Divided health and the crisis of capitalism
The coronavirus is revealing aspects of society that were little noticed, even though they deserved a great deal of attention. In this piece, I tease out well-known features of Canada’s health system to which, in non-COVID times, we paid little heed. I set out to show that the health system reflects some social democratic impulses by bestowing the benefits of the provision of therapeutic care on all in a fairly equitable fashion. At the same time, it embeds the logic of class relations by shifting many of the risks of disease and injury onto the working class.
Canadians are proud of their health treatment care system. It is funded in a relatively progressive basis as income earners make contributions in proportion to their taxable incomes, at least up to a point. The delivery of services is basically provided as a public service via publicly-run hospitals, even as the patients have access to private, independent professionals and clinics. Access is available to one and all. The depth of a patient’s pocket is not determinative, even though some private care can be bought by those who wish to do so. It is reasonably efficient and respects the principle (if not always the reality) of equitable delivery of necessary services.
The qualifiers are inserted because there are many gaps. For instance, there is a cap on contributions, making the funding more regressive than it might be; some people are buying private insurance to get quicker and more individual service. As well, the non-coverage of dental health, pharmaceutical needs or vision care are big lacunae in a system aspiring to provide holistic treatment for all. Still, it is fair to say that Canadians like to think of their injury and diseases treatment scheme as a major social achievement. After all, when asked to nominate the most influential Canadian of them all, they chose Tommy Douglas. It makes them feel that they truly value human life. Of course, this sentiment is re-enforced by the near-by United States’ eye-popping failure to provide access to all despite its capacity to deliver excellent medical services.
But now that the pandemic rules Canada, it turns out that having a socially-funded and fairly administered health treatment system is not enough. Neither is it in other nation states that have comparable (or even better) health treatment delivery systems, such as the United Kingdom or France. The incidence of infections and deaths are alarming. Indeed, one of the greatest fears of politicians and the medical professions is that the much-vaunted and admired health treatment system will not be able to cope with the flood of patients, imperiling people suffering from non-COVID diseases and ailments. Daily, we are presented with the number of COVID-19 patients admitted to hospitals and how many of them are in intensive care units (ICUs). It is clear that those data are the ones that press on political decision-makers as they determine what precautions ought to be taken: no lockdowns, partial lockdowns in some areas, total lockdowns in some areas, total lockdowns, random testing, targeted testing, mobile testing, rapid testing, some contact tracing, intensified contact tracing, and on and on.
The reason that the vaunted treatment care scheme does little to halt the rampaging pandemic is that the Tommy Douglas inspired health care scheme is but one department of the overall health-safeguarding framework. Its focus is narrow. It sets out to take care of people who are hurt or suffer from diseases. It is a system that acts with mercy and compassion toward existing victims, not potential ones. That is left to other departments of the overall health regime.
Many government agencies are tasked with regulating conduct that may cause physical harm, such as activities that affect consumers, workplaces, the environment, food, water and drug quality, vehicle and transport safety, and the like. As well, all the provinces have public health authorities whose job it is to enable the making of informed decisions to promote health and to contribute to the reduction of health inequities, in particular, to furnish the professionals whose job it is to study and act on the spread and control of disease.
Again, it is clear: we purport to care about people’s well-being and, with these agencies, we set out to ward off health harms before they occur.
However, there are many gaps. Supposedly conquered tuberculosis is making a vigorous comeback in our north. We remember Walkerton and are horrified by the lack of potable water (year after year) in First Nations communities. US-made airplanes, cleared for use here, fall out of the sky. A terrifying opioid addiction crisis is sweeping the land. Lakes, rivers and oceans are endangered. The Alberta tar sands exploitation continues to be one the most polluting exercises anywhere. Air quality warnings come with increasing regularity. Automobiles whose malfunctions (air bags, ignition failures) kill, have to be recalled, again and again. And then, of course, there is COVID-19.
These gaps exist because our health-safeguarding agencies have to make decisions within a very specific political framework. What features of that framework influence them most? The coronavirus helps us see what is going on.
