Health care professionals, medical students, and students of public health are increasingly aware of the “social determinants of health.” Everyone has begun to realize that poverty is the most important cause of illness. Too often, however, the analysis stops there, instead of asking what the root cause of poverty is, the question is: what causes those “social determinants”? Why do resources remain unequally distributed, why cannot everyone access the same quality of health care? Addressing only “social determinants” conveniently avoids discussing their causes in the global politico-economic system and the structural violence used to preserve that system. Poverty results from neoliberal capitalism, and together with climate catastrophe and nuclear war, constitute existential threats to the survival of the human species, as identified by Noam Chomsky. We all find ourselves, not as we have ourselves chosen, participating in the current unsustainable organization of the material forces of production, the real foundation of our societies and their ills. As Marx clearly identified: “these relations of production constitute the economic structure of society, the real foundation, on which arises a legal and political superstructure, and to which correspond definite forms of social consciousness.” Unless we can change the way that these forces of production have compelled us to participate in unjust systems, and unless we lay the foundations for new forms of social consciousness, we face the collapse of our civilization. Globally, health and health delivery systems are in crisis. Deteriorating social, political, economic, and environmental conditions in developing states lead to pollution, conflict, famine, population displacement, and a catastrophic loss of biodiversity. Sea-level rise and tropical cyclones threaten the very existence of island states and the poor and marginalized who live in inadequate dwellings in low-lying areas. Despite reduction of infant mortality and the extension of life-spans, the promise of improved health recedes. The poor and marginalized continue to suffer from tuberculosis, malaria, HIV, cholera, dengue, and Ebola — as antimicrobial resistance increases and vaccination refusal results in a resurgence of preventable diseases. Populations everywhere have rising rates of chronic noncommunicable diseases. Incremental reforms will not mitigate these existential threats. We cannot eliminate these threats unless we reorganize the fundamental basis of our economic and social life and eliminate capitalism. This situation demands of us that we adopt revolutionary thinking and revolutionary practice. Revolutionary Medicine Throughout history, empires have flourished and collapsed without threatening the existence of the entire human population. Epidemics typically had limited geographic distribution. Neither scenario fits the world today. As Marx noted: “The philosophers have only interpreted the world, in various ways; the point is to change it.” The practitioner of revolutionary medicine must think not reductively, but rather dialectically. A man’s decision to smoke may increase his risk of heart disease and cancer in the long run. But as one of the few ways he has of coping with stress, it may save the lives of his wife and children. Our assumption of conditional rationality means that we cannot expect to change behavior by education alone: rather, we must alter those circumstances that make such harmful choices seem optimal. From the individualist perspective, we might say in the name of harm reduction, “Go ahead and smoke.” From the revolutionary perspective, we need to work with the man, the woman, their workplaces, and their societies to combat alienation, addictions, and violence against women and children. Revolutionary medicine is the medicine wherein health workers understand the social origins of illness and the need for social change to improve health conditions. It is created from the practice of the people’s struggles against their oppressive conditions. Revolutionary medicine serves the oppressed classes in advancing their struggles. Proletarianization. Health workers toil harder and longer to accomplish increasingly complex patient care and administrative burdens. Corporations demand adherence to specific formularies and prior authorizations – only to deny treatments. Employers escalate their documentation demands in a coding arms race with insurers. Is this exploitation of health workers simply the business plan of the corporate health care system? In Marx’s labor theory of value, the difference between the market price of a good — and the cost, largely labor, of producing the good — is the profit margin, the surplus labor that is extracted from the worker. Commodified medicine leads to the proletarianization of health workers. We find ourselves alienated from our patients, the products of our labor (better health for patients), and our workplace. Consequently, we become alienated from our fellow workers and, ultimately, from ourselves, from our own humanity. Health worker alienation, often termed “burnout,” is actually “moral injury.” Health, as a commodity, damages the health of patients and causes the entire society to be ill, diseased. Class-conscious solidarity among health workers will ensure that health is recognized as a human right, that surplus labor should not be extracted for profit, but rather used by workers to ensure the health of their communities. In the future, digital algorithms might take over-diagnosis and “curing,” allowing health care workers to focus on “healing.” In a capitalist society, the division of labor forces each worker to perform a particular task repetitively … while in communist society, where nobody has one exclusive sphere of activity, but each can become accomplished in any branch he wishes, society regulates the general production and thus makes it possible for me to do one thing today and another tomorrow, to hunt in the morning, fish in the afternoon, rear cattle in the evening, criticize after dinner … without ever becoming hunter, fisherman, herdsman or critic. The post-revolutionary health worker will be a global citizen, helping to create cohesive, equitable, socially just societies that address health everywhere. Otherwise, all of us face increasing threats to our own health and well-being. Revolutionary medicine is required to create such a society. Seiji Yamada is a family physician. Arcelita Imasa is a family medicine resident. Gregory Maskarinec is an anthropologist. Source
