The distribution of cholera cases around the Broad Street pump, as discovered by John Snow

By Ellen Isaacs

The mission of this blog has been to focus on racism as a primary and essential aspect of capitalism, especially American capitalism, without which that system could not survive. In the article recently published, Racism is a Scourge on the Public’s Health, we began to illustrate the role of racism in adversely affecting the health of non-white as well as white workers. We would now like to delve more deeply into the relationship between capitalism and public health—the promotion of health of entire populations.

The Needs of Capitalism

Capitalism exists to make profits. This is not a moral statement, but the underlying mechanism of the system, for a business must be successful at not only making but maximizing profits, or it will lose out to competitors. Profits are derived from the difference between the value of goods produced and the investment in the means of production, ie labor, machinery, advertising, etc. It is the cost of labor where the major flexibility lies, and wages depend on the costs of maintaining the worker in working condition, providing training, and replacing workers lost to disability or retirement. Thus a low-skilled worker in a time of high unemployment, when he or she can be easily replaced, is much less valuable and is paid less than a highly trained one with scarce skills. In addition, there is the factor of what workers demand above the owner’s minimum, via strikes or other struggles. (For a full discussion, see Schatzkin A, Health and Labor Power: A theoretical investigation, Int J of Health Services, 8:2, 1978.) In fact, Medicare and Medicaid, which cover the poor, elderly and disabled in the U.S., were created in 1965 in response to the massive unrest of that time, the civil rights and the burgeoning anti-Vietnam War movements.

Services that are necessary to maintain workers in general, such as public schools, sanitation, and health care, are general expenses to the capitalist system, a large part of which is recouped via taxes paid by workers themselves. Of course, capitalists also want to guarantee their own disease-free survival, so the control of conditions that might adversely affect them, such as epidemics, is also a consideration in understanding the history of public health. They also want to have a general level of health care infrastructure and scientific advancement so that they can live long and comfortably.

When Must an Epidemic be Quashed?

The history of cholera provides some interesting insights. Although cholera most likely originated in India around 500 BC, it did not cause epidemics until the early 1800s, when increased urban congestion, commerce and migration facilitated its spread. By 1860, millions had died around the world in various epidemics. In 1854, the bacteria causing the disease was identified, but it was the discovery by John Snow in the same year that a contaminated well in London was the source of the disease that first enabled successful measures to control it. Now that clean water is readily available in the developed world, cholera is virtually unknown. The disease, however, continues to flourish in underdeveloped countries and is endemic in Africa and South and Southeast Asia. Although two vaccines, rehydration solutions, antibiotics, and means of achieving safe water are well known, the number of cholera cases continues to rise, with almost 600,000 being reported worldwide in 2011. In all of the endemic areas, there is a disparity between illness rates of the rich and the poor, among whom poor sanitation, overcrowding, and lack of safe drinking water promote disease spread ( A major epidemic was imported to Haiti in 2011 by Nepali UN peacekeepers, and another epidemic has erupted in Yemen as American supported Saudi bombing has destroyed the sanitation infrastructure.

It is clear that the health and survival of the poorest people of the world, away from capitalist centers of production, is not of enough concern to the wealthy and powerful to mitigate the plagues of cholera and the many other infectious diseases that plague only the destitute poor of the less developed world or those whose well-being is less important than a military objective

Keeping Workers Productive

Within capitalist nations, where industrialized production requires the well-being of a large number of workers and the availability of healthy young workers for the military, the level of health and health care must be ample to maintain this productive force. In 19th century England, as factory production flourished, workers lived in filthy crowded hovels, ate very poor diets, worked 15-hour days, suffered exposure to filthy air and toxins, and had frequent crippling accidents. As Edwin Chadwick, chief author of the Sanitary Acts, noted, the “depressing effect of adverse sanitary circumstances on the laboring strength of the population …is to be viewed with the greatest concern….The pecuniary cost of noxious agencies is measured by with data within the province of the actuary, by the changes attendant on the reduced duration of life, and the reduction of the periods of working or production by sickness.”

