medicina al final del imperio

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Social Medicine ( www.socialmedicine.info ) - 1 - Volume 7, Number 1, December 2012

Matthew R. AndersonDepartment of Family and Social Medicine, MontefioreMedical Center, Albert Einstein School of Medicine,Bronx, New York 10467, USAEmail: [email protected]

EDITORIAL

Howard Waitzkins Medicine and Public Health

at the End of Empire Matthew Anderson, MD, MS

I first heard Howard Waitzkins thesis that UScapitalism as we have known it has ended, and em-

pire in its previous form has ended at the Interna-tional Association of Health Policy in Europe(IAPHE) conference in Ankara, Turkey on Sunday,October 2, 2011. I must admit I was skeptical ofthese ideas. Certainly, only the previous year theObama administration had stepped in to massivelysubsidize the US financial sector and take over twomajor US automobile manufacturers; this clearlyhad nothing to do with the declared rules of a capi-talist economy. However, public subsidization of

private enterprises has been common throughout UShistory. True, there was evidence that the US empirehas been weakened, yet were we not still involved ina massive war on terror that seemed to have no dis-cernible end? Was it really time to speak of an endof capitalism and empire?

But three days later I found myself standing inFoley Square in Manhattan in the midst of a massiveOccupy Wall Street demonstration. Around me werethousands of people including many union mem-

bers. There were two large contingents of physicianactivists as well as hundreds of nurses participatingwith their unions. People were talking about issues income inequality, racism, imperialism, prosecutionof Wall Street crimes that had been completelyswept off the table by the corporate media in the US.On this beautiful fall afternoon, it seemed that an-other world one free of capitalism and empire might in fact be possible.

The success of the Occupy movement drew meto read and, indeed, to study Medicine and Public

Health at the End of Empire . In this editorial, I will briefly describe the book and then address the impli-cations of the books closing challenge of how todevelop strategies for activism that can extend counter-hegemonic spaces to broader socialchange.

Empire Past, Present and Future The title of Waitzkins book suggests that it is

about the current state of medicine and publichealth. However, the book is divided into three sec-tions: Empire Past, Empire Present, and Em-

pire Future, and its 189 pages cover a vast amountof material stretching from the origins of socialmedicine in the Industrial Revolution right up to theObama health care reform bill.

It is unfortunate that we do not really have atextbook of social medicine available in English.The three-volume University of North CarolinaSocial Medicine Reader has been available for someyears, but it is only a reader. Fortunately, in assem-

bling his five decades of work in social medicineinto one volume, Waitzkin offers us something veryclose to a social medicine textbook. It is certainlythe best introduction to the field in English.

The book is particularly strong in its examinationof the underlying economic and political forces thatdrive the development of corporate medicine. Chap-ter 2 traces how academic medical centers, philan-thropies (such as the American Heart Association),

powerful corporations (such as American Opticaland Hewlett-Packard), and the government (includ-ing the US Department of Commerce and the USPublic Health Service) collaborated to promote theestablishment of coronary care units (CCUs) in the


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1960s and 1970s. Such units were not demon- strably more effective than simple rest at home andWaitzkin attributes their development and promo-tion to the imperative of corporations to maximize

profits. As the market for existing medical equip-ment matures (i.e., becomes less profitable due tocompetition), corporations are obliged to createmarkets for new goods. Whether or not the newtechnology is actually useful is not really a concernfor the corporations. This, it should be noted, is nota problem that can really be fixed. It is inherent inthe structure of a capitalist economy.

This story is repeated in the 1990s with the in-troduction of for-profit managed care. Again, similaractors academic medicine, philanthropies, profes-sional organizations, government, corporations (inthis case health insurance companies like Aetna andCIGNA) aligned to promote for-profit managedcare, a health systems intervention that had not beenshown to provide superior clinical or economic out-comes. As had occurred with CCU technology,when the US market for HMOs became saturated,the companies tried to tap into the vast Latin Ameri-can social security funds by marketing the virtues oftheir brand of managed care. The mess that resultedfrom the neoliberal dismemberment of public healthsystems in Latin America has been well documentedin the pages of this journal.

It is refreshing that Waitzkin pulls away the cur-tain and exposes the true driver of health policy:

profit maximization. Corporations are driven by theneed to maximize profits regardless of health conse-quences. Let us not forget that tobacco companiesmake a product that eventually kills their customers.This should give us pause when we hear that weneed more business thinking in the organization ofhealth care services.

