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From New International, Vol.4 No.12, December 1938, pp.369-372.
Transcribed & marked up by Einde O’Callaghan for ETOL.
“SOCIALIZING” MEDICINE has been a topic of newspaper comment ever since the beginning of the economic crisis ten years ago. Even before that, there was enough dissatisfaction with medical service to have necessitated the studies of the Committee on the Costs of Medical Care from 1928 to 1931. Recently, every periodical from the New York Times to the pulp magazines such as True Story has discussed the subject over and over again. Most publications appear to be in substantial agreement that some change is necessary, except those representing the Manufacturers Association of American Medicine – the American Medical Association. Upon deeper examination one finds many differences of opinion as to the extent and type of “socialization” that should be undertaken, but the fact remains that there is today more of a popular interest in health and medical care than at any time since the early years of the century, when the most outrageous abuses of quacks and patent medicine manufacturers were curbed as a result of popular demand.
The interest of all classes in these problems is due to several causes: for one thing, people of widely different incomes may have identical health needs; moreover, even the richest cannot feel secure about his health unless at least the infectious diseases are reasonably well checked among all classes. Employers have learned, too, that they lose money by high rates of sickness among workers, with the rapid labor turnover and the constant discontent which they produce. But the most important reason for this sudden, unprecedented concern of the bosses over the health of the workers is that reforms in medical service constitute one of the few important concessions that capitalism can now offer the working class without directly affecting its own interests. As there is a genuine need for such changes, the initiative could safely be left to the spontaneous demand of the people. Naturally, members of the working class, who feel the direct effect of the woefully inadequate health services far more than others, are pressing for new benefits with more insistence than any other group.
It was in fact largely due to the political pressure of various labor and farm organizations that the administration finally called the National Health Conference in July of this year, after postponing any such definite action month after month because of the violent reactionary opposition of the AMA. The central offices of the AF of L and the CIO were represented at the conference as well as a number of their constituent unions, such as the Amalgamated, the SWOC, the Cannery and Packing Workers, the UAW, the ILGWU, and the UMW. In addition, there were the Railway Brotherhoods, the Farm Bureau Federation and other farm organizations. But the Conference also included many organizations from other classes as, for instance, the American Legion, women’s clubs, church groups and large corporations.
All this is evidence of a wide interest in better medical care, but the tendency to cut across class lines has produced the greatest confusion among workers (often encouraged by specially interested persons) as to what constitutes a truly progressive program. There is serious danger that measures designed to increase the dependence of the workers upon the state machinery through bureaucratically controlled health services will almost certainly be instituted unless the demands of the masses are vigorously put forward upon a strictly class basis.
It is idle to tell readers of The New International that there are untreated medical needs in every section of the working class in every part of the country, without including the questions of preventive care (which exists, if at all, only among the most privileged classes). Reactionary elements constantly belittle the problem, however, arguing that the small existing needs do not justify a major change in the system of care, and for this reason the question of the adequacy or inadequacy of present facilities has become an important issue in itself. One needs only to be reminded of a few facts to realize how false the claims are of those who defend the status quo [1]: the maternal mortality rate in the US is (1936) 57 per 10,000 live births – more than twice that of Sweden; there are 40,000 deaths a year from tuberculosis, half of which are preventable; nearly one adult in ten is infected with syphilis; there are 60,000 new cases of congenital syphilis every year – ninety-eight percent of which are preventable; there is urgent need for nearly 50,000 public health nurses, for 70,000 dentists, and for 400,000 hospital beds if even minimum health standards are to be met. Most revealing of all from the workers’ standpoint are the facts which indicate what groups of the population are the ones who suffer the most from this appalling inadequacy of service:
|
Family |
Annual days |
Annual physician |
|
Under $1,200 |
8.9 |
1.9 |
|
$1,200-2,000 |
5.7 |
2.0 |
|
$2,000-3,000 |
5.0 |
2.3 |
|
$3,000-5,000 |
3.0 |
2.7 |
|
$5,000-10,000 |
3.0 |
3.6 |
|
$10,000 and over |
3.0 |
4.7 |
From this table we see that the lowest income group has a disability rate nearly three times that of the well-to-do but at the same time receives less than half as much medical attention. Put in another way, it is found that nearly thirty percent of serious disabling illnesses among relief families and families just above relief level received no physicians’ care whatsoever, while in families with more than $3,000 income the figure is only 17 percent These figures are a dramatic answer to the old saw that the very rich and the very poor receive fine service while only the middle classes suffer! The highly touted “gifts” of free medical service by government, philanthropy, industry, and doctors all told amount to little more than one-fifth of the $3,500,-000,000 spent in this country annually for all forms of medical care – the rest comes directly out of the pockets of the sick people themselves. This represents about four percent of the entire national income, and reliable studies show that in each income group almost exactly four percent of the family income, on the average, is spent on health – quite contrary to the self-righteous claims of those who would have us believe that the rich pay for the sicknesses of the poor. There is little doubt that working class families bear the brunt of the inadequacies and inefficiencies of all the health services.
