The Health Care Debate: Social Reflections

Friday, 29 October 2010 12:21 By Richard Lichtman, t r u t h o u t | Op-Ed | name.

The Health Care Debate: Social Reflections
(Photo: Pete Souza /

In a recent Nation magazine forum in which participants responded to Eric Alterman's account of the structures that bind the political possibilities of the Obama administration ("Why a Progressive Presidency is Impossible for Now") and that articulated Alterman's notion that "the system is rigged ... against us," Theda Skocpol rebutted his "wrongheaded" assertion with her own judgment that, among other triumphs, Obama and "his unwieldy party.... achieved comprehensive healthcare reforms that are the most far-reaching and economically redistributive social accomplishments since the New Deal."(1)

I will forgo the seductive temptation to compare the first years of the Obama administration with the similar period of The New Deal and turn to a different but more fundamental issue. One of the profound consequences of the recent "healthcare reforms" is the fact that they were at most reforms, and this means quite simply that the measures passed further institutionalized the ultimate control of health by private corporations. That is the ultimate political and ideological significance of "reform"; a change in content and a further strengthening of the ultimate structures through which these changing contents take place. Since the government has for most of the past century exerted some control over the nature of health care, this fact alone is not a far-reaching change. The only question that was permitted entry into debate was the degree of control and the degree of its effect. And this contraction of the dialogue leaves the ultimate ownership of health decisions more fully in private hands.

However, beyond this dispute among conservatives and liberals that manifested itself in the constricted debate that received official sanction, lies an obvious and conspicuous omission; the very meaning of "health," and its relation to the larger social and political system that determines its significance. Instead, the conversation has been carried on as though health is a characteristic that can be understood independently of its surrounding social institutions. At least, no such relationship has been recently explored, so far as I know. This is not surprising as it is a characteristic of our prevailing sense of alienation that the world is broken into isolated fragments to be analyzed independently of each other and then, at best, summed in accordance with their costs and benefits to provide for a final estimate.

Nothing approaching a socialist voice was permitted in the conversation, though, at one point, Obama suggested that were he creating the world de novo, including a genuine, "first new nation," it might well have been wise to consider something of a collective, democratic approach to health care. Since Americans know so little about any possible alternative to blatantly capitalist forms of ordering the creation, distribution and payment of health provision, they may have concluded that all the significant alternatives were being considered and since "single payer" plans were excluded from the colloquy, such prospects were beyond the pale. Some might even have concluded that the single-payer plan they never got to hear about was equivalent to a "socialism" of which they have even less understanding, identifying it with "communism," "The Soviet Union, "Stalin," the "Gulag" and, finally, a purely emotional expletive equivalent to the cry of desecration one omits after catching one's hand in the car door.

What is true in all this is that socialism does not differ from liberalism by degree; it differs in kind. It is not a question of how much of various "commodities" are to be provided, but of the relationship of various persons to each other; the nature of their communal existence; the definition of physical, mental and moral well-being; the relation of human nature to physical nature; and the understanding that prevails regarding time, process and the arrival and departure of human beings from one generation to another.

The claim that health is one aspect of a vital whole is not an esoteric matter. Brief reflection is sufficient to convince one that health cannot be separated from the remaining essential values of life. Consider its relation to labor. The kind of work one does - the stress or pain or fatigue or exhaustion or humiliation or danger of deadly consequence on the one hand, or the exuberance, delight, vitality or gratification and fulfillment on the other - these can hardly be irrelevant to the health or illness of workers who carry out these tasks. And a short intellectual step will take us beyond labor to the environmental and ecological circumstances in which this labor occurs, so that we see immediately that labor and its surroundings constitute an inseparable whole. Labor transforms the environment that in turn transforms the laborers, who then alter the natural and social worlds in which they exist. Climate, soil, food, animal life and the totality of natural and spiritual existence are altered radically and more and more permanently by the structure of industrial labor that prevails. Catastrophic disruptions of the "natural environment" simultaneously shatter the "life world" of human beings, who do not live in a factually constituted environment, but in a surrounding system of meaningful relations. Every human act is accepted through its meaning and every human act transforms the system of meaning by which one is consequently embraced. Whether the "facts of nature" are the embodiment of spirits, the design of God, the dead hand of molecular sub-particles or visions still evolving is not merely to be seen or heard, but produced and consumed along with the products of labor itself.