The importance of Latin American Social Medi-cine (LASM) is emphasized throughout the book.LASM has provided inspiring examples of activism

both inside and outside government. In the early2000s Mexico Citys progressive mayor, AndrsManuel Lpez Obrador, successfully opposed theneoliberal health policies of President Vicente Foxand set up a variety of programs to address the so-cial and health needs of the citys poorest inhabit-ants (See our interview with Dr. Asa Cristina Lau-

rell in Social Medicine Volume 2, Number 1). Dur-ing the same period Salvadoran health workers suc-cessfully mobilized to oppose the privatization oftheir health care system (as described on page 172of End of Empire and in Mauricio Torres contribu-tion in this issue). LASM has also provided us witha sophisticated critique of neoliberal health policy.Waitzkin points to the emphasis on theory inLASM, noting:

Practitioners of social medicine have arguedthat a lack of explicitly stated theory in North

American and European medicine and publichealth does not signify an absence of theory.

Instead, an atheoretical or antitheoretical stance means that the underlying theory re-mains implicit, subtly supporting the status

quo and dominant groups in society.Thus, the pro-ruling class basis of US medicine

is hidden behind a veil of an allegedly value-neutral science.

Finally, Waitzkins day-to-day work as a clini-cian is not absent from this book. Chapter 12 is de-voted to Militarism, Empire, and Health and de-scribes the Civilian Medical Resources Network, anorganization created by Waitzkin (among others) tocare for active duty US military personnel withhealth problems not addressed by the military health

care system. This is an outstanding example of howactivism can inform and be informed by clinical

practice and is in the best tradition of the engagedclinical medicine that characterizes much of socialmedicine.

End of Empire? Waitzkin devotes the last section of the book to

the argument that US capitalism and empire in their previous forms have ended. He points to multiplesetbacks for US imperialism including the success-

ful opposition to the Free Trade Agreement of theAmericas (FTAA), the US inability to dominate theWorld Trade Organization, and the rise of progres-sive governments in Latin America. He also citesthe ever-controversial Lenin who described themoribund nature of advanced capitalism and itstendency toward war and financial crisis.


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What then is the way forward for socio-medicalactivism in helping to create a post-empire world?Waitzkin, like many others, points out the failure oftraditional political structures. Public policy is in-creasingly dictated by an unelected transnationalstate (embodied in organizations like the WTO andthe World Bank) that is subject to the dictates ofcorporate interests. When, for example, AnneVeneman moves from leading the United NationsChildrens Fund in 2010 to the Nestl Board of Di-rectors in 2011, she illustrates the revolving door

between public institutions and private corporations.In the US, the two major political parties are nomi-nally subject to democratic elections; in reality, bothare firmly in the pockets of the large corporationsand have been unable to address the needs of the

people. The union movement has been largely dev-astated; only some 7% of non-state workers in theUS currently participate in unions. While unions areclearly vital to any progressive change, they are notin a position to fundamentally challenge the rulersalone.

The traditional political structures have failed usand there is widespread discontent. The vehicle forthis discontent has fallen on civil society, asomewhat nebulous entity. Certainly, civil societycan play a radical role, as we have seen in the caseof the Occupy movement. But it can easily play aconservative role by mollifying discontent through

various state-funded welfare initiatives. There is noobvious litmus test to decide what is the right rolefor civil society.

One vision of the Occupy movement is to createan alternative power structure on a local levelthrough spaces (Zuccotti Park was one until its oc-cupiers were brutally evicted by the police) wherethe dominant rules do not apply and an alternativevision is in constant process of invention and rein-vention. This radical vision calls for spaces mentaland physical where, in the words of Waitzkin,empire becomes demystified and unacceptable.This is clearly one potential opened for us by Occu-

pations. The challenge, as enunciated by Waitzkin,is to move beyond isolated spaces and isolatedstruggles. This is very much on the agenda of activ-ists who are trying to create alliances among thevarious Occupations.

The struggle for a post-capitalist society has beenongoing since at least the early 1800s and currentactivism in the Occupy movement is one chapter inthat much larger history. A careful reading ofWaitzkins book helps situate our activity withinthat broader context. Waitzkin challenges us to becreative in fostering a vision of medicine and pub-lic health constructed around principles of justicerather than commodification and profitability. Thiswill require reinventing democracy in our 21st-century world.

medicina al final del imperio

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