Some reactionaries argue that poorer people could have more medical care if they were not so ignorant and superstitious about doctors, hospitals, and clinics and would seek their services more freely. There is some truth in this: how could it be otherwise with the woeful lack of health education in these classes and their experiences with the crowded conditions of public clinics? More important than ignorance, however, is the simple fact of the worker’s meager wage and his need to spend it first for the daily necessities of food and clothing, leaving little over when illness strikes. To add to the seriousness of the situation is the fact that when a worker is sick his wages stop at once and his family is left with nothing whatever. For all but the most dramatic emergencies and the most advanced illnesses, therefore, he is afraid to call the doctor because of the expense, and if one visit can be stretched, by taking a chance, to cover a whole sickness, he will take that chance and not ask for a second call. Unfortunately, he is more apt to try a patent medicine or a druggist’s recommendation, partly in ignorance, perhaps, but much more in the hope that a ten cent bottle of medicine may prevent a ten dollar doctor’s bill.
Worst of all, what little the worker is able to spare for health is spent for an inefficient system of care which is as antiquated as the ox-cart. This country, with a ratio of one doctor per 815 persons, ranks highest in the world in numbers of medical men. Far more satisfactory medical care than this country has ever had, however, is given regularly in the Scandinavian countries, with a ratio of one physician per 2,156 persons. It is obviously not a question merely of the number of licensed doctors. What are the causes of such glaring inefficiency? For one thing, the system of medical private practise, with its reduplications of equipment, office space, technical assistance, etc., is wasteful in the extreme. This overhead alone eats up, on the average, forty percent of a doctor’s income. In addition, no one doctor can possibly keep up with all the ramifications of modern medical science; extensive laboratory tests and consultations with specialists are essential for the proper care of a very high percentage of cases today. What chance has the worker of getting these services for his small payments so long as practitioners are isolated in separate offices with no access to other men or to laboratories? But the “overhead” can be strikingly reduced and the ease of consultation and laboratory work much increased by the assembling of many doctors into a single group where they can pool their knowledge and share the expenses of equipment, etc., for the benefit of the patient. That such groups are more efficient both medically and financially is amply testified by the success of such institutions as the Mayo Clinic, and the Ross-Loos Clinic.
In another way, the inefficiency of the present system is exemplified by the relatively small expenditure on preventive medicine. Of the $3,500,000,000 annually spent on health, only about three percent goes for any kind of prevention – the other ninety-seven percent is used in trying to cure those already sick, many times with entirely preventable diseases. How can the worker possibly take advantage of modern knowledge of preventive medicine, no matter how much he has saved for medical care, with such a meager program of public health education? If he could go regularly for physical examination, if he could send his wife for proper prenatal care, if he could have his children vaccinated against infectious diseases, the same amount of money he now spends would bring in many times its present returns in increased health. In fact, it is reliably calculated that if the total now expended on medical care in this country were put to really efficient use through group clinics, periodic health examinations, enlarged public health services, training much needed public health nurses and dentists and the like, it would be more than sufficient to furnish adequate care for every man, woman, and child in the country. In this respect, the problem of medical care under capitalism is no different from those of food and clothing – there are resources enough to provide plenty for all, but utilization of the resources is wasteful, inefficient, and unequally distributed, all to the disadvantage of the workers who produce them.
