Modern Capitalism as a Threat to Health

At What Cost: Modern Capitalism and the Future of Health By Nicholas Freudenberg New York, NY: Oxford University Press; 2021 Hardcover: 416 pp.; $29.95 ISBN-10: 0190078626 ISBN-13: 978-0190078621

Nicholas Freudenberg, a professor of public health at the New York City’s public university, has long been insightful about the many ways that society affects health, from HIV infection to incarceration. His previous book, Lethal but Legal,¹ described how corporate practices not only permitted but also promoted consumption that is harmful. In recent years, he has turned his attention to examining how the food system became an important contributor to the avalanche of obesity and a host of other diseases. He helped frame the notion of “corporate determinant” of health and the more commonly used phrase, “commercial determinant,” which add corporate and commercial activity to the list of societal determinants of health. It was at a meeting in Bangkok, Thailand, in early 2019 that I first heard Freudenberg talk about modern capitalism as a root cause of the apocalyptic scenarios that we now face—floods, droughts, fires, frayed safety nets, and the worst pandemic in a century. At the time I thought that in a setting far from home, at a session hosted by the progressive People’s Health Movement,² he felt encouraged to discuss capitalism, which is rarely referenced in the US public health. But Freudenberg has always been outspoken, wherever he is, and, in fact, he was sharing the thinking that we have now in book form.

MODERN US CAPITALISM AS A ROOT CAUSE OF ILL HEALTH

Anyone who cares about health, the environment, our food, dignity, and fairness should read At What Cost: Modern Capitalism and the Future of Health. It is truly a brave survey of a serious topic. In the United States, it takes courage to be critical of capitalism. More than other wealthy nations, the United States has kept alive the notion of the so-called “communist menace” and lurking socialism. Of wealthy countries, only the United States endured the McCarthy period. At What Cost makes a compelling case to extend examination beyond health-harming corporate actions—Big Tobacco, Big Food, Big Pharma, and now Big Tech—to explore the social and economic relations that entrench and enable such behavior. The most important message of this book is that capitalism, particularly the rapacious form of 21st century US capitalism, with its greatly accelerated income inequality, is not inevitable. Our very planet, let alone the people and other living things that inhabit it, depend on controlling a system whose logic is profit.

Modern capitalism is a sweeping topic. The book ably breaks it down into manageable parts, beginning with the distinguishing features of modern capitalism: globalization, financialization, market concentration, privatization, deregulation, tax cuts, and austerity. I was not familiar with the word “financialization.” It refers to the growing dominance of finance over manufacturing. A variety of ways of packaging and moving around money are now a key way of generating profits. Then, to make these interrelated phenomena practically meaningful, Freudenberg shows how they work to affect what he calls the “pillars of health”: food, education, health care, work, transportation, and social connections. There is the rise of ultraprocessed foodstuffs made with ingredients that do not exist in a home kitchen. And there is the emergence of publicly funded, privately managed charter schools; Ubers to skip that subway ride; and gadget-galore medicine. Reading the book, you will see how all trace their logic to these characteristics of capitalism. For example, Uber would like to maintain the use of cars for transportation and take over a chunk of the public transport market. This makes continued car transport, including driverless cars, appealing. But pouring cars onto the streets, leaving it to humans to stay out of the way, seems unlikely to end road carnage and will not end air pollution or consumption of fossil fuels. But only the market is in charge, and no one is “in charge” of the big picture. Through case examples, with clear compelling prose, we see how these abstract concepts manifest in everyday life. Each section ends with how an alternative vision is possible. Drivers organize; teachers strike in defense of childhood.

