The Political Economy of Health: Revisiting Its Marxian Origins to Address 21st-Century Health Inequalities

Abstract

The “political economy of health” is concerned with how political and economic domains interact and shape individual and population health outcomes. However, the term is variously defined in the public health, medical, and social science literatures.

This could result in confusion about the term and its associated tradition, thereby constituting a barrier to its application in public health research and practice.

To address these issues, I survey the political economy of health tradition, clarify its specifically Marxian theoretical legacy, and discuss its relevance to understanding and addressing public health issues. I conclude by discussing the benefits of employing critical theories of race and racism with Marxian political economy to better understand the roles of class exploitation and racial oppression in epidemiological patterning.

The term “political economy” has been variously defined since it was first used in the 17th century and then subsequently by classical economists and political theorists such as Adam Smith, David Ricardo, and Thomas Malthus. It refers to “the combined and interacting effects of economic and political structures or processes, and by extension, to the scholarly study of this domain.”^1(p181) It is premised on the idea that “politics and the economy cannot be separated. Politics both creates and shapes the economy. In turn, politics is profoundly shaped by economic relations and economic power.”² Those researching political economy therefore investigate “the relation of politics to the economy, understanding that the economy is always already political in both its origins and its consequences.”^3(p1792) Traditional objects of analysis in political economy include production (how a society organizes the production of goods and services and the generation of wealth—and under what conditions), distribution (how a society distributes these resources), and consumption (what goods and services a society makes available and to which of its members).

The study of political economy developed alongside the emergence of a novel political–economic system: capitalism. This system is characterized by the private ownership of capital goods or “the means of production”—that is, the things used to produce the goods and services needed for human subsistence, such as factories, machinery, buildings, land, and raw materials—by capitalists or the capitalist class. To survive, the working class is compelled to seek employment from the capitalist class in the companies they own. This employment entails engaging the means of production to produce goods and services that are then sold for a profit on the market as commodities. Some portion of the profits are distributed to the workers as wages, and the remainder is retained by the company, to be either reinvested or kept by the capitalist owners as increased wealth.

Over time, the study of the capitalist political–economic system expanded to consider the “varieties of capitalism”^4,5 that subsequently developed—such as welfare state capitalism, in which a system of capitalist production coexists with various social protections (e.g., access to education, health care, housing, jobs, unemployment insurance, pensions)—as well as competing political–economic systems, such as social democracy, socialism, and communism. In broad terms, these latter systems are characterized by degrees of public—rather than private—control of capital goods by workers, the state, or otherwise democratic institutions; production decisions that are driven by social needs, rather than the realization of profit; and a commitment to expansive social protections and equality. However, as history has shown, “actually existing” capitalist, socialist, and communist systems often diverge significantly from these attributes—and both characterizing and distinguishing among these systems has been the topic of intense, centuries-long debate.

The study of political economy therefore commonly centers on political–economic systems—or the different ways of organizing political and economic life and the impact of this organization on the aforementioned domains of production, distribution, and consumption. These systems encompass the organization of the production process (i.e., ownership and control of the means of production—i.e., capital) and the associated conditions of the production process (i.e., working conditions), the distribution of economic resources (i.e., inequality), and the degree of access to social protections (i.e., the social or welfare state). In broad terms, the “political economy of health” refers to the extension of the study of political economy and political–economic systems into the domain of health to explore the relationship among these topics and changing epidemiological distributions over time. The connections between political economy and health are very well characterized in the historical public health literature, even going back centuries.^6–10

Today there is a renewed interest in political economy in the academy, with a number of centers devoted to the topic recently established at high-profile US universities (e.g., University of California, Berkeley’s Network for a New Political Economy; Stanford University’s Moral Political Economy Project; and the Law and Political Economy Project, which began at Yale University). Interest in political economy is also reflected in the field of public health, where there is widespread concern about the health consequences of an economy increasingly characterized by low-wage, precarious employment, ever-expanding inequality, and a political process that is unduly influenced by corporations and the wealthy.¹¹

However, despite the relevance of the political economy of health to understanding and addressing contemporary health inequalities, it is not widely referenced in the public health or medical literature. When political economy is invoked in the literature, it is not always explicitly defined.¹² In those instances when it is defined, no standard definition is evident. This is especially problematic because various theoretical traditions that employ the term “political economy”—such as Keynesian, neoclassical, neoliberal, institutional, rational choice, and Marxian—approach questions of political economy in often widely discrepant ways.^1,13 The following sections provide a survey of the specifically Marxian political economy of health tradition by clarifying its historical origins and reviewing contemporary definitions of the term.

