Marxing Public Health Discourse

Paying tribute to one of the giant philosophers of all time– Karl Marx, the visionary and fountainhead of justice and equality, as he turns 200 today, is an honour. He stands tall among the socialists of human history.

Karl Marx laid great stress on social equality and social justice. For him, fundamental concepts of social justice were rooted in economic justice. According to him, economic inequality, and the existence of private property, resulted in social injustice. An academic book ‘Shifting Paradigms in Public Health: From Holism to Individualism’ authored by Vijay Kumar Yadavendu and published by Springer, is a must-read for the socialists of today. The book is deeply influenced by Marxian concept of social justice and talks about inequalities in public health. A Marxist intellectual, Yadavendu discusses the theoretical shift with regards to public health that gradually takes place from collective to the individual.

In ancient times, societies and civilisations had tried to discover rules that would ensure good health of a collective. They had understood the fact that an individual is part of the larger collective. The shift of focus started happening after the consolidation of science, which emphasised on individual causations and exactness.

In the arena of natural sciences, the health of an individual is reduced to a bio-physiological and neuro-physiological system, which in turn is broken down into a number of sub-systems – anatomy, cells, molecules and genes that are a functional part of a whole. This constitutes the fulcrum of modern science and medicine, where the disease is considered malfunction of one or many sub-systems resulting in somatic, psychological and social dysfunction and health is just opposite to disease. On the other hand, ancient civilisations like that of the Greeks and other contemporary ones talk about holism in context of health. The health of a population depends on a range of factors both internal and external. It talks about the interaction of an individual with his/her physical, psychological as well as socio-economic environment.  This holistic approach to health cannot be seen only as a bio-physiological occurrence but is also very much determined by historical, cultural, social and economic standards.

Such a holistic approach to public health was the vision of Karl Marx, is missing today as individuals have been reduced to an amalgamation of cells, genes and molecules that constitutes a human body.  Such thoughts have evolved from a positivist school of science. The onus of being healthy or sick lies with the individual. So more and more research work and subsequent improvement in biomedicines and vaccines revolutionised the entire pharmaceutical industry. There is little or no scope and space for a holistic approach to health or disease. Such reductionist outlook paved the way for social inequality that plagued society at large.

One can’t deny the fact that medical science has made lots of improvement in providing adequate healthcare facilities to humans. For instance, in India, life expectancy at birth increased from 22 years at the start of the century to 62 years at the turn of a century, and infant mortality rates declined from 200 to about 66 (per 1,000) during the same period. Huge budgetary allocations were made in the health sector to reduce infectious and communicable diseases in developed countries. As a result, communicable diseases like malaria, tuberculosis became extinct in developed countries such as India.  Though much credit for the improvement of health status has been given to the advancement of bio-medical discipline in developed nations, few public health practitioners viewed that such impressive improvement is due to less exposure to infection, improved nutrition and better living standard coupled with advancement in the bio-medical field. But most of the public health practitioners did not shed light on food security, better standards of living, better housing and working conditions, water supply and sanitation as determinants for better human health. Instead, it chooses to give full credit to the role of bio-medicine and its impact. Thus the major understanding of public health research and the vision of its future growth has remained confined to the reductionist model of science and medicine.

The publication of Black Reportin1980’s shook the edifice of confidence in the United Kingdom. The report stated that despite rapid enhancement of aggregate health status, disparity or inequality in health status among various groups of the nation or between nations has widened. Fresh entrants in the field of diseases like AIDS and resurgence of tuberculosis and malaria especially among impoverished communities and countries shook the faith in bio-medicine.

Health inequalities reflect on the underlying social injustice like poor access to health care, inadequate food, impure water, unsafe living and working conditions and of course extreme poverty. In the words of Laurel Garrett, ‘If the passage of time finds ever-widening health gaps, disappearing middle classes, international financial lawlessness, and still rising individualism, the essential elements of public health will be imperilled, perhaps nonexistent, all over the world.’ As a result, there is a growth of myopic vision that the source of disease and ill health lies within the individual, in his/her genes and molecules or in a form of bacteria that resides in his/her body. It has so much influenced individuals’ mind that the cure lies locked within a pill available in the market, purchased at a cash price. This led to a booming industry of drugs.

Thus attraction to drugs acts as a catalyst to sustain such attitude that certain ‘technological fix’ or ‘behavioural modifications’ would solve all problems, rather than focussing on broader and more effective structural changes. More light is shed on the individual expertise rather than on historical and socio-economic aspects.   In the Sub-Saharan region where AIDS is a major cause of mortality, rampant in plantations, mines and urban squatters, emphasis is on curative medicines and preventive vaccines. There is least effort to improve the socio-economic standards of living of those working in such areas.

The crucial role that IMF and the World Bank plays in disbursing funds to developing and under developing countries facilitates and nurtures the environment of social injustice. These monetary institutions emphasise on cutting down of state expenditure on social welfare schemes in such countries. One gets to witness inflation, unemployment, fund reduction in health sectors, lack of infrastructure, poor or no sanitation, waterworks causing ill health and total disintegration of public health systems. The economic policy of the state in the form of liberalisation and privatisation is definitely lowering the chances of healthy survival of the deprived societies of the state, the author notes.

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