There is another aspect of the need for medical care, and it is one in which it differs from needs for other necessities. While needs for most things are quite predictable, illness strikes for the most part without warning as to time, place, or duration. If the medical expenses of a given family are added up for a full generation they usually come to about the average amount for its income group – approximately four percent of the family income for the whole period. But year by year, the costs of illness fall very unevenly and may be so severe as to ruin altogether some families while others escape without paying anything. Statistically, this works out to mean that ten percent of the families of a given income group bear forty-one percent of the medical costs of that group for the year, while fifty-eight percent of the families hi the same group bear altogether only eighteen percent of the costs. But statistics tell little of the real story; through them it is hard to see the hopeless burden of misery and debt that an illness costing $1,000 can put upon a family which earns at most $2,000 all told. Obviously, there is only one way of dealing with such catastrophes – the application of the insurance principle, either through general taxation or through periodic prepayments directly into health insurance funds.
To meet the need indicated above there have been a great number of proposals which must be briefly outlined. All of them have been called “Socialized Medicine” at one time or another. The most prominent and, for the immediate future, the most important of these is the program presented at the National Health Conference which the next Congress will be asked to enact. It envisages the expenditure of gradually increasing sums until, by the tenth year , a total of $850,000,000 per year is to be spent, half to be obtained by the Federal government and half by local and State authorities. This money would be used for five purposes:
This is a fully progressive program, so far as it goes, and should be supported by all labor groups, together with demands for a more rapid increase of the size of the appropriations and for a larger total expenditure. It remains to be seen whether or not Congress will enact the necessary legislation, but the most vigorous support will be needed for there will be violent and well-paid opposition from many groups of reactionaries.
Complete State Medicine, with every doctor a salaried officer of the government, is the second important method of “socializing” medicine now being seriously proposed. This is supported by the Medical League for Socialized Medicine, and to a certain extent, by the famous “Committee of 430” which is leading a revolt within the AMA. From a working-class point of view, this would be dangerous because it would remove all possibility of workers’ control of their own doctors and leave their health needs at the mercy of the capitalist state. Strikers in Flint and in Minneapolis, for example, had great difficulties in obtaining medical aid from ordinary private practitioners during labor crises and, judging from their experiences, a state-controlled medical service might prove a powerful weapon against militant workers.
Compulsory Health Insurance, on either a Federal or State basis, is widely proposed and has received the official endorsements of both the AF of L and the CIO If the premiums could be obtained from employers without wage reductions, and if, at the same tune, workers’ control of the services rendered could be assured, this would be a very valuable means of obtaining certain benefits. These two conditions are not likely to be fulfilled, however, and if they are not, the compulsory insurance method might well become as dangerous a weapon of the state as complete State Medicine itself. Unfortunately since the leaderships of both the large labor groups are themselves not interested in direct workers’ control, they are ready to believe that the whole system can be put down paternalistically on their members and made to work willy-nilly. Moreover, compulsory health insurance in itself does not make any provision for health education or preventive medicine and without these features is at best only a sort of crutch. Another difficulty is that unless provision is made for the rendering of medical service by physicians in group clinics, rather than in private practise, the method would be wasteful in the extreme and prohibitively expensive if anything approaching proper care were given. Finally, any compulsory insurance scheme which does not include hospitalization, consultation with specialists, and benefits for dependents as well as the worker himself will be worth next to nothing. Nevertheless, if all these precautions can be observed, there is a great deal to be gained from giving the benefits to so large a number of persons as would naturally be included. Its soundest application, from the working-class point of view, would be in connection with powerfully built, self-controlled trade union health associations.
Such associations can be built upon the principle of voluntary health cooperatives, such as have been so successful in the Scandinavian countries and have been started in a few places in this country. If such organizations are to be truly progressive, certain fundamental requirements must be strictly observed:
There are, however, serious objections to voluntary health associations as a solution for the widespread need for better medical care. For one thing, the payments do not include support by the employers or the government, and they do not compensate in any way for the inequalities of income in different parts of the country. Moreover, the membership will tend to rise and fall with economic circumstances, often leaving the individual without benefits just at the time he needs them most. Finally, the lack of centralization of control leaves the way open for great variation in the quality of service given as well as for local racketeering and political interference. For these reasons, voluntary associations can be widely useful only as integral parts of a larger program.
So far as actual steps toward “socialization” are concerned, the hospital insurance plans have proceeded much farther than any others. To the extent that these plans offer real benefits workers should be encouraged to join them, but it must be pointed out clearly that at best they are no more than a stop-gap and offer none of the advantages of a continuous, all-inclusive health service. Furthermore, these plans were originally instituted to save the privately owned hospitals from bankruptcy, and even today the membership has no voice in their management and no control over the budgets of the hospitals to which the funds are eventually paid. As nuclei about which genuine, democratic health associations can be built, they may in many instances prove to be of great value.
