Usage
The term ‘class’ is used for widely different purposes.
Researchers whose purpose is primarily descriptive (eg demographers or statisticians) tend to treat ‘class’ as a descriptive variable, often closely linked to household income or wealth. A spectrum from very rich to very poor is defined and the numbers and circumstances of households at different points on the spectrum are described. A vast body of research in epidemiology has documented the links between burden of disease and income or wealth and other indicators of ‘socio-economic status’ (eg, Demakakos et al. 2016; Kokkinen et al. 2019).
The Marxist use of ‘class’ arises from an analysis of the structures and dynamics of social and economic power. The Marxist starts with a revulsion regarding the suffering of poverty and the unfairness of gross inequality. (See Engels 1845 (1845/1969) report on the condition of the working class in England.) From this revulsion stems a need to understand how poverty and inequality are reproduced and how they might be remedied. Marxist answers to these questions centre around institutional systems of production, distribution and exchange and the power relations which shape how such systems operate. In their analysis of such institutional systems and power relations the classical Marxists drew upon an analytic framework structured around different relationships to the means of production (ownership, management, wage labour). Marxist use of class analysis is closely linked to their analysis of the stocks and flows of the capitalist economy, including conflict over the distribution of the economic surplus and the dynamics of crisis and development.
Class analysis provides powerful insights into understanding the capitalist economy but its significance for Marxists also turns upon its implications for political strategy, including its identification of the working class (actually, ‘the proletariat’) as the principal agent of progressive political change (including revolution).
Capitalism operates differently in different countries, corresponding to their historical context and to their locus in the global capitalist economy. Reflecting in some degree these different experiences, different schools of thought contend within the Marxist tradition regarding both their analysis of contemporary capitalism and their preferred trajectories of political engagement. These different analyses and strategies also shape their approach to class relations and their usage of the term ‘class’.
Capitalism also develops across time which calls forth evolving economic explanations and changing foci of socialist strategy and necessarily the associated connotations of ‘class’. One dimension of capitalist evolution has been towards increasing economic integration across national borders. This started with pre-capitalist trading relations and conquests, through the period of colonial conquest and exploitation, to state-centric imperialism (Lenin 1973 [1916]), through to contemporary transnational capitalism. Nevertheless, a class analysis centred on the national economy has continued to characterise discourses of political strategy in many settings even while economic analysts have highlighted the changing social relations of capitalism associated with colonialism, imperialism and contemporary globalisation.
As a consequence, a divergence is sometimes evident in the discursive implications of ‘class’ when used in settings where the focus is primarily on explaining contemporary global capitalism in contrast to settings where the focus is on political organising.
In the national economy where class is defined by people’s relationship to the means of production a national proletariat is envisaged as confronting a national bourgeoisie. In the classical Marxist accounts of European capitalism there is a clear recognition of the role (and brutality) of colonial conquest and contribution of colonial exploitation to capital accumulation in the metropolis. Lenin’s theory of imperialism developed this picture with his recognition of the separate roles of finance capital and industrial capital in the colonial/imperial structures.
However, while the focus was on political engagement in Europe, a construction of class was deployed which still focused on the social relations of the means of production in the metropolis.
The transformations of the late 20th century included political independence for the erstwhile colonies, the global reach of huge transnational corporations sitting astride global supply chains and the integration of the global economy, in part a consequence of the trade liberalisation associated with the neoliberal ascendancy.
With globalisation came some retheorising of ‘class’ with increasing use of the concept of a ‘transnational capitalist class’ (Sklair 2012; Robinson and Sprague 2018). It is not so clear what axis of analysis (to define the fundamental confrontation) is being used here, nor how the oppositional forces are being constructed.
By some accounts (eg, Madi 2018; Bello 2009) the most critical axis of analysis would be the control over global finance capital rather than the ‘means of production’. In such a framework the transnational capitalist class would be defined by its control over global investment (including speculation) and the oppositional force a global mélange of middle classes, working classes and marginalised peoples.
This provides for a plausible explanation of the power relations which control the global capitalist economy but as the basis for political strategy it leads to further questions. These include questions about the prospects for a convergence of political movements reflecting these different oppositional forces; the possible processes which might lead to a stronger sense of shared subjectivity and solidarity across the mélange; and the forms of political engagement which might yield people’s control over global finance and investment.
