by Abby Cartus
There’s a quotation often attributed to Big Bill Haywood, co-founder of the Industrial Workers of the World: “I’ve never read Marx’s Capital, but I have the marks of capital all over me.” Usually considered to be a literal nod to Haywood’s long history of bruising encounters with the shock troops of capital—police and the Pinkertons—paging through Capital: Volume 1 reveals the deeper relevance of these words. It might surprise the casual reader to find the book full of tables showing frequencies and rates of illnesses and mortality as a function of employment in “manufacture,” i.e., the punishing industrial capitalism of mid-1800s England. Are these health consequences—pulmonary illness, lost limbs, infections, premature death—also the marks of capital?
Harvard epidemiologist Dr. Nancy Krieger advanced the concept of “embodiment” to theorize how we incorporate, literally and biologically, the effects of the social, political, and economic formations in which we live. Embodiment is the idea that “our living bodies tell stories about our lives,”1 and those stories reflect our total embeddedness in the grinding experience of American capitalism. A person might embody the repetitive stress of an Amazon warehouse shift in their inflamed joints and tendons, or embody structural racism in the form of housing discrimination, exposing them to mold, dust, and air pollution and causing the bronchial inflammation that leads to asthma. These are the marks of capital; more specifically, of the racial capitalism that has defined the existence of the United States. They spell out a familiar story of injustice, inequity, and misery.
Technically, Timothy Faust’s Health Justice Now is a book in four parts, but conceptually, it has two major concerns. The first, addressed in the first half of the book, is health finance, one of many factors that condition the patterns of health, disease, and suffering in the United States. The second concern, filling the book’s second half, is embodiment: how our sociopolitical arrangements conspire to produce states of health and disease at both the individual and population levels. In this way, Faust first presents detailed examinations of our for-profit health finance system and the “socialized” alternative (federal universal single payer), followed by the structural and social determinants of health. For as much as Health Justice Now is about the machinations of health finance and the details of single-payer, it’s also a book about health as a function of power. It’s a book about a society that makes us sick, then punishes, scams, and profits off of us for it.
The first half, about health finance, is invaluable. Often the discourse around health care subtly collapses the distinction between an immoral system and an irrational one. Faust is careful to emphasize the immorality of the system while stressing its fundamental rationality—it’s rational to the corporations, shareholders, hospital systems, and ultimately individual people who profit from it. The case for single payer is morally obvious, but tangled in a sticky, bewildering web of legislative, procedural, and actuarial detail that Faust explains with deft expertise and compelling humor. Crucially, although the tagline of the book is “Health justice is the goal, single payer is the tool,” Faust understands that an overhaul of the health finance system in the form of single payer is a necessary but not sufficient step towards health justice.
To think this through, consider maternal mortality. At over 17 deaths per 100,000 live births, the United States has far and away the highest maternal mortality rate of any high-income country, and that rate is rising—it has been rising, pretty much uninterrupted, since at least the late 1980s.2,3 Disaggregated by self-reported race/ethnicity, the picture is even grimmer: Black and Native American people are four to five times more likely than white people to die as a consequence of pregnancy2,4,5 and have higher case-fatality rates for the same complications6 than their white counterparts.
Health finance is important here. A high degree of health insurance “churn” around pregnancy and delivery7 is likely at least partially responsible for low utilization of critical prenatal and postpartum care. Around half of all births nationwide are covered by Medicaid,8 which designates pregnant people as “categorically needy” regardless of income level. However, rules vary by state, and Medicaid enrollment can end as soon as 42 days after giving birth. Recognizing that comprehensive postpartum care is critical (many morbidities and deaths, especially those related to cardiovascular dysfunction, occur after birth), the American College of Obstetricians and Gynecologists (ACOG) is pushing a total transformation in postpartum care.9 But vulnerability to ejection from the Medicaid rolls soon after birth poses a significant obstacle to achieving substantial reforms. Single payer, obviously, would improve this situation.
But health finance is only one contributor to the total burden of poor maternal health. Issues of “embodiment”—the stuff of the second half of Health Justice Now—drive the distribution of health and disease in the United States, including the yawning chasm of racial inequity in maternal health outcomes. Evidence suggests that women with higher burdens of “comorbidities” (basically prevalent, coexisting health conditions) are at much, much higher risk of obstetrical complications and pregnancy-related death.10-12 The key to this is embodiment, which is to say the health- and disease-producing consequences of our sociopolitical context. Who is more likely to be sicker going in to pregnancy, who is more likely to experience pregnancy-related morbidity, and who is more likely to die from a complication is patterned by familiar structures like poverty and racism. This injustice is, of course, not limited to pregnancy and birth.
It is a credit to Health Justice Now that Faust is clear about the limits of health financing schemes to achieve what he terms “health justice.” Contra some prevailing sentiments in public health, preventive care is not the solution to the grotesque and cruel incentives of our health finance system. Single payer is. Not all illness is preventable, and there is no excuse for the political inaction on single payer that condemns people to sickness and death, financial burden, exploitation, and misery so that some piece of shit hospital exec can re-tile his pool. But our task is two-fold: not only to achieve single payer, but also to fundamentally transform our entire world so that it does not produce such affliction and distress. There are few precedents in the US for the kind of tectonic shift in the power structure it would take to achieve either objective.