However, labor does not occur as a series of individual acts, but is defined within a system in which production, consumption, exchange, distribution, replacement and addiction are socially organized. And that predominant system, in its numerous variations, is more and more "capitalism," which is dominated by the need to increase production for the sake of profit and the control of "everything" by the minuscule population that controls its vast rapacious enterprise.

Of course, the world that labor ingests and transforms is mediated by science and technology, however simple or sophisticated, so that our vision must expand again to embrace dimensions of life activity that have passed beyond the narrow definition of health. However, the technological imprint of science on the world bears a vision of beauty or efficiency or power or domination, and these characteristics must also be included in our larger sense of the whole we are appropriating. In short, health is a constituent of our life world which, as is the case with all the variables of our existence, acts as a nodal point that derives its nature and meaning from the meeting of all we are and do, the integration of nature, spirit, culture and history.

This introductory reflection does not, of course, define the nature of health, which is a normative term that indicates the good life of individuals, their proper functioning both "physical" and "mental" in their interrelationship, in so far as the knowledge and resources of a particular society makes this fulfillment possible. We cannot provide a universal definition of the term "health" as the conditions of human realization as well as the very meaning of the term itself change with the changing historical transformations of various social systems. All we can say is that a society that is serious about the health of its members makes health an "end," that is, an intrinsic value of existence rather than a mere "cure," which is simply the amelioration of previous dysfunctions. This is no less than to say that health is the embodiment of the good life of the members of a given society.

I will take the liberty of asserting, without attempted proof, that a good society nurtures the equality of its members. What "equality" means and why it is a superior form of social relationship is the subject for another essay. What I am interested in at this moment is the fact that equality of health opportunity must mean equal participation in the social, economic and political worlds we have maintained are essential to health itself. If equality be our compass, we must recognize that our own society is terribly lost, adrift in a maelstrom of privilege and destitution in which the possibilities of technical and human progress are overwhelmed by the exploitation that capitalism imposes upon its participants. We begin with the consideration that wealth is viciously maldistributed in contemporary American society.

The distribution of wealth in the United States is more heavily skewed in favor of the wealthy than is the case with any of the European capitalist societies and so more closely resembles Mexico than Sweden or Norway. Domestically, there has been a sharp increase in inequality of wealth over the last 35 years. In 1976 the top 1 percent of the population owned 19.9 percent of the wealth and the bottom 99 percent, 80.1 percent. By 2007, the top 1 percent owned 34.6 percent and the bottom 99 percent 65.4 percent, respectively.(2) The top 5 percent own more than half the wealth of the nation.(3) The top one percent is estimated to own between 40 and 50 percent of the nation's wealth. However, even these figures do not present the extreme concentration of wealth. In June 2005, The New York Times published an account of wealth distribution entitled: "Richest Are Leaving Even the Rich Far Behind":

Draw a line under the top 0.1 percent of income earners - the top One-thousandth. Above that line are about 145,000 taxpayers, each with at least $1,6 million in income and much more.

The average income for the top 0.1 percent was $3 million in 2002, the latest year for which averages are available. That number is two and a half times the $1.2 million, adjusted for inflation, that group reported in 1980. No other income group rose nearly as fast.

The share of the nation's income earned by those in this uppermost category has more than doubled since 1980, to 7.4 percent in 2002.

Next, examine the net worth of American households. The group worth more than $10 million comprised 338,400 households in 2001, the last year for which data are available. The number has grown more than 400 percent since 1980 ... while the total number of households has grown only 27 percent.(4)

These figures represent wealth distribution before the Bush tax cuts were to go into effect, a fact which likely offsets to some extent the loss of wealth undoubtedly undergone by this segment of the very richest since the financial crisis of 2008, although I am unaware of authoritative, current figures. Nevertheless, the extraordinary maldistribution of wealth enjoyed by this segment of the population can be said without exaggeration to "credit" them with owning the wealth of the nation. In fact, wealth distribution is presently very close to the imbalance that prevailed in 1928.