HISTORY OF THE POLITICAL ECONOMY OF HEALTH

When the term “political economy of health” emerged in the 1970s, political economy commonly referred to a broadly Marxian approach to social scientific analysis.^14–17 The political economy of health is therefore most closely associated with the works of Karl Marx, Friedrich Engels, and the Marxian theoretical tradition,^18–20 even if this legacy is more often implied than stated outright in the public health literature. Early works in the political economy of health by Waitzkin and Waterman,²¹ Navarro,²² Doyal and Pennell,²³ Laurell²⁴ and Breilh Paz y Miño²⁵—as well as special eds on the topic²⁶—are situated explicitly in the Marxian tradition, incorporating concepts, theories, and problematics developed or emphasized by Marx and Engels, such as class and class struggle, material inequality, exploitation, profit or capital accumulation, working conditions, the organization of production, and global imperialism and underdevelopment.

Despite the centrality of Marx, the origin of the political economy of health is commonly traced to Marx’s long-time collaborator, Friedrich Engels and his book The Condition of the Working Class in England.^7,27 In that work, Engels explored the health effects of the development of industrial capitalism on workers and their families in Manchester, England. Through a long-term, ethnographic engagement in the town, Engels shows how social and working conditions produced by this new industrial form of capitalist political economy resulted in widespread suffering and premature death among workers, while producing untold wealth for the capitalist class who owned the factories. More than 200 years later, the influential Black Report echoed Engels’s insights in stating that many health inequalities in the United Kingdom can be seen as “consequences of the class structure: poverty, working conditions, and deprivation in its various forms.”^28(p334)

Engels wrote of learning from the workers about the concept of “social murder,” which the workers used to refer to how their social and working environments put them and their families “under conditions in which they can neither retain health nor live long . . . [and] hurries them to the grave before their time.”^7(p107) Engels sympathized with the workers and noted, “Society knows how injurious such conditions are to the health and the life of the workers, and yet does nothing to improve these conditions.”^7(p107) Although Marx’s principal concern was not with the relationship between human health and capitalism, Engels’s book profoundly shaped Marx’s thinking. David McLellan, a prominent historian of Marx, calls the book “the foundation document of what was to become the Marxian socialist tradition.”^7(pxix–xx) Richard Horton, the editor of the Lancet, even claims, “Public health was the midwife of Marxism,”^29(p2026) as Engels’s ethnographic descriptions of socially produced disease among English and immigrant Irish workers in Manchester provided Marx with important insights into the nature of production, exploitation, and suffering under the capitalist political–economic system.

The origins of the political economy of health are also associated with the 19th-century European and 20th-century Latin American social medicine traditions—and the works of Rudolf Virchow and Salvador Allende.^30,31 Virchow, a 19th-century physician whose name today is commonly associated with discoveries in the area of cellular pathology, read Engels’s 1845 work. Like Engels, Virchow wrote about the material conditions in which disease manifested and how political and economic forces prevented social reforms aimed at alleviating poverty, food insecurity, and harsh labor conditions among the poor and working classes.^32(p111)

Virchow wrote that biomedical and public health interventions among these classes would always fail if they did not challenge upper-class political power and capitalism’s economic exigencies, which together produced the social conditions that were fundamentally responsible for health inequalities. Virchow’s famous dictum, “Medicine is a social science, and politics nothing but medicine on a grand scale,”^33(p548) conveys his belief that acting in the political domain should be central to the practice of a reformed medicine that is based in the social sciences, rather than narrowly in biomedicine.