The American Medical Association, as the official organization of the country’s 110,000 private practitioners, has consistently opposed all forms of change in the present system of fee-for-service medical care. This does not mean that the rank and file of the Association’s membership really supports such a completely reactionary position. In fact, a large majority of the doctors are themselves having the greatest difficulty making a living and would welcome regular salaries from government or insurance sources. But the Association’s tricky electoral system is such that virtual control of the organization is assured for the wealthy big-shot consultants who are rightly afraid that any change toward “socialization” would threaten their lucrative practises. The Association exercizes autocratic control over the rank and file by means of its power to expel unruly members and thereby deprive them of the right to admit patients to most hospitals. It is by using this power that the AMA has been fighting the Group Health Association in Washington and similar organizations in other places. The only hope for such organizations at present is the building of hospitals under their own control. Fortunately, the AMA cannot directly threaten the license of a physician to practise, although in the case of the Elk City (Oklahoma) Cooperative, for instance, it has attempted to use its influence to force the state authorities to revoke licenses. Another powerful weapon of the central officialdom of the AMA, represented by Dr. Morris Fishbein, is its control of the advertizing in medical journals throughout the country. If a certain journal becomes rebellious, Dr. Fishbein puts on a financial squeeze-play by warning advertizers to withdraw from it or face the cancellation of their contracts with the Journal of the AMA – their chief means of contact with the medical profession at large. When the Milbank Fund, which is financed by Borden’s Milk Co., showed too much interest in socialized medicine the AMA told its members to advise their patients to avoid Borden’s products. The boycott was so effective that the Milbank Fund found it advisable to withdraw from the field to save Borden’s from ruin.
Recently, a special meeting of the House of Delegates of the AMA was held to discuss the Government’s health program. The plans to extend public health services, build hospitals, and to insure against wage loss during sickness were heartily endorsed, but any form of insurance which would provide actual medical care in sickness was denounced as “bureaucratic, costly, and political.” In the happy phrase of the New York Times correspondent, “The doctors expressed alert reservations to any plan which might tend to separate them from any patients other than those unable to pay.” At this same meeting, approval was given to “cash indemnity” sickness insurance, by which cash benefits are paid to the sick subscriber who then pays his own doctors’ and hospital bills. Adequate medical care, if purchased on such an individual basis for minimum fees, would cost approximately $310 annually per family (exclusive of dentistry) – obviously a prohibitive figure for most families. The same service, purchased through group practise plans, would cost less than $100 annually. It is at once apparent that the AMA’s approval of cash indemnity insurance is an empty gesture intended merely to give the appearance of progressive action while diverting public attention from the real issues at stake.
Both the AF of L and the CIO have, up to the present, confined themselves to the support of compulsory health insurance mentioned above. Possibly the CIO convention will offer a more complete program. Certain unions, however, have made attempts to deal with the situation individually. The oldest effort is the Union Health Center of the ILGW. This is merely an out-patient clinic which is partially supported by union funds but which charges in addition a small fee for each visit. The service is excellent and the union members show a considerable pride in having their own medical service, but it is clearly a very limited effort. The UAW has been running a Medical Research Institute (recently suspended for lack of funds) with one full-time doctor and several part-time doctors, but this has so far devoted itself almost entirely to the pressing problems of Workmen’s Compensation. Minneapolis Teamsters Local 544 has been trying out a plan for the retention of a physician on a part-time basis; the Food Workers in New York have a somewhat similar plan but it is practically limited to periodic health examinations. Some of the best plans now in operation are those of various Railroad Brotherhoods – the Trainmen in particular have gone so far as to take care of their own tuberculosis members under private physicians at Saranac Lake, NY. Except for these and some smaller attempts such as the Wage Earners Health Association of St. Louis, little is being done by labor organizations as yet Perhaps the most hopeful sign for the future was the announcement last August that the UMW is contemplating an all-inclusive health service for its members. If this attempt is successful on a large scale, it may well serve as a model for other working class groups.