Towards the end of the book, Faust cites a poll indicating that 70% of people in the US are in favor of Medicare for All. This is ostensibly a positive thing, but it also foreshadows just how difficult any fight for single payer, let alone health justice, will be. If Medicare for All is so popular, why are we losing so fucking badly? Faust chronicles a litany of failures to achieve universal health coverage through legislation, and (correctly) situates the best chance of success in a social movement for health justice. However, in her book Health Care for Some: Rights and Rationing in the United States Since 1930, Beatrix Hoffman surveys a long history of social movement agitation for health justice and an equally long history of setbacks and failures, punctuated with some successes by specific groups (the Black Panther Party, ADAPT, ACT-UP) in specific fights.13 This leads to the perhaps regrettable conclusion that health justice is just regular justice, and the way we get it is the same as the way we get any other kind of justice: by grappling with and challenging capitalism and power. It’s no comfort that there’s no special threshold of ghoulish and malicious profit-seeking behavior, or horrifying stories of suffering in the service of shareholder profit, above which the balance of power will tilt in our favor. We’ll have to fight for it, and from what we know about social movements, political and historical conditions must also be favorable, just as we must be prepared to exploit them.
Health Justice Now is a crucial entry into the discourse around healthcare. It’s critical that people come to understand both basic health finance and how our society makes us sick if we want to have even a glancing hope of building a better, healthier, more equitable society. I don’t know how to do that, exactly—I don’t think anybody does—but it’s quite clear that a confrontation with interests that are much richer and more powerful than we are is inevitable. Another, as Reclaim Idaho’s successful campaign to expand Medicaid in their state demonstrates, is that we have to build it together, brick by brick. Every death from insulin rationing, every new mother who dies because she couldn’t afford to return to the ER, every surprise bill, every medical bankruptcy, every health indicator on which the United States lags woefully behind other countries is a fissure in the system that is beating us up just as surely as the police beat Bill Haywood. It’s our job to jam ourselves into those fissures and pry them the fuck open. To throw ourselves upon the gears. The alignment of political and electoral incentives may not always be in our favor, and the path may not always be clear, but we have to be ready and we have to try. Our lives depend on it. ◊
Abby Cartus is a Ph.D. candidate in epidemiology at the University of Pittsburgh. Her research concerns maternal morbidity and mortality in the United States.
Citations
1 Krieger N. Embodiment: a conceptual glossary for epidemiology. J Epidemiol Community Health. 2005;59(5):350-355.
2 Petersen EE, Davis NL, Goodman D, et al. Vital Signs: Pregnancy-Related Deaths, United States, 2011-2015, and Strategies for Prevention, 13 States, 2013-2017. MMWR Morb Mortal Wkly Rep. 2019;68(18):423-429.
3 Creanga AA, Berg CJ, Ko JY, et al. Maternal mortality and morbidity in the United States: where are we now? J Womens Health (Larchmt). 2014;23(1):3-9.
4 Holdt Somer SJ, Sinkey RG, Bryant AS. Epidemiology of racial/ethnic disparities in severe maternal morbidity and mortality. Seminars in perinatology. 2017;41(5):258-265.
5 Creanga AA, Bateman BT, Kuklina EV, Callaghan WM. Racial and ethnic disparities in severe maternal morbidity: a multistate analysis, 2008-2010. Am J Obstet Gynecol. 2014;210(5):435.e431-438.
6 Tucker MJ, Berg CJ, Callaghan WM, Hsia J. The Black-White disparity in pregnancy-related mortality from 5 conditions: differences in prevalence and case-fatality rates. Am J Public Health. 2007;97(2):247-251
7 Daw JR, Hatfield LA, Swartz K, Sommers BD. Women In The United States Experience High Rates Of Coverage ‘Churn’ In Months Before And After Childbirth. Health Aff (Millwood). 2017;36(4):598-606.
8 Markus AR, Andres E, West KD, Garro N, Pellegrini C. Medicaid covered births, 2008 through 2010, in the context of the implementation of health reform. Womens Health Issues. 2013;23(5):e273-280.
9 American College of O, Gynecologists’ Committee on Obstetric P, Association of Women’s Health O, Neonatal N. Committee Opinion No. 666: Optimizing Postpartum Care. Obstet Gynecol. 2016;127(6):e187-192.
10 Bateman BT, Gagne JJ. The Obstetric Comorbidity Index predicts severe maternal morbidity. BJOG. 2015;122(13):1756.
11 Adam K. Pregnancy in Women with Cardiovascular Diseases. Methodist Debakey Cardiovasc J. 2017;13(4):209-215.
12 Admon LK, Winkelman TNA, Heisler M, Dalton VK. Obstetric Outcomes and Delivery-Related Health Care Utilization and Costs Among Pregnant Women With Multiple Chronic Conditions. Prev Chronic Dis. 2018;15:E21.
13 Hoffman B. Health Care for Some: Rights and Rationing in the United States since 1930. Chicago: University of Chicago Press; 2012.