The most recent report of the Census Bureau, utilizing a standard that is anathema to any decent life, indicates that approximately 15 percent of our population presently lives in poverty. There is nothing historically unusual about this figure, which has tended recently to fluctuate between 13 and 17 percent and has reached 20 percent or so in recent times. What is quite striking is how obvious, and yet apparently unimportant to political consideration, the knowledge of this gross inequality in the distributions of wealth is and has always been in the United States. In the understanding of ordinary people and "professionals," who make their living analyzing such statistics, the gross imbalance of wealth simply seems politically irrelevant.

It is true that the figures change somewhat over time, indicating progress or regress as the economy waxes or wanes. During those times when inequality lessens, there is often a liberal claim that the situation will be ameliorated by the normal process of the market under the control of government regulation, ameliorated until equality is achieved. However, whether the standard of living rises or falls for the population as a whole, the distribution of wealth bears no continual and consistent positive relation to this consideration, but charts a course that is independent of the sheer quantitative facts of income and wealth. If anything, an increase in national wealth tends to produce an increase in the disparity of the distribution of wealth, and a decrease in wealth a lessening of this disparity, since ultimately the wealth that is produced is simply the result of the exploitation of those who make the wealth available. So, accumulated wealth is the result of accumulated exploitation, which reveals itself in the further inequality that is a mark of capitalist domination.

Neither traditional academia nor political movements pay very much attention to this social deformity. The fact of substantial inequality persists without any indication of continuous, widespread, overt opposition to this condition and even less to the underlying factors that have produced it. Demands for equality of gender or racial opportunity have been present since the beginning of the republic; sometimes at a whisper and other times as an imperative cry that will not desist. But when has a movement been founded on the gross absence of equality, either of opportunity or, even more, of the substantial quality of life? And where are the theoretical studies and popular accounts of the situation that would educate the larger public that suffers the ills of this situation? Where are the social-psychological studies of contemporary American ideology that reveals the device by which the great majority of the population is tethered to its own subordination? This maldistribution is, nevertheless, not merely an affront to basic justice, but the access through which a whole series of ills manage to penetrate society and take up a deeply corrupting residence there.

When set out in cold, stark statistics, the fact of gross concentration of wealth by the corporate elite and the horrendous power that this wealth provides its class position is impossible to avoid. Social power can only be maintained by its utilization and so the fact of the unequal distribution of wealth is inseparable from the effect of this distribution on every facet of social life.

The effect of gross inequality of disposable income on physical health has long been recognized, and the citations I provide below have been frequently replicated. A study by Aaron Antonovsky and Judith Bernstein on the relationship between social class and infant mortality in Western Europe and the United States concludes:

It was found that although infant mortality has declined dramatically in the past century, the inverse relationship between social class and perinatal, neonatal and postneonatal mortality has not narrowed, in spite of the advances in medicine and surgery, sanitation and housing conditions, and the overall rise in living standards which were presumed to be of special benefit to the lower classes.(5)

Furthermore, a study, "Recent Trends in Infant Recent Trends in Infant Mortality in the United States," published by the Centers for Disease Control "found that at least 28 other countries now have lower death rates for infants in the first year of life."

The US's relative position has declined steadily. In 1960, it had the 12th lowest infant mortality rate, but by 1990 had dropped to 23rd place, and by 2004 - the latest year of the CDC's comparative world figures on living standards - the US ranked 29th. The most recent study, published in July and titled "The Measure of America," estimated that the US is now in 34th place.(6)

More specifically, the relation of infant mortality rates of blacks and Hispanics as compared to the remainder of the population is, "... non-Hispanic black women had the highest infant mortality rate in the United States in 2004 -13.60 per 1,000 live births, compared to 5.66 per 1,000 births among non-Hispanic white women."(7) (The Washington Post, May 2, 2007.) The gross disparity between non-Hispanic black women and non-Hispanic white women is not surprising when one recognizes that one-third of black children grow up in poverty. It is, however, horrifying; especially when one locates these facts within the current developing findings that children raised in poverty tend to suffer an impairment of their neural development, which in turn impairs "language development and memory - and hence the ability to escape poverty - for the rest of the child's life."(8) (Krugman, The New York Times, September, 16, 2010.)