The task of a revolutionary party with respect to medical care is to help workers everywhere to obtain the greatest possible concessions without ever losing sight of the fact that these will be at best merely temporary gains on the road towards socialism. In particular, the largest possible support must be sought from federal, state, and local government funds together with obligatory employers’ contributions. Equally important is the retention of direct control of the services by the workers themselves. Probably these two ends can best be achieved by urging a large Federal Health Program but at the same time insisting that any program, whether compulsory or otherwise, should allow full autonomy for all voluntary health associations which may be formed. Such a plan will benefit from federal aid in equalizing to a certain extent the economic differences in various sections of the country and in maintaining a uniform standard of excellence in the service. Employer’s contributions should be made through general taxation rather than through direct dealings with individual groups, thus avoiding as much as possible the passing on of the burden to the workers through wage cuts as well as employer intervention in the workings of a health association, especially in times of strikes or other militant action. Federal and State subsidies to the voluntary groups should be as large as possible and in the form of regular grants-in-aid given without conditions other than those guaranteeing a high standard of service. Members of health associations would thus retain the responsibility for their own organizations which would promote at the same time the development of independence and the confidence in their own physicians without which no system of medical care can be successful. If labor organizations are to urge such a plan, they must cease at once their unhealthy dependence on the government to take care of them and begin immediately to build their own health associations into powerful groups which can demand autonomy and subsidies when Federal action is finally taken.
The achievements of medical science in the past seventy-five years have been almost unbelievable. It is not necessary to
repeat in detail the horrors of the days before Pasteur, before anesthesia, before Lister, before the discovery of X-rays, salvarsan, insulin, or sulphanilimide to be assured that we are now living in an age of extraordinary technical advance. But the brilliance of these discoveries (and they have been well publicized) has tended to obscure a less pleasing side of the picture: the failure of capitalist society to distribute these benefits to any except the most privileged classes. Laboratory workers continue to search for new methods of cure, but they are studying details and refinements now – the magnificent sweep of the years from 1860 to 1920 has faded away. While medical science is still far from being able to solve all the problems of health, there are many diseases today which could be entirely wiped out if the knowledge already available were to be applied for improvement of the millions who need it so desperately.
To name but a few examples of the ever-widening gap between technical resources and social usefulness, consider the failure to control syphilis, maternal mortality, and the nutritional diseases, especially pellagra. Many details of these conditions are not yet understood, yet all the fundamental information for stamping them out is already at hand. It is safe to say that there is no disease about which our knowledge is so complete as it is about syphilis. The causative organism, the methods of infection, excellent means of testing for its presence, and a nearly certain cure for it have all been known for twenty-five years. And yet the syphilis rate in this country is among the highest in the world! Obstetricians have shown repeatedly in small communities that they can cut present maternal mortality figures in half whenever they have the opportunity to use their knowledge to the utmost advantage. The cause of pellagra and effective means for its prevention and cure were discovered over twenty years ago, and yet starvation wages and tenant farm conditions continue to take their toll in pellagrous insanity and death. Further research on these conditions may be valuable to abstract science, but the crying need in these and many other fields today is not for more research but for wider use of the knowledge we already have.
Such tragic failures to utilize scientific information for the benefit of all are only conceivable under the chaotic wretchedness of capitalism. Already the example of the early years of the USSR has given a hint of what can be done when medical knowledge and medical research are used for the improvement of society instead of for the profit of the practitioner. The achievements of the Soviet Union in public health work amazed the entire world and were long the envy of physicians everywhere. Such solid accomplishments remained intact long after other Soviet institutions gave way under the plunderings of Stalinism. But scientific leaders could not escape forever the disasters which befell their comrades in other walks of life, and one by one they too have now fallen victims to the increasing ferocity of the purges. Demands for favors from the privileged officialdom have undermined the usefulness of workers’ health centers and sanatoria. Scientific work has deteriorated, cramped by an ideology which insists upon results that suit its momentary whims. If medical science in the USSR is to fulfill its early promise, it must be freed from the totalitarian yoke.
But, no matter how easily accessible the best medical techniques might be made, the fundamental problems of workers’ health cannot be solved under capitalism. The best imaginable health program cannot be more than a feeble palliative so long as mass unemployment, crowded slums, low standards of living, chronic malnutrition, mutilation and death from war are the expected lot of most of mankind. Only through the final victory of world socialism can the vast stores of available scientific knowledge really be put to work for the full benefit of humanity. “Socialized medicine” is a meaningless phrase except in a socialized society.
1. Statistics are from the reports of the President’s Technical Committee on Medical Care, and from publications of the Julius Rosenwald Fund.
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