Convergence and solidarity are by no means inevitable. The recurring emergence of various forms of neofascism (Roberto 2018) points to various scenarios in which ‘fear of the other’ overcomes any rational case for building solidarity. Such scenarios also point to the limitations of a one dimensional – class based – analysis of society which ignores or discounts axes of analysis centred on gender, nationality, ethnicity, or religion. See intersectionality.
Implications
These different meanings of ‘class’ are evident in useful descriptions, explanations and strategies in relation to both population health and health systems.
Health inequalities in countries
There is a huge literature describing the disproportionate disease burden carried by poorer as compared with richer people within countries and societies. (See Virchow (2006[1848]) as a reminder that this literature has a rich history.)
Much of this literature is commonly categorised as dealing with the ‘social determinants of health’. Theories on offer for making sense of the relationships between health and class include:
- absolute material insufficiency;
- greater exposure to material hazard;
- alienation, lack of social support, lack of social capital (Kawachi and Kennedy 1997);
- perceived subordinate status (Marmot 2005);
- high pressure and low control at work (Karasek and Theorell 1990)
- relative powerlessness.
Much of this literature uses social class as a descriptor, as a metric for documenting health inequality. However, defining class in relation to the means of production, rather than treating it as a continuous variable, suggests that, under capitalism, opportunities for good health are in some degree the outcome of class struggle.
This idea of a ‘struggle for health’ (Sanders 1985) is illustrated in the debate over ‘social determinants’ versus ‘social determination’. The case for ‘social determination’ as a more useful term (Breilh 2008) is based on its explicating the production of health inequality is an active political process while the use of ‘social determinants’ is commonly taken as suggesting a set of disembodied ‘factors’ each of which has to be explained and addressed separately (housing, education, social security, etc). Breilh characterises his 2008 paper as “an invitation to confront the menacing forces producing our unhealthy societies and an opportunity to form fraternal partnerships on the intercultural road to a better world”.
Health inequalities between countries
A comparable research literature on health inequalities between countries reflects some of these same contradictions between disembodied factors versus the active production of health inequalities through institutional and political processes shaped by the global distribution of power.
The descriptive side is not open to debate. The relationship between population health indicators and country level GDP per capita is stark.
The political processes underlying the ‘development of under-development’ (Frank 2019 [1986]) are only partly hidden. The covert subversion and economic and military coercion by the imperialist powers of resource-rich states which do not provide access for transnational corporations to their resources is well documented, Iraq and Iran being contemporary cases. Less blatant is the network of trade agreements which have been used to drive the neoliberal program globally. The asymmetrical rights and obligations associated with this trade regime have reproduced the barriers to economic development previously associated with colonialism while enriching the elites of the global North. However, the combination of imperial power and the market forces of neoliberalism has also contributed to the emergence of elites in the global South who are just as invested in the neoliberal program, notwithstanding its contribution to widening inequality.
The neoliberal regime depends in part on its ideological ascendancy, promoting the benefits of trade liberalisation, creating evidence to justify invasions, selling ‘there is no alternative’. This regime is sensitive to the need for legitimacy and is vulnerable to the threat of delegitimation. The World Bank and the Gates Foundation illustrate the significant investment directed to promoting the legitimacy of the regime while recognising inequality, poverty, malnutrition and avoidable mortality as problems to be solved.
The explanations of inequalities between countries and strategies for reducing such inequalities are highly contested. The Bank focuses on particular institutional sectors (agriculture, urban development, or health care financing) and produces policy packages which focus solely on particular sectors while accepting as fundamentally beneficial the structures and dynamics of the global economy.
Among those critics who do recognise the ways in which the reproduction of inequality is embedded in the governance of the global economy a range of explanatory systems are evident, ranging from a focus on transnational corporations, to the international financial institutions, to US imperialism.
The theory of a transnational capitalist class, which brings together the ultra-wealthy, the managers of the big corporations and banks and the political elites of North and South; which envisages this class as having common interests, similar lifestyles, and a shared consciousness; and which deploys its political and economic power to maintain and protect the existing regime. This narrative provides significant explanatory power, although largely ignored by public health academia and by the policy gurus of global health governance.
However, the implications of transnational class theory, for political strategy, are not widely appreciated, and are barely acknowledged in the ‘development and health’ literature and policy discourse.
The People’s Charter for Health (PHM 2000), the founding document of the People’s Health Movement, is an exception. While not using the language of transnational class theory, the Charter structures its political program around the task of building a global social movement around the struggle for health (Sanders 1985); working to build solidarity and a shared understanding across numerous constituencies across all countries. Clearly a global social movement for health is not a sufficient driver of change but the program clearly envisages the building of solidarity across those social and political movements who do not accept the reproduction of inequality and who see the taming and replacement of neoliberal capitalism as necessary for human and planetary health.