The issue of impaired infant development raises the question of the mechanism by which this relation between poverty and health is established. We must transcend the domain of "health," strictly defined, and note once again, if only for a moment, the nature of the industrial system which surrounds the province of health and establishes its tendencies. One quite evident source of transmission is the particular distribution of toxins in the neighborhoods of the poor. The least fortunate of the population are often the recipients of the most potent "poisons" that the industrial-chemical system can discard. As Samuel S. Epstein, one of the foremost ecological cancer experts in the world has noted:

An informed consensus has gradually developed that most cancer is environmental in origin and is therefore preventable. The striking increase in cancer death rates in this century cannot be accounted for by aging alone and cannot be due to genetic changes in the population ... a series of epidemiological studies have concluded that environmental factors cause from 70 percent to 90 percent of all cancers.(9)

The recognition that environmental agents are the major cause of cancer and the identification of the specific causal roles that many of them play, has led to an increased concern about the carcinogenic and other toxic effects of the many new chemicals which are being produced and dispersed in the environment.(10)

A clue to the precise causality which leads from the general fact of environments pollution to the lives of the poor is a matter of further research, but the outline of the situation is suggested in Epstein's observation:

The nature of these environmental factors involved in Geographical clustering of excess cancers in heavily industrialized locations is gradually becoming clearer. Evidence is accumulating of the discharge or escape of a wide range of occupational carcinogens from inside petrochemical and smelting plants into the air and water of the surrounding community ... carcinogens such as nitrosamines, vinyl chloride, kepone, tetrachloroethane, benzene, benzidine, arsenic, and asbestos, have all been found and measured in nearby communities ... (11)

If we were to estimate that the cancer rate for blacks and whites in the United States was significantly different, or that the mortality ratios for different social classes was again notably different and that people belonging to social classes IV and V are more likely to die of cancer at any age than their counterparts in class I and II, we would again be correct. The relationship between one's being and one's health, or well-being, is mediated by the inequities through which capitalism determines one's life chances.

But the situation is much more pervasive than the distribution of chemical toxins. According to a recent study in Israel:

Several studies from Europe have over time shown that children growing up in poverty will have long lasting effects on their physical and mental health. Poverty exists even in developed countries [sic] such as the United States and Israel (25 percent of children living in poverty), where it is a major public health problem of a magnitude that is markedly different than Scandinavian countries (3 percent) ...

A research group of scholars from the School of Geography at the Universities of Leeds, Bristol and Cardiff took the data from the 1896 study of (Charles) Booth and compared it with findings of the 1991 United Kingdom census of the population ...

They found that for many causes of death in London, measures of deprivation made around 1896 and 1991 both contributed to predicting distribution. The present mortality from diseases known to be related to deprivation in early life (stomach cancer, stroke, lung cancer) was predicted more strongly by the distribution of poverty in 1896 than in 1991.... This present day study showed that today's patterns of diseases have strong historical roots and the fundamental relation between spatial patterns of social deprivation and spatial patterns of mortality is so strong that a 100 year difference in time did not make a big difference....

In the United States the official poverty rate for children declined sharply between 1960-69 but had an upward trend between 1969-93 with a steady figure of around 20 percent of the children poor, 18.3 of those 6-17 years of age and 22.7 percent of all those under six years of age.

Poverty can have serious effects on child development and health, and is often associated with other risk factors, such as low birth weight, single parenthood, unemployment, unsafe neighborhoods, maternal depression, low social support, welfare dependence and stressful life events. Poverty means less or even lack of medical services which will influence the child from the foetal stage. Mothers living in poverty will not be able to get the right nutrition during pregnancy, will not receive proper antenatal care and as a result will have a higher incidence of low birth weight babies, higher infant mortality and therefore a higher risk for permanent neurological and developmental impairment.(12)

The last paragraph sets out a nightmare of impoverished existence, a world of decay and despair which, to a very large extent, replicates itself from one generation to another.