A FRESH LOOK AT CURRENT CHALLENGES

I learned a lot. For example, New York City’s pioneering 2006 restriction of artificial trans fat in restaurant food eventually led the US Food and Drug Administration to remove these unhealthy fats from our food supply.³ But a consequence was a massive increase in demand for palm oil. Globally, palm oil production has a devastating environmental impact. Likewise, I reflected on the US focus on food components—sugar, salt, fat, calories—as bad actors, whereas Freudenberg highlights how Monteiro et al. from Brazil showed how the food preparation process—ultraprocessing—more than particular components makes for unhealthy food⁴; how tax cuts for wealthy individuals and corporations created the budget shortfalls used to justify budget cuts to social safety nets; and how global trade agreements forced patent restrictions for lifesaving pharmaceuticals on poor nations, protecting private profits, which is now playing out with global access to COVID-19 vaccinations.

I have spent many years thinking about racism in the United States and its impact on health. At What Cost invokes transport apartheid and food apartheid as consequences of the US racial hierarchy. Freudenberg acknowledges Ibram X. Kendi’s image of racism and capitalism as “conjoined twins” with neoliberalism reinforcing US systemic racism. But racism joins the author’s list of challenges—sexism, climate crisis, etc. In contrast, I find racism not only a driver of inequality but also foundational to US capitalism. For this reason, racism deserves a more prominent place than Freudenberg offers in the understanding of US capitalism. Africans were captured and kept in bondage for their labor. The purpose of racism is not to make Black people miserable; it is exploitation. The embrace of White supremacy is all I can find to explain why such a large slice of the White working class chooses class collaboration over class solidarity. Much of the failure to challenge modern capitalism has foundered on reluctance to acknowledge this actual history of the United States: a country that began as a settler colony and procured land through genocidal campaigns against the people whom the Europeans found here. Enslaved people then worked this land. This profitable, bloodstained enterprise catapulted the United States into the ranks of wealthy nations and helped establish the brand of capitalism we have today.

The usual argument is that poor and working-class White people have been misled by racism, which causes them to overlook their own exploitation and instead blame their problems on Black people. Furthermore, it is the failure to make compelling the “racism harms everyone” argument that permits this misunderstanding to persist. I have heard this rationale for many, many years. If White people understood that everyone can win, and no one has to lose, we would have a different politics. Heather McGhee’s The Sum of Us eloquently makes this case.⁵ The costs of our contemporary brand of capitalism are all around us. The United States departed from the upward life expectancy trajectory of other wealthy nations around 1980, and 2015 marked a decline that the COVID-19 pandemic has accelerated.^6,7 The recent Lancet Commission on Public Policy in the Trump Era showed that had the United States’ trajectory of life expectancy increase remained in the middle of the pack of G7 nations (which also includes Canada, France, Germany, Italy, Japan, and the United Kingdom), more than 450 000 total deaths would not have occurred.⁶ Not since 1964 has the majority of White voters voted for a Democrat for president. Is this narrative of “being misled” accurate? Or, as Isabel Wilkerson suggests in Caste: The Origins of Our Discontent, does the “long game” indeed favor White racial solidarity?⁸ Kendi’s “conjoined twins” tells the truth because, in the United States, racism and capitalism share the same heart.

A White choice for solidarity was on display in the global outpouring following the police murder of George Floyd. My daughter recounted a protest in New Orleans, Louisiana, where thousands in a multiracial group marched through the city and adjoining areas. The group approached a parish once known as a “sundown” parish, meaning no Black people allowed after sundown, where police in military attire stood in the street. The march leaders, mostly young people of color, called out on bullhorns: “White people to the front.” I will not forget the awe in my daughter’s voice as she said, “And Mom, they went.” There have been Whites who died for Black rights over many generations, but this felt different.

Freudenberg ends by making plain that although better technology is often credited, health advancements most importantly are attributable to social movements that improve overall living conditions. The book does not take responsibility for crafting a path to undoing modern capitalism, but invokes the role of social activism and calls for public health to align itself with a large array of diverse social movements. In 2015, it felt brave to talk about racism.⁹ At What Cost tells us that now it is time to be brave and talk about capitalism. Freudenberg has good company. Thomas Piketty’s Capital became a bestseller¹⁰; Case and Deaton titled their bestselling book Deaths of Despair and the Future of Capitalism.¹¹ I suspect that a conversation about capitalism also will take us to one about racism.