Medical hegemony and class (and gender and race and …)
The social class lens can also sharpen our understanding of the role of the medical profession in shaping political priorities regarding risks to public health and equitable, affordable access to health care. In many countries access to medical training is restricted to those families who can afford the quality of education and the cost of university training. In countries where access to medical care is associated with large out of pocket costs (medical fees or private insurance premiums) a certain ideological affinity may be evident between medical practitioners and their upper-class customers.
The class and ideological connections between the medical profession and the upper-class serves both sides; political support for medical privilege and medical hegemony in return for medical support for an individualised and personal choice view of illness and access to care.
This relationship is clearly evident in the professional support for individualist and behavioural approaches to health promotion linked to the neglect or discounting of the structural dynamics behind health inequalities.
One of the core elements of the primary health care model, celebrated at Alma-Ata in 1978 and elaborated since then, is the concept of ‘community involvement’ which is seen as encouraging health care practitioners to recognise the forces shaping the health of ‘their’ community and to build partnerships between practitioners and community which can work to address those forces.
By contrast, fee for service medicine, fiercely defended by the medical profession in many countries, promotes a more individualised approach to health care and entails and institutional framework much less able to work with communities to engage in the social determination of health.
The theory of a transnational capitalist class can be usefully applied here to a range of transnational industries including pharmaceuticals, junk food, and big oil, all of which benefit in different ways from a cooperative and well aligned medical profession.
Health care financing: universality versus safety nets
The social class lens can also bring into focus the class in the politics of health care financing. Assuming a progressive income tax scale the upper class has a strong incentive to restrict public funding of health care (and aged care, education, urban infrastructure, etc). However, the upper class is comfortable in buying private health insurance cover and managing gap fees. However, working class people vote and a need to shore up the perceived legitimacy of the governance regime resurfaces periodically.
These dynamics work out in different ways in different countries and times. However, a common pattern involves private health insurance and private health care for the rich sitting side by side with publicly funded safety net programs providing ‘essential’ health care services albeit with limited range of services and less comfortable amenity.
The theory of a transnational capitalist class is also useful here given the support provided by the World Bank, USAID and the Rockefeller and Gates foundations for ‘universal health cover’. Despite the reference to universality, the model of health care financing being promoted under this slogan envisages a multi-tiered health system with a minimal safety net for the poor and privately funded private practice care for the rich. The support of the transnational capitalist class for multi-tiered health care is consistent with its palliative approach to inequality and the co-dependence of global finance for investment opportunities and national politics to attract such investment, including through low tax and deregulation.
Class struggle, population health and access to affordable health care
It would be incorrect to picture the working class as passive recipients of health policies (population health and health care) which are determined by upper class (and transnational capitalist class) dominated political institutions.
The processes of political determination of health policy can be usefully pictured in terms of class struggle (including anti-colonial struggles and resistance to imperialism). This is particularly clear through an historical lens including for example:
- the classical narratives of population health in England during the Industrial Revolution (Szreter 2004; McKeown 1979);
- long-standing and ongoing struggles around occupational health (Berman 1978);
- the many stories of revolutionary doctors including Virchow (Ackerknecht 1957), Bethune (Allan and Gordon 1973 [1952]), Che Guevara (Anderson 1997) and Allende (Waitzkin et al. 2001);
- the prominence of health as a rallying focus in anti-colonial struggles, in China (Sidel, Sidel, and Sidel 1982), Guatemala (Behrhorst 1975), Brazil, Thailand and in the struggles of indigenous peoples for self-determination in settler colonised countries (see Foley 1991, from Australia, for example).
These struggles are ongoing but the application of class theory to explaining and strategizing has necessarily changed over time. While the struggles around occupational health which Berman describes in the US are usefully understood in terms of traditional class struggle between capital and labour, the contemporary struggles of fisher communities in India involve both the domestic ruling class and the transnational capitalist class which has allowed the industrial fishing fleets of ocean fishing countries to exhaust global fishing stocks.
Limitations of class analysis
The limitations of class analysis are not unique to health care but health related instances are significant.
Many important struggles around occupational health have been driven by women who have seen patriarchy as a critical way of framing their struggles around occupational health. The gender axis cannot be simply reduced to class as if patriarchy plays no role in the labour movement.
References
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