However, in regard to mental illness, the development of our understanding of a meaningful relationship between a group's social existence and its mental state only reached a significant stage in the 20th century as a result of the works of Faris and Dunham; Hollingshead and Redlich; and Srole, Langner and Michael, and others. In the 18th century, concern with what we would now call "mental illness" or some less weighted term was, with rare exception, of very slight general interest. As one physician noted:

Defining madness as "A delirium without a fever," and admitting That this "was not a very accurate" definition, he stated: "There is no great occasion to be solicitous about the definition of a disease which everybody knows."(13)

The fundamental question that occupied theorists in the 20th century was the relationship between social class and the incidence and distribution of "mental disorder." In the words of one commentator, generally shared by the overwhelming majority of those who studied the matter, and summed up by Marc Fried as follows:

The gross question, do the lowest social class groups show the highest rates of severe psychiatric disorder, must be answered clearly in the affirmative.(14) The evidence is unambiguous and powerful that the lowest social classes have the highest rates of severe psychiatric disorder in our society.(15)

Even when the correlation between social class status and mental illness was quite clear, the causal relation between them became the prevailing question of the period. One particular finding was confirmed repeatedly for various American cities and for a number of European cities that have been studied: it was the finding of Farris and Dunham that the highest rates of schizophrenia were located in the lowest socioecnomic sections of the city (Chicago). It was also noted that the correlation was strongest the larger the city under investigation.

Two quite different general theories were offered in explanation: on the one hand, the view that the nature of social existence, in particular the extreme stress and dislocation of lower class existence was the basis of corresponding mental illness and the ultimate cause of the movement of those class members to the poorest and most chaotic sections of the city. Hagstrom emphasized the condition of powerlessness among the poor:

The situation of poverty ... is the situation of enforced dependency, giving the poor very little scope for action, in the sense of behavior under their own control with is central to their needs and values."(16)

On the other hand, a rival theory which came to be known as "the social drift theory," held instead that people who, for genetic reasons, developed severe mental illnesses such as schizophrenia, drifted to the poorest sections of the city, that their "illness" was produced elsewhere and migrated as it were, along with their social status. So, two fundamentally different views came to prevail: a socially causal theory and a socially selective theory, founded on a genetic view of biological determination. Farris and Dunham, who had produced the original Chicago study, "Mental Disorders in Urban Areas," held to the theory of social determination since, in their view, evidence indicated that social location followed rather than preceded the development of the illness.

The investigations carried out by Langer and Michael under the title of "Life Stress and Mental Health, The Midtown Manhattan Study" led the authors to maintain:

Respondents were divided into six groups of approximately equal size according to their father's SES (socioeconomic status.) From high to low status the proportions of Impaired (in percent) were: 17.5, 16.4, 20.9, and 32.7. There was a definite increase in impairment as status decreased. The lowest third of the sample contained about twice the proportion of impaired persons as the highest third. This same trend appeared with even greater strength when the respondent's mental health was examined according to his present (adult) SES. In the Impaired category were 12.5 per cent of the highest of the six status groups and 47.3 of the lowest status. (17)

The next major contribution to our understanding of the relationship between mental illness and society occurred with the publication of "Mental Illness and the Economy," by M. Harvey Brenner. In the words of one commentator, Brenner is very clear that:

mental hospital admissions move inversely with cycles in employment, and that the mental hospital admissions response to a given degree of economic downturn has become greater over this time period not less, despite the development of welfare, unemployment compensation, old-age benefits, outpatient mental facilities, and community mental health centers. (18)

And in Brenner's own words:

The factual basis for the relation involves fluctuations in mental hospitalization levels and rates and fluctuations in the employment  index in New York State. [Brenner' work is a study of the previous hospitalization and unemployment records of New York State] (since replicated by other states) stretching back in time for 127 years from the publication of the book in 1973.(19)

Exploring the general relation further, three phenomena are observed. First, it is clear that instabilities in the national economy have been the single most important source of fluctuation in mental-hospital admissions or admission rates. Second, this relation is so consistent for certain segments of the society that virtually no major factor other than economic instability appears to influence variation in their mental hospitalization rates. Third, the relation has been basically stable for at least 127 years and there is considerable evidence that is has had greater impact in the last two decades.(20)

The major aspect of the study is a statistical analysis of the complex set of relations among hospital attendance, the state of the economy and in particular, the levels of unemployment. And what is the fundamental theoretical implication of the study? Beyond the aforementioned assertion of the relationship between the level of unemployment, the state of the economy and admittance to psychiatric hospitals the larger conclusion is:

.. that despite our philosophic orientation, the destiny of the individual is to a great extent subject to large-scale changes in the social and economic structure that are in no way under his control. This perspective must eventually affect our understanding of individuality and personal freedom, even in modern times.(21) These findings raise questions about the utility of therapies that do not take into account disturbances in the patient's social environment that may have made treatment necessary.(22)