Take the lack of masks, gloves, protective clothing and ventilators when the pandemic began to rage: did no one foresee that we might need them? Of course not. Many people could predict that there would be a call for these things. In fact, it turns out that we have a large number of well-qualified epidemiologists, people who specialize in the study of the spread of diseases in communities. They would have known that, after SARS, there had been a much-discussed report that recommended, in the strongest language, that all this equipment be manufactured and capacities to deal with the next epidemic be readied. Most likely, given their professionalism and dedication, there were many epidemiologists and professional colleagues who recommended that we should act on these suggestions. This was not done. Worse. Less than nothing was done. Wanton destruction was the response.
There had been some PPE left over after the SARS epidemic but, as it was not needed, it was allowed to deteriorate and then be dumped. More grave, as Linda McQuaig has documented, was to permit a fine public research centre, the Connaught Laboratory, first to wither and then to die, ignominiously. More recently, for reasons not shared with the public, an attempt to set up new research by partnering the National Research Council and a Chinese firm collapsed. This left Canada, a nation state that prides itself on being a first world nation, especially when it come to health, as a mendicant nation, albeit one with money.
When COVID hit, Canada was woefully unprepared. And yet we say we care. This is why we have all these agencies. Why then can we see such abject failure anywhere we look during this modern plague?
A large part of the answer is that our governments have bought into the argument that the delivery of anything, any service, any public good, should be left to the private sector. This reliance goes a long way toward explaining why our governments have been so reluctant to close down profit-seeking businesses. They believe that the cost of the cure (saving lives) might be more than the cost to an economy where overall welfare depends on thriving and competitive markets (saving money). So, despite the advice of public health advisors, lockdowns are partial, illogical and temporary. Governments respond, haphazardly, capriciously, to laments by businesses saying that they are being pilloried unfairly. Market freedom is equated with personal liberty by some. In this ideological milieu, profit-seekers have way more influence than epidemiologists. The cautions and strategies proffered by the people who truly care about caring for all of us are not all that persuasive.
And it is not just the private sector’s opposition to cost-imposing public health measures that hampers efforts to prevent harms to the population. By adhering to the mantra that governments charged with looking after the public should leave a vacuum and wait for it to be filled by private enterprise, governments are pushed into a no-win position. The private sector does not actually do anything unless it can make a profit. After SARS there was no profit in PPE manufacturing; so there was no PPE when the new virus came. Before COVID-19, in the absence of an immediate crisis, why would profit maximizers spend money searching for new preventive products which they might not be able to sell? So, when the pandemic hit, no vaccines were ready. Governments had to spur pharmaceutical companies into action. They knew what to do: for-profit researchers and manufacturers needed to be showered with cash.
Governments everywhere promised money to private pharmaceutical companies to find a vaccine. Less than two weeks ago, more than 50 projects were in full flight. In November, a couple of good results were announced in North America. It turned out that the technology and know-how had been there all along, unused. Once the dollar signs were flashed, the vaccines were designed and tested at breakneck speed (Warp Speed, was the Trumpian slogan).
The Pfizer-BioNTech vaccine is funded by the German government, Moderna by the US. The Pfizer-BioNTech vaccine was first approved as fit to be used by the UK, even before the US did so, followed by approval in Bahrain and Canada, also before the US and Germany. A little later, newsreaders, radiantly smiling and hyperventilating, showed a picture of the first Pfizer-filled needle plunging into a 90-year-old woman’s arm. As an afterthought, a couple of days later, it was revealed that the UK had agreed to shield Pfizer from any liability should things not work out all that well. None of this risk-taking for capitalists! Let the losses land on those injured and on a government that will have to look after those victims. This makes sense because governments, having put their faith in the private for-profit sector in order to deliver on government’s promise of public health safety, do not have much bargaining power. This may have something to do with how easy it was for the regulators who oversee the safety and efficacy of new pharmaceuticals to approve the vaccine. Perhaps too easy. There is a muted, but generally shared, acknowledgment that lots of questions are dangling in the air.
