Howard Waitzkin: Medicine and Public Health at the End of Empire.

Legge, David ; Waitzkin, Howard

Howard Waitzkin

Medicine and Public Health at the End of Empire

Paradigm Publishers, Boulder CO, 2011, 256pp, $60.

Health is determined before and beyond the health care system: stunted girls in India, buried miners in China, AIDS in Southern Africa, gun violence in the US. It is self-evident that stocks and flows of the global economy powerfully influence population health and accordingly the political structures and relationships which shape the global economy powerfully determine population health outcomes. The challenge facing the institutions and practitioners of public health is how to engage with the structural determinants of health, including the dynamics of the global economy and its control.

The magnitude of the challenge is reflected in a grumbling debate between Anglophone public health which talks about the 'social determinants' of health and the Latin American social medicine movement which insists on the 'social determination' of health (Breilh 2013). The Anglophone focus has been on pathways of influence; the Latin Americans have sought to direct our focus to the social relations which reproduce those pathways. It is a more overtly political analysis.

Public health needs to access the insights of political economy; needs to be able to see and talk about the economic dynamics and the political logics which reproduce an appalling global burden of preventable and treatable illness, injury and disability. However, it is a two way street. Familiarity with the political economy of health can enable political economists to follow these dynamics and logics through to their real impact on real people.

Building a conjoint discipline around the political economy of health is a neglected project, dependent on committed individuals who are willing to swim against the tides of empiricist scholasticism in public health and neoclassical mythology in economics. Such commitment is exemplified by Howard Waitzkin, Distinguished Professor Emeritus in the Department of Sociology and the School of Medicine at the University of New Mexico and primary care practitioner in rural northern New Mexico. During a career spanning over forty years, Waitzkin has published in sociology, health services research, political science, social policy and political economy. Through his work with the United Farmworkers' Union and in other fields he has blended political activism with his scholarly writing.

Waitzkin's 2011 collection, 'Medicine and public health at the end of empire', offers a window onto this career of engagement with the political economy of health. It is a reworking of some major research projects within an integrating narrative of 'empire past, empire present, and empire future'.

'Empire past' takes us from Frederick Engels and Rudolf Virchow in the 1840s, through an analysis of the 'medical industrial complex' in the USA in the 1960s and 1970s to a comparative analysis of revolution and reform in Cuba and Chile.

'Empire present' explores the period of neoliberal globalisation from the 1970s. In setting the scene for this section Waitzkin draws on the work of William Robinson (2004) who invites us to reconsider class analysis and the structures of governance in a globalised world. Robinson sketches the rise and composition of the transnational capitalist class (TCC) and in less detail describes the more fragmented subordinate classes, still largely circumscribed by national boundaries. Robinson also describes the emergence and component structures of the transnational state apparatus through which the TCC effects its global hegemony.

Waitzkin uses this framework to describe and analyse the role of trade agreements in shaping health and health care; he analyses the WHO Commission on Macroeconomics and Health, demonstrating how the discourse of health policy is bent to meet the needs of economic governance; he explores in detail the phenomenon of 'managed care' both within the US and as part of the neo-imperial relationship with Latin America; and he explores the impact of the World Bank's project of 'health sector reform' in Latin America. A strong feature of this section is Waitzkin's use of discourse analysis to reveal the workings of political power.

Finally, in 'Empire future' Waitzkin looks for inspiration in the social medicine movement of Latin America and in the successes of popular struggles in El Salvador, Bolivia, Mexico City and Venezuela. This section is strong on inspiration but less clear in terms of analysis. Waitzkin's announcement of the 'end of empire' in the title of this collection is based on the emerging instabilities and imbalances of global capitalism; the weakening of US hegemony; and the growing willingness of Latin American countries to defy the imperium. The apparent optimism of his announcement is not linked to any analysis of the crisis of the global economy nor the scenarios of change which might emerge from such an analysis.

There are a few weaknesses which are inevitable in a project of this kind: sewing together a number of reports from different research projects within an integrating narrative that has been articulated in the writing of this book but was perhaps not the original purpose of the research. As a consequence there are some areas which could be attended to in the next edition: the funding crisis of the WHO warrants closer attention; the book is largely focused on the Americas and this detracts somewhat from the global perspective; and perhaps for this reason the underlying analysis of the global economy is not strong.

Nevertheless it is an important book, in part, because of the strengths of many of the chapters. However, the importance of this book is also because it belongs to a very small but important genus; surveys of population health which are embedded in a rigorous political economic analysis, in Waitzkin's case an explicitly Marxist analysis. Other iconic instances of this genus are Navarro (1976) and McKinley (1984). On the other side of the debate, the World Bank maintains a continuing stream of beautifully produced, neoclassically inspired, accounts of the virtuous cycle linking health and economics: investing in health improves productivity which leads to improved population health outcomes. It is as if the industrial revolution never happened.

The project of building a stronger political economy of health is an important challenge for public health and for political economists. Waitzkin is a beacon to guide this project.

References

Breilh, J. (2013), 'Beyond the current crisis: Mobilizing for health for all urgent agreement and agenda for life: towards an organic & cohesive world health movement', Social Medicine 7(2): 42-46.

McKinlay, J. B. (ed.) (1984), Issues in the political economy of health care, Tavistock Publications, New York.

Navarro, V. (1976), Medicine under capitalism, Croom Helm Ltd., London.

Robinson, W. I. (2004), A Theory of Global Capitalism: Production, Class, and State in a Transnational World, Johns Hopkins University Press, Baltimore, MD.