The reader may find Brenner's contention a rather hyperbolic cautionary tale, for what else should we expect if not that humiliation, rage, powerlessness and dread should cause mental distress if they are not already aspects of the disturbance itself? However, Brenner is well justified in his reflection as the predominant trend of therapy since the time of Freud has been precisely to eliminate considerations of social and political context and concentrate instead on the "interior" aspects of the patient's psyche. Disturbances are thought of as residing somewhere and somehow within the individual, and even if it were conceded that society may have had some role in causing the distress that is now lodged within the patient, the fact of relevance is thought to be the present location of the malady, rather than the causal sequence that has led to its setting up place where it currently resides.

Were this essay permitted to proceed many times it available length, I would pursue the theoretical error that derives from conceiving of subjectivity as separate from the objective world toward which it continually directs itself, which it continually ingests, and which is essential to the self's recesses, however mysterious and esoteric they may be thought to be. And the fact that this objective world is made up not only of mountains, streams and the starry skies above, but also of authority, deceit, personal isolation, massive manipulation and alienation is equally an aspect of "objectivity," and even more, frames the meaning of the hard facts themselves.

It is not necessary to pursue the theoretical issue because the great preponderance of therapists are moved by a more immediate and germane consideration: that however much they may share the view that political, economic and social systems continually leak into the "interior" of the self, the therapist is helpless to alter these factors and is, therefore, well advised to ignore them for the sake of the efficacy of the therapy which he or she can in fact effect. The place for the therapist to exert influence upon the social world is in the voting booth or the street, we are told; the sanctity of the therapist's office is designed specifically to shut out the world and move back and down and into the subterranean caverns of the self. Nor is the agency of the practice to be devoted most immediately to reshaping the future, but regressing layer by layer further into the receding past.

So, as Brenner notes:

economic change has substantial impact on psychiatry as an institution and on the lives of the persons who eventually become mentally hospitalized ... historically, the role of psychiatry as an institution has been intimately tied to dislocations in the economic system."(23)

The specific function of psychiatry (and therapy in general) has been to treat the effects of economic rupture and decline, as evidenced in the suffering of individuals, by treating them individually, ameliorating the chaos one victim at a time. The result of this procedure is not only to turn attention from the social system to the individual, but to implement a perspective that goes far beyond blaming the victim. Rather, the practice of focusing on individual men and women serves too often to construct these individuals as bearing some interior fault line which, under duress, gives way and drags them beneath the wave of their own internal deficiency.

It is a terrible paradox of the current situation that the social roots of the horrendous extent of current employment - 9.5 percent officially and something approaching twice that figure when those incapable of finding more than part time work and others who have lost the will to pursue an extreme improbability are factored into the equation. It is clear that the individual is not responsible for his or her condition, for it is not ordinary individuals who have willingly "disemployed" themselves, but the system of capitalism that moves inexorably through the cycles of its own compulsive need to expand, regardless of who is damaged or destroyed in the process. It should be clear beyond denial that the extent and distribution of mental distress is the result of forces beyond individual control.

However, there is a more extensive tendency among individuals in this society to blame themselves for the socially instituted misfortunes they experience. This is something we all know by common observation and what I perceived personally in a more focused and deliberate setting when working with a group of unemployed on a grant from the California Department of Health in the early1980s. At that time, the official unemployment rate reached close to 11 percent at its peak. Many of those looking for work had been set loose by plant closures and knew perfectly well, intellectually, that these decisions were no fault of their own. How could they have held themselves responsible for the strategies of corporate boards? The poignant fact that constantly overwhelms logic is the irrational depth of the social construction of the self, which learns to punish itself for its failure to achieve the ideals of this "liberal" society. Few psychotherapists have been able avoid the seduction of the view that traces self-abnegation to the turning inward of aggression. One of those was E. Bibring, who believed that depression arose from the conflict and ensuing tension between ideal and reality. But it is the contradiction between ideal and reality that is the foundation of liberal society and, when internalized, the foundation of the "liberal" individuals, who can only accuse themselves of the failures which they are constantly driven to enact.