Another prominent figure in the genealogy of the political economy of health is Salvador Allende, Chile’s first democratically elected socialist president. During his medical training, Allende received instruction from former students of Virchow who had emigrated from Germany to Chile. As the Chilean minister of health, Allende penned the report, “The Chilean Socio-Medical Reality,” which—in the spirit of writings by Virchow and Engels—identified the organization of labor and the working and living conditions of the working class as responsible for its outsized disease burdens.

One of Allende’s unique contributions to the social medicine tradition was his interrogation of exploitative international economic relations shaped by wealthy countries and imposed on poorer ones, first under slavery and colonialism and subsequently under various forms of corporate, political, and economic neocolonialism.^{32(p113–117)} Allende became a prophet of his own future, as his reforms to counter neocolonialism and improve the conditions of the poor and working classes in Chile engendered a coup d’etat in 1973 that was initiated by the Chilean upper class and assisted by the US Central Intelligence Agency, which was eager to see a popular, democratically elected socialist leader deposed, especially during the height of the Cold War.³⁴

CONTEMPORARY DEFINITIONS

As with the term “political economy,” the “political economy of health” is also variously defined. Importantly, many scholars who use the term are not drawing principally on its Marxian legacy as I have described.^35,36 Among scholars working specifically in the Marxian tradition, a generally shared understanding of the political economy of health emerges from surveying their definitions of the term. I consider a number of these definitions.

Raphael and Bryant state that the political economy of health posits that “how a society produces and distributes societal resources among its population” is an important determinant of population health. They write that the issues considered by this perspective are “the production and distribution of wealth,” “issues of capital accumulation and the organization of labor,” and “the extent to which society relies on state control of the distribution of resources versus market control of such activities.”^37(p238) Elsewhere, Raphael³⁸ writes about political economy in terms of economic and political systems that distribute resources based on the relative levels of power that different individuals and entities are able to exert in society. For instance, powerful organizations, such as transnational corporations, are able to shape policy to their benefit, whereas a disempowered, nonunionized working class cannot. This power imbalance, and the corporate-friendly policies such an imbalance gives rise to, ultimately results in an upward redistribution of wealth, increased inequality, and diminished population health outcomes.

Krieger writes:

The underlying hypothesis [of the political economy of health] is that economic and political institutions and decisions that create, enforce, and perpetuate economic and social privilege and inequality are root—or “fundamental”—causes of social inequalities in health.^39(p670)

and

At issue are priorities of capital accumulation and their enforcement by the state, so that the few can stay rich (or become richer) while the many are poor—whether referring to nations or to classes within a specified country.^39(p670)

According to the political economy of health:

Core questions include: how does prioritizing capital accumulation over human need affect health, as evinced through injurious work-place organization and exposure to occupational hazards, inadequate pay scales, profligate pollution, and rampant commodification of virtually every human activity, need, and desire?^39(p670)

Krieger also writes that the political economy of health is “predominantly concerned with how capitalist political–economic systems’ imperative to maximize profit harms health.”^40(p178) Although Krieger echoes the role of inequitable, elite-captured institutions in perpetuating inequality, she also specifically indicates the role of capitalism and its requirement for profit maximization, which occurs at the expense of human health.

Baer writes that the political economy of health “is in essence a critical endeavor which attempts to understand health-related issues in the context of the class and imperialist relations inherent in the capitalist world-system.”^18(p1) Baer divides the political economy of health between “the political economy of illness” and “the political economy of health care.” The former refers to the study of how illness is socially produced by the capitalist political–economic system and the latter

is concerned with the impact that the capitalist mode of production has on the production, distribution, and consumption of health services and how these processes reflect the class relations of the larger societies in which medical institutions are embedded.^18(p2)

Here, Baer expands the conceptual remit of the political economy of health to include class relations, the organization of production, imperialism, and global capitalism (as a “world system”).