We know there are some things we do not know about the Pfizer and Moderna vaccines. We are told they have a 95 percent effectiveness rating. It is a little hard to know what this kind of claim signifies. I remember that, after the first Iraq invasion, at a Senate debriefing, a committee was told that the bombing had had a 98 percent success rate. It turned out that it meant that 98 percent of the bombs had left the planes, not necessarily that they had hit their targets. But even if it is assumed that the effectiveness rate of these two vaccines is very high, it is also true that the people who approved their use admit that they do not know whether there might not be some undesirable side effects, over and above the common ones of some muscular pain or a short-lived fever and some problems for people with unusual allergies. Perhaps many think it is worth the gamble, although it is worrisome that the virus which is being combatted is generating some very unexpected lasting ill-effects even after patients have been ‘cured.’ As well, it is also known that it is not known how long any immunity gained will last. Worse, as this is being written, new alarm bells are ringing. In the UK, in South Africa, in Nigeria, new mutant variants of the virus are on the move. They are way more contagious. How different are they? The producers of the vaccines and panicked governments are busy telling us that there is no reason to believe that the approved vaccines will not be effective against these new variants. Right.
Still, vaccines are here and hopefully they will be truly effective. But that will not mean there is nothing to be concerned about. There will be a need for governments to prioritize the distribution and inoculations. This will lead to controversies. The context in which the politics of a capitalist society and purists who advocate for the health of all human beings battle for supremacy is brought out by the coronavirus saga.
Our governments’ abandonment of doing the research and production necessary to discharge their obligations to provide for the public’s health have forced them, first, to bribe profiteers to produce vaccines and, second, to engage in unseemly bidding wars merely to be permitted to buy the vaccine. All neoliberal governments understand: for-profit producers will insist that those who have paid or who can pay the profit-yielding purchase price should be the only ones who will receive their vaccine. These kinds of governments, including our own, agree—health is not to be equally accessible to one and all.
Being a wealthy country, Canada has outdone itself. The Trudeau government has reported that it has contracted with so many vaccine makers and potential makers that it has the potential to buy five to six times as many doses as our population could conceivably need. As Rick Salutin quipped: “Our national skill isn’t making, it’s shopping.”
Subliminally, the excess signifies that Canada really does care about health care, even if it fails to take enough precautions to avert bad health. More concretely, it also means that there may be less of the (thus far) most promising vaccines to go around for less well-placed nations. In a decent world, one which really cared about human well-being, this ugly outcome would not be on the table. It arises because dollars count in a world of remedies organized for, and largely by, pharmaceutical corporations.
From the mid-1980s on, Big Pharma, proudly led by Pfizer executives, was part of a vigorous and vociferous campaign to protect intellectual property rights on the basis that this would give its members the incentive to develop health-protecting drugs for the world. They won. The Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) prevents nation states from manufacturing needed drugs if a private profiteer can claim it has taken out a patent, unless, of course, a country which has the capacity to manufacture such drugs (as notably India and South Africa do) is willing to pay. When, in May, over 100 countries asked that, for the duration of this epidemic, intellectual property rights be set aside, the European Union, the US, the UK, Japan, Brazil and Canada opposed this. We think that capitalists need and deserve our protection. Somewhat guiltily Canada is making a large monetary contribution to a World Health Organization effort to fill in the gaps. An organization called COVAX will be funded to deliver vaccines to poorer nations from other producers when they become available.
Even if some vaccine producers may not take the Moderna or Pfizer stance (as the Oxford product and the Chinese and Russian vaccine producers may not) the message is clear: in practice, our fervently declared devotion to public health is seriously constrained by our more profound adherence to the primacy of the private accumulation of wealth.
This will matter when the time comes to distribute the vaccines bought by Canada. As vaccines are delivered lot by lot, priorities have to be identified. Filled with collective shame by our collective failure to ensure dignified and safe conditions in nursing and long-term care homes and, simultaneously, anxious about the great danger the virus presents to the elderly crowded into warehouses, there seems to be a consensus that we should inoculate those in nursing and long-term care before we get to anyone else. And this leads logically to an understanding that frontline health care workers should also be among the very first to be vaccinated. Everything else is up for grabs. A likely scenario might be to go next to people over, say, 65, on a descending age scale, or persons at greater risks because of underlying conditions such as diabetes or kidney problems, or Indigenous peoples whose living conditions put them at risk. None of this has been determined. But surely, as public health principles dictate the stopping of the spread as quickly as possible, would it not make eminent sense to identify the key sources of spread and begin there?