French peasants of the tenth century could provide for their own food, shelter and clothing; we cannot. We live, as not only Marx but Smith and Ricardo well knew, in a market exchange society in which we can only survive by relating quite dependently upon others. In Smith's liberal theory this condition constituted freedom, since we are not compelled by a higher authority - king, or guild or corporation - to do or forbear any particular economic act. We might produce and consume as we chose. But the terrible irony of this arrangement was that the totality of individual choices imposed a conclusion that no one chose and which has the power to crush the participants of this amiable travesty.

Where individual freedom is denied in practice but ideologically exalted, who else are individuals free to condemn for the misery and frustration of their lives but themselves? It is this insanity, this blatant self-contradiction that splits consciousness and sets it in perpetual opposition to itself. And it is this dark current of "the rigged system," that forever grieves and disorients us, and that plays a conspicuous role in every irrational movement that erupts in American history from the Know Nothings of the 1840s, who raged against Catholics and the Pope, to the Tea Baggers of today, who in this darkly structured century, know nothing of what exactly they fear, unless it be the colossal terror of the government, without which they would be not merely helpless, but ultimately, nonexistent.

The ultimate act of denial of this awareness of dependency is in fact the exaltation of ourselves and our total autonomous power. For are we or are we not the ultimate agents of our own existence? We are said to be; yet, apparently we are not, as Smith well knew, though behind his back as though by an invisible hand, and Marx as the foundation of his social view of freedom, still to be created. For freedom requires our control of the social structures that control us, and this is the ultimate meaning of the enlightenment exhortation to self-determination, which can be no more compelling than in the instance of health, where the causes of decline and the prospects of renewal lie precisely in the life we live together.


1. The Nation, August 30/September 6, p.20.

2. G. William Domhoff, "Who Rules America?" p.6.

3. "The Wealth Divide: The Growing Gap in the United States Between the Rich and the Rest," an Interview with Edward Wolff.

4., Thursday, January 25, 2007.

5. Aaron Antonovsky and Judith Bernstein, "Social Science and Medicine," (1967) Abatract, vol.11, issues 8-9.

6. World Socialist web site.

7. Washington Post, May 2, 2007.

8. Paul Krugman, The New York Times, September, 16, 2010.

9. Samuel S. Epstein M.D., "The Politics of Cancer Revisited," East Ridge Press, Freemont Center, New York, 1988, p. 19.

10. Ibid., p. 24.

11. Ibid., pp. 37 - 38.

12., The Internet Journal of Pediatrics and Neonatology, ISSN: 1528 -8374, Joav Merrick M.D., DMSc, Mohammed Morad M.D., Eli Carmeli Ph.D.
13. Thomas J. Scheff, editor, "Mental Illness and Social Process," Harper & Row,  New York, 1967, p. 3.

14. Marc Fried, "Social Differences in Mental Health," in "Poverty and Health," edited by John Kosa, Aaron Antonovsky and Irving Kenneth Zola, Harvard, University Press, Cambridge, Massachusetts, 1969, p.123.
15. Ibid, p. 113.

16. Ibid, p. 151.

17. Thomas S. Langer and Stanley T. Michael, "Life Stress and Mental Health," The Midtown Manhattan Study, Vol. II. The Free Press, New York, 1963, p. 78.

18. Joseph Eyer, Review of "Mental Illness and the Economy," International Journal of Health Services, Volume 6, Number 1, 1976, p. 139.

19. M. Harvey Brenner, "Mental Illness and the Economy,"  Harvard University Press, Cambridge, Massachusetts, 1973, Preface, i.

20. Ibid.

21. Ibid. ii.

22. Ibid. iii.

23. Ibid. p.226.

Richard Lichtman

Richard Lichtman is a philosopher who specializes in the relationship between the social and psychological dimensions of human life. His approach is broadly interdisciplinary: he has taught in departments of philosophy (University of California, Berkeley), humanities (San Francisco State University), sociology (University of California, Santa Cruz) and psychology (The Wright Institute, California School of Professional Psychology, etc.) and has been a faculty member of the Council on Educational Development (CED) program at the University of California, Los Angeles. His books also indicate the range of his interests: Essays in Critical Social Theory covers a broad range of topics in economic, social, and political theory, while The Production of Desire is a detailed analysis of the works of Marx and Freud. 

Last modified on Friday, 29 October 2010 12:21