According to Birn et al., the political economy of health perspective views health

in terms of the nature of power relations and control over resources, their implications for social inequalities, and the institutions that challenge or reinforce the distribution of power and resources at local, national, and international levels.^30(p13)

Although scholars of political economy discuss the importance of social relations along intersecting axes of race, ethnicity, sex, gender, sexuality, ability, citizenship, and nationality in shaping power relations and the distribution of resources, they commonly emphasize the role of class and the political struggle between owners of capital (i.e., the capitalist class) and the working class in shaping these power relations. The balance of power in this class struggle in turn shapes the character of the political–economic system, which in turn shapes the extent of social—and health—inequality.³⁰

From this perspective, when members of the working class are organized and thereby empowered, they can translate their material interests into social and political change, which results in transformation of the political–economic system.⁴¹ For example, working-class movements have established redistributive, universal social welfare systems in the areas of health care and education, occupational safety standards, minimum wage laws, guaranteed vacation, family and medical leave policy, and guaranteed pensions in old age. They have won legal protections for workers’ rights and for the civil rights of women, racial and ethnic groups, and gender and sexual minorities. Working-class movements were also central to 20th-century decolonization, as exemplified by the work of Nelson Mandela and the African National Congress.

Working-class empowerment is accomplished through actions such as political organizing; increasing union density; labor agitation, such as taking part in labor strikes; and engaging in broad-based social movements against exploitation, oppression, hierarchy, and injustice. Some engage in electoral politics to achieve formal representation of working-class interests in the political sphere. These actions often incorporate feminist, antiracist, immigrant, LGBTQI (lesbian, gay, bisexual, transgender, questioning [or queer], intersex), and disability rights frameworks and goals out of a recognition that historically marginalized and oppressed people often face outsized material deprivation and compounded forms of discrimination and exploitation in the workplace and society writ large.

Although an empowered working class can exact concessions from the capitalist class and the state in the form of higher wages, social protections, and redistributive taxation policy, some advocate moving beyond simply a more robust welfare state and expansive social protections and embracing alternative political–economic systems altogether, such as socialism.⁴² This entails extending democratic control beyond the political sphere and into the economic sphere and the workplace, which are currently controlled by corporations, their capitalist owners, and the upper tiers of management and which are organized according to profit making and competition in the market rather than worker or societal well-being. Economic decisions about what to produce, how to produce it, and how to distribute those products would—at least in part—be driven by questions of social need and distributional justice, rather than commodity exchange and profit maximization. In this way, such alternative political–economic systems may overcome the contradiction between capitalism and health and result in more equitable health outcomes.

As this review demonstrates, Marxian political economy of health is concerned with a set of issues that fall broadly in a leftist political imaginary inspired by the Marxian tradition. The role of economic inequalities and class stratification is prominent. Many of these definitions emphasize social structures, institutions, and public policy as well as their role in exacerbating or ameliorating economic and health inequalities—often along the social axis of class but also along axes of sex, gender, race, ethnicity, nationality, and citizenship status. Additionally, the relationship between the capitalist class (i.e., the capital-owning class, the upper class, or—more colloquially following the Occupy Movement—“the 1%”) and the working class is framed as central to understanding these inequalities and the political–economic systems from which they arise. An empowered working class that is committed to social justice can realize universal economic, social, political, and civil rights, while limiting the influence of the capitalist class and their corporations in society.

Many definitions discuss the contradictions between structural aspects of capitalism—principally the imperative of capitalists to accumulate ever more capital by maximizing the profit of their corporations—and population health outcomes. In this way, these definitions echo sentiments expressed in volume 1 of Capital, where Marx writes:

Capital therefore takes no account of the health and the length of life of the worker, unless society forces it to do so. Its answer to the outcry about the physical and mental degradation, the premature death, the torture of over-work, is this: Should that pain trouble us, since it increases our pleasure (profit)? But looking at these things as a whole, it is evident that this does not depend on the will, either good or bad, of the individual capitalist. Under free competition, the immanent laws of capitalist production confront the individual capitalist as a coercive force external to him.^43(p381)&&&

For Marx, disease and injury among the working class under capitalism is not simply the result of unscrupulous business owners but rather of an imperative of the system itself: capitalists must maximize their profit in order to compete with other capitalists. Efforts to maximize profit can take various forms—for example, suppressing worker pay, increasing worker productivity, flexibilizing the workforce, lobbying for regressive taxation policies and fewer publicly funded social protections, dismantling corporate regulations, relocating jobs to countries with fewer regulations and lower labor costs, and commodifying what were previously public domains of life, such as energy, transportation, education, and health care systems. In recent decades, the intensification of these practices has come to be referred to as “neoliberalism,” which some argue characterizes contemporary global capitalism.

