stance, and the stomach for hard political organisational work.
Possibilities for South Africa
Healthcare is an ideal rallying point for “the Left” in South Africa. It affects everyone; is linked to jobs; housing; food and water access and to direct experiences in climate change. It may be possible to unite the Left (spectrum of ideologies) for a national health system, free at the point of access and universal coverage. Is de-commodifying health care possible in a capitalist economic framework via parliamentary reform? It has been done in bankrupt postwar Britain, in post war torn poverty stricken USSR, in Cuba despite economic blockade. It cannot be unaffordable if the profit factor has been removed. The current ideological vacuum and lack of mobilisation in this area, has been filled by Parties like the EFF, who have made equitable healthcare their rallying call for 2018 which will be heard and understood by many South Africans. It is important to counter this populist approach.
The NHI project in South Africa, has not been the answer thus far because:
- It does not decommodify healthcare provision. As evidenced by the ideas of running ‘pilot clinics’ to show how it works. It is essentially a financing mechanism, so a pilot clinic cannot demonstrate any outcomes.
- inadequate support from its own authors, the ANC, or the left when it is attacked by medical industry (SAMA, Pharma, and other ‘experts’ on health)
- it already has capitulated on issues of contracting out GPs
- the lines of accountability and areas of responsibility on Government are confusing and inaccurate – between national and provincial health authorities, provincial government, between technical HODs and political heads. This serves private health interests, since more profit is to be made in the confusion, but is antipathetic to a system of universal health care. So perhaps a first campaign can be linked to that and directly linked to the outcomes at Life Esidemeni.
- does not align with the NDP, or other government plans.
Virchow concluded, in his report in 1848, what he labeled radical political recommendations, Polish as an official language, democratic self government, separation of church and state, and the creation of grassroots agricultural cooperatives. He says that capital and labour must at least have equal rights and the living force must not be subservient to non-living capital.
As Contemporary Marxists, we need to locate the contemporary issues in Marxist theory. Today- I would like to see a left analysis of the causes of Life-Esidimeni, the listeriosis outbreak, high CS rates in the private sector and inadequate access to CS in the public sector.
History shows us that consistently it is the trade unions, poor, socialist parties who have fought the battles in and out of parliament for free equitable health care.
Profits may be OK for the cosmetic industry and automotive and other industries, but health,education housing, transport, food, water and energy should not be subjected to the unregulated market.
Author: Natalya Dinat grew up in London, as a child of political exiles, so experienced first hand the NHS in the 60’s and the beginning of its demise in the 70’s. She is, by training a Medical doctor, trained in the USSR, as an ANC cadre (1984-1991), Specialised in OBGYN and worked at Wits and Chris Hani Baragwanath hospital, left the state sector in 2011 and was in private practice until last year. Her unit, through Wits has received grants from Pharmaceutical companies and local and international AID organisations to conduct research, mostly HIV, women’s health, public health and clinical trials and end of life care.
 Excepted from Virchow RC collected essays on Public health and epidemiology 1848 Vol 1 Rather LJ ed, Boston Mass, Science History Publications; 1985;204-319