Within the U.S. at this time, the same sort of calculation was going on. The economist CEA Winslow wrote in 1908 that improved factory ventilation would pay for itself by decreasing absences and preventing workers from being stupefied by late afternoon. Another economist, Irving Fisher, wrote a report using a cost-benefit analysis of disease pointing out the loss of work years by early death. In 1925, Dr. Arthur Emmons of the Harvard School of Public Health urged the control of human waste to decrease turnover, absence and disability. Stacy May, a WWII era Rockefeller linked economist, summed up the capitalist view of health: “Where mass diseases are brought under control, productivity tends to increase – through increasing the percentage of adult workers as a proportion of the total population, and through augmenting their strength and ambition to work….” He later stated that “penetration’’ of foreign countries, under the guise of promoting health for its own sake, that much easier. Medicine and public health were found to be more effective than missionaries for achieving expansionist ends.

One example of a corporate attack on disease for its own ends is that on hookworm. Hookworm, which still flourishes in Africa, was brought to U.S. by the slave trade beginning in the 17th century. By 1910, the Rockefeller Sanitation Commission for the Eradication of Hookworm Disease documented that nearly 40% of Southerners were infected, the cause of the so-called “laziness” (due to the resulting anemia) which affected the agricultural productivity and economic development of the region. They therefore initiated a program of sanitation, education and medication dispensaries which significantly mitigated the problem (Ettling J. The germ of laziness: Rockefeller philanthropy and public health in the New South. Cambridge (MA): Harvard University Press; 1981). In each area where the program was instituted, productivity increased.

There should be no doubt that the calculation of benefits to the employer from a healthy work force has not decreased with time. In 2011, an oft quoted paper (Hymel PA, Loeppke RR, Baase CM, et al. Workplace health protection and promotion: a new pathway for a healthier—and safer workforce. J Occup Environ Med. 2011;53:695–702) reiterates the claim that: The two factors, personal health and personal safety— [are] each essential to a productive worker and to a productive workplace. Just last week, the NY Times (7/25/17) described a new program in Britain to provide widespread talk therapy for common mental health problems like anxiety and depression. The justification was, of course, “just on lost work alone, the program would pay for itself.”

The Role of Racism

When public health initiatives are created, justified or continued on the basis of increasing worker productivity, it is not hard to understand that those who are not working or who hold positions with lower qualifications and are easily replaceable will be less likely to benefit. In the US, low-wage and low-skilled jobs are disproportionately filled by black, Latino and immigrant workers. Recently, the NY Times (7/30/17) published an article showing that black households averaged 55% of the income of whites at every income level, the same as fifty years ago. Low income not only correlates with higher disease and death rates, but these differences are exacerbated by racism.

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Sometimes the profit motive directly drives practices that worsen health among large numbers of workers. Although it is a complex problem, the obesity epidemic in the U.S. correlates with the policy of the agriculture department in the 1970s to encourage the mass production of corn and high-fructose corn syrup, which are used as sweeteners in soft drinks and many foods, especially inexpensive junk food. Since 1995, about $81.7 billion has gone to subsidize corn, which is cheap and allows more food to be sold at affordable prices. Less than 1 percent of farm subsidies go to support the research, production and marketing of fruits and vegetables. Many foods which we don’t even think of sweet are made more tasty by adding corn syrup, such as ketchup or baked beans. The average calorie consumption of Americans increased by 700 a day from 1970-80, even as sedentary life-styles were increasing. Currently about 1/3 of all Americans are obese, which leads to diabetes, heart disease, and increases the risk of other illness such as some cancers. Now that the obesity rate in children has risen to about 20%, resulting in health expenditures, illness during the productive years, and the ineligibility of 25% of potential military recruits, there is at least more debate about agricultural subsidy policies. The decision process involves weighing the incomes of farmers against health and productivity costs, as opposed to making primary the health of all Americans.


In sum, we submit that health services for workers, from the unskilled to the professional, are necessary under capitalism to provide a dependable workforce, in order to maximize profits. To admit this is in no way seen as a dark matter to be couched in euphemisms, but is proudly touted with all sorts of cost-benefit analyses. In medical student and resident training the introduction to every lecture on a condition starts with a statement that cost in loss of time from work is XXX million/year and the expenditure in medical cost is XXX million or billion/year. Thus young doctors are inculcated with the ethic of measuring treatment or prevention benefits on the basis of profitability to capitalism, as opposed to the well-being of patients. When a group of sufferers, such as the cholera-stricken in Haiti or Yemen, are of no particular value to the local or international capitalists, their suffering is allowed to continue. What we must strive for is a view of public health as maximizing the health and quality of life of all for its own sake. To do that will require a mass movement that unites workers, students and professionals of all nationalities and ethnicities in struggles that will, of necessity, go beyond the scope of public health.

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