TOWARD A RACIAL POLITICAL ECONOMY OF HEALTH

This call for renewed attention to the political economy of health and Marxian theory is occurring simultaneously with the development of other important social theories in public health.^40,44 In recent years, theories of racism, racialization, and intersectionality and the traditions of Black radicalism, Black feminism, and critical race theory have provided important insights into the causes of racial health inequities, particularly in the United States.^45–49 Rather than repeat timeworn—and often crudely reductionist—debates over “race versus class”^50,51 or the relative merits of centering the role of capitalism or racism in explaining health inequalities, public health scholars should synthesize perspectives on racism and racial oppression with those on capitalism and labor exploitation.

In the Marxian tradition, attempts to explain the relationship between capitalism and racism constitute a rich and longstanding literature.^52–62 Marx himself addressed the relationship at some length, incorporating it into the history of European colonialism and imperialism.⁶³ Although Engels explored the impact of industrial capitalism on the social conditions and health of the English and Irish working classes, Marx situated England’s political economy firmly in a global racial political economy defined by colonialism and the Atlantic slavery system:

Without slavery you have no cotton; without cotton you have no modern industry. It is slavery that gave the colonies their value; it is the colonies that created world trade, and it is world trade that is the precondition of large-scale industry.⁶⁴

Marx’s work challenging racial oppression extended well beyond analysis to his steadfast support of President Lincoln and the Union Army during the American Civil War and his involvement in the abolitionist movement in Britain. For Marx, the emancipation of enslaved people was both a matter of justice and a fundamental precondition to the broader unification of the working class in their fight against capitalism.⁶⁵

From a Marxist perspective, racism serves a number of different purposes for the capitalist class.⁶¹ Importantly, it acts as a barrier to working-class solidarity and empowerment by cleaving the class along racial lines. Animosity between workers on account of racism undermines their ability to develop a shared vision and project for realizing their otherwise shared interests. Through this cleavage, the capitalist class facilitates worker exploitation. A divided working class is unable to build sufficient power to realize higher wages, safer working conditions, and broader social protections, for example, or to pursue alternative political–economic systems. This division results in higher profits accruing to the capitalist class. Moreover, it facilitates the hyperexploitation of the oppressed subclass of racialized workers, who do not—on average—enjoy the same benefits as the rest of the working class. They work for even lower wages, for longer hours, and with even fewer workplace and social protections. Finally, racism entails racist ideology, the purpose of which is to rationalize and thereby justify racial hierarchy, often through claims of biological, behavioral, cultural, or moral inferiority among the racialized subclass. Such ideology also serves to obscure capitalism’s failings by directing popular anger and frustration away from the workings of an unjust political–economic system and toward spurious social and moral pathologies of the racialized subclasses.

Similar ideas were recently expressed by Thomas LaVeist during the closing general session of the 2019 American Public Health Association conference, 1619–2019: Health and Justice Denied, when he stated, “I would go as far as to say, the ideology, White supremacist ideology, racism, is in service to the capitalism, because it’s really all about exploiting labor and how do you position yourself to be able to exploit the labor.”⁶⁶ Deepening this engagement between theories of racism and Marxian theories of political economy is a promising approach to investigating and addressing imbricated race- and class-based health inequalities—as well as the systems that produce them—in the United States and globally. Indeed, recent work in public health takes up the generative concept of “racial capitalism”^67–69 in relation to health inequalities.^49,70,71

CONCLUSIONS

Although there have been important additions to scholarship on the political economy of health in the past decade,^40,72–79 it is not a mainstream area of public health research or practice. I have reviewed the political economy of health literature, clarified its specifically Marxian legacy, surveyed contemporary definitions, and discussed its relevance to understanding and addressing pressing public health issues. The political economy of health is necessary for explaining and addressing persistent health inequalities and emerging public health crises under global capitalism, a political–economic system that shapes nearly all aspects of our lives but that attracts relatively little attention in the field of public health. If public health is to fully engage with the structural determinants of health and the system that produces them, the political economy of health will have to move from the field’s margins to the mainstream.