It is becoming increasingly obvious that, in all locales, there are a number of hot spots when it comes to the prevalence of infections. They are closely correlated with three factors: poverty, non-white racialized communities and workers who are essential to the rest of us who want to continue to live as unaffected by the virus as possible. Our admiration for these workers is expressed again and again by the politicians and pundits. However, until very recently, no serious effort has been made to look after their health. Their refusals to work in newly dangerous circumstances have been classified as unacceptable by ministries of labour charged with their welfare—meat packing plants, farmers using migrant labour, cleaning service workers, transport personnel, construction workers, utility workers, delivery drivers, postal workers, warehouse workers, cashiers. All of them must be kept at work. It is comforting if it is not known that they are in danger and will, in due course, endanger everyone in addition to their immediate families. So, for the longest while, workplace outbreaks were not documented or publicized. Workers’ own efforts to avoid harm was frustrated because they could not stay home if feeling poorly because very few employers offer paid sick leave. Their need for a regular income is a coercive force. Aggravating all this is the fact that many of these workers are employed as casual or temporary employees, often via an employment agency, rendering even the feeble entitlements other workers have almost meaningless. To make it even more awkward, in the deprived areas in which they live, the facilities for testing are even worse than they are elsewhere.
The logic of a class-divided society has been in plain view for anyone caring to look. Thus, even though it is those very hot spots, those very workers who ought to be prioritized when it comes to vaccination, they may well—and indeed are likely to—be on the bottom rungs of that vaccination ladder. This is not just idle speculation. After all, their plight has been all but ignored throughout this pandemic (with a few noteworthy exceptions like Dr. Lawrence Loh in Brampton) by our supposedly caring public health administrators and agencies. What would Tommy Douglas have thought?
In a class-based society, there is a systemic bias that favours the dominant class even when it comes to the health of the population.
Occupational health and safety
It took long and bitter struggles for workers to win the right to income replacement when injured at work and a measure of preventive regulation to make their workplaces somewhat safer. The contemporary workers’ compensation and occupational health and safety legislative schemes are reflections of the fact that going to work is dangerous to workers’ health.
Every year, activists get together to mark a Day of Mourning. The International Labour Organization reports that, worldwide, two million deaths are attributable to injuries or work-related diseases. Every year, year after year. That works out to 6,000 per day, every day. In Canada, 2.78 people die as a result of work-inflicted injuries every day. Many more (the numbers are difficult to document), die from work-related diseases. Of course, many workers are injured or suffer diseases that do not kill them but do harm to them and their loved ones. Worldwide, 270 million injury-causing events are recorded and 160 million diseases and illnesses are attributed to work every year. There are very few owners and major shareholders among those killed and injured.
It is a class thing.
It is clear that, as public health instruments, the legislative schemes are not working all that well. The reason is the same as that which causes the mishandling of the ravages of COVID-19. The culprit is the privileging of the private accumulation of wealth over the sanctity of the health and well-being of the working class.
The schemes are a cost to capital. Capitalists do not like this. Their power to resist is great because governments rely on them to invest their capital. Just as Big Parma needed to be bribed to produce vaccines, capitalists in general are free not to use their capital and need to be cajoled and placated. The right to withhold capital means that investment by capitalists is treated benignly. It follows that governments will feel pushed to regulate capitalists’ activities only if considerable harm has already been done.
Basically, the story goes something like this. If one worker loses a hand in a machine, that is called an accident and nothing happens. If 10 workers lose their hand in that machine, it is called a cluster and heads are shaken and worker representatives complain. If 120 workers lose their hand in the machine, a regulation to put a guard on that machine may be enacted. The workers’ compensation schemes provide the necessary data of the incidence of harms as workers apply for income replacement.
The built-in reluctance to inhibit capitalists who are seen as virtuous welfare creators, rather than blameworthy harm-doers, means that governments consult them when imposing restrictions on them. Talk about the fox minding the chicken coop. The ensuing standards are low. The fear that capitalists may withdraw their property also induces governments to wield a very soft stick (more like a wet straw) when monitoring and enforcing their regulatory schemes. This has been brought out in dramatic fashion during the pandemic. As anxious workers tried to exercise their legal right to refuse work that had become much riskier, Ontario’s Minister of Labour, Training and Skills Development, Monte McNaughton, denied their applications by the hundreds. The Toronto Star reported that the same ministry had inspected 31,500 premises since the start of pandemic but had only found one employer sufficiently heedless to warrant being fined. Yet, the incidence in infections of workers in manufacturing had risen by 77 percent in two months. This “softly, softly on employers” approach is not confined to the pandemic. In December 2019, the ministry proactively inspected only one percent of all workplaces. When it did hold people to account for breaches of existing standards, they were mostly workers.
This is a recipe for the infliction of bad health. It is even more so when it is sought to prevent diseases arising from the workplace. The cause of the illness may be quite difficult to attribute to exposures at work as the workers are also exposed to many possible harm-causing substances and products elsewhere and there may be genetic predispositions which might explain some manifestations of diseases. This is reflected in workers’ compensation regimes. Very few diseases are recognized as being sufficiently linked to work conditions to be worthy of an award of compensation. It is only a few years since it was accepted that being exposed to asbestos at work was sufficiently linked to lung diseases and cancers to attract compensation. Of course, asbestos processors and miners had known about the causal link since 1932 when the first peer reviewed medical report was published. All around the globe, the employers lied and hid this knowledge. For decades. The consequences are horrific. The ILO estimates that, over the next 40 years, 107,000 people will die every year as a result of their past and, in some places, continuing exposure to poison that fills the coffers of profit-seeking asbestos miners and processors. Or, more locally, the workers’ compensation body (misleadingly named the Workplace Safety and Insurance Board to erase any mention of workers or compensation) was shamed by activists into reviewing its refusal to recognize the huge number of disease-causing substances workers had been exposed to by General Electric in Peterborough. The plant deployed 3,000 toxic chemicals, of which at least 40 are known or suspected cancer agents.
Leaving the initiative to benign capitalists to generate wealth by investing their property means that regulators only know what dangers are built into any operation if employers tell them or unacceptable outcomes come into view. There are a huge number of untested substances in use in workplaces. For instance, the products used in beauty and hair salons contain some 10,000 chemicals. Only 11 percent of those have been tested and analyzed by regulators. Or, to return to unacknowledged connections between workplace conditions and serious illnesses, there are very conservative studies which show that four percent of all cancers (some suggest the figure may be as high as 20 percent) are workplace related.
There are many risks in the workplace. All of them are borne by workers, and all of them are created by capitalists with a helping hand from capitalism-favouring governments. As a crucial department of public health regulation, workers’ compensation and occupational health and safety works very poorly. It does so for the same reasons that we, in Canada, compared to many other countries, have had such a bad handle on the spread of the coronavirus. We do a fair job when it comes to providing treatment for people who suffer the inevitable injuries or diseases that will befall people at large. Such injuries and diseases are suffered randomly—that is, they are likely to affect any segment of society. They cut across classes. When preventative measures are called for to avert risks that are not so randomly distributed, the story changes.
In a class-divided political economy, many risks are likely to impinge primarily (often only) on the working class; all too often on the poor, those with little power, and upon non-white, racialized, or Indigenous peoples. In those settings there is a much reduced impulse to avert the risks, especially if such attention demands restrictions on the ceaseless drive for the maximization of profits that is the life blood of capitalism.
Class matters. It always did. As Albert Camus wrote in The Plague: “The pestilence is at once blight and revelation. It brings the hidden truth of a corrupt world to the surface.”
Harry Glasbeek is a Professor Emeritus and Senior Scholar, Osgoode Hall Law School, York University. His latest books are Class Privilege: How Law Shelters Shareholders and Coddles Capitalism (2017) and the follow-up, Capitalism: A Crime Story (2018) both published by Between the Lines, Toronto. Professor Glasbeek is a frequent contributor to Canadian Dimension.