The Elephant in the Room: Capitalism

The Merriam-Webster Dictionary defines the expression “elephant in the room” as “an obvious major problem or issue that people avoid discussing or acknowledging.” 100 For us, the elephant in the health equity room is the contemporary form of neoliberal global capitalism. We are not alone in this belief. Not only is there an extensive political science literature of the catastrophic effects of capitalism on all aspects of contemporary life,24,101–108 there is an increasing willingness in the mainstream public health and health care community to acknowledge capitalism as a primary threat to health equity through its adverse effects upon access to food, education, housing, income and wealth, quality employment, and transportation.40,81,109–112 How does capitalism threaten health equity?

Capitalism requires that society be organized along capital accumulation by the production and then selling of products at values greater than what is involved in producing them, i.e., raw materials, infrastructure such as buildings and machinery, and wages.113,114 These processes of production and distribution usually produce profound social inequalities which must be legitimized since Braudel notes that “Capitalism, the privilege of the few, is unthinkable without the active participation of society.” 115 (p. 50) Without such legitimization and consent of those being governed, discontent can escalate into organized resistance. Ideas of individual freedom, equality of opportunity, and the virtues of free enterprise provide such legitimization.

Wright considers the problems of capitalism – clearly related to adverse health effects – within three clusters: Equality/fairness, democracy/freedom, and community/solidarity. 112 Regarding equality/fairness, Wright argues: “In a just society, all persons would have broadly equal access to the material and social means necessary to live a flourishing life.” 116 (p. 10) By any measure, capitalism makes the attainment of fairness in terms of life outcomes difficult for many. While the structures, processes, and effects of capitalism were managed during the period of monopoly capitalism from 1945 to 1975, under contemporary neoliberal global capitalism (see below) the current era sees social inequalities increasing with day-to-day life for most not improving or worsening. Neoliberal governance has led to growing corporate domination of the political process such that the state is reduced to the role of handmaiden of this sector.

For Wright, democracy and freedom are linked and support self-determination: “In a fully democratic society, all people should have broadly equal access to the necessary means to participate meaningfully in decisions about things that affect their lives.” 116 (p. 15) Doing so requires access to power and the ability to shape public policy that affect their lives.

Global neoliberalism has the corporate and business gaining greater control over public policy that organizes production and distribution of economic and other resources.107,117 The corporate and business sector also comes to dominate societal discourse concerning the nature of economic and political processes -- justifying these changes -- through its control of the mainstream media and through the action of corporate and business-friendly political parties. 114 Democracy comes to be reduced to voting for one of the pro-business parties that dominate public discourse.118,119 The illusory process of freedom comes to mean little since as Coburn notes “capitalists preach democracy, but practise power.”, 41 (p. 68)

Wright states: “Community/solidarity expresses the principle that people ought to cooperate with each other not simply because of what they personally get out of it, but also out of a real commitment to the wellbeing of others and a sense of moral obligation that it is the right thing to do., 116 (p. 18) Such a communitarian view of society provides a sense of purpose and meaning in life and supports equality/fairness and democracy/freedom.

The lack of democratic processes and the growing competition for resources amongst the population under capitalism weakens already fragile concepts of community and solidarity. Neoliberal processes – now dominant in this age of global capitalism -- celebrate the fraying of ties amongst the population thereby reducing the sense of common purpose and weakening the public’s ability to control their future.120,121

A core concept related to capitalism’s effects upon health is exploitation. We think about exploitation in two ways. The first is Wright’s concept of economic oppression. 122 This occurs when (1) the material welfare of one group is causally related to the material deprivations of another; (2) the causal relation in (1) involves coercively enforced exclusion from access to productive resources; and (3) this exclusion is morally indictable. In this definition, deprivation is caused by excessive accumulation by others. The second is that exploitation is an inherent feature of capitalism. For Marx, the worker forced during employment to produce surplus value to benefit those who control the means of production is capitalism’s key feature of exploitation. 123 Another aspect of capitalism is the alienation of workers who are estranged from the products of their labour and lack the power to control the production and distribution of economic and other resources. Øversveen and Kelly and Baum use alienation theory to explain the adverse health effects of income inequality in capitalist societies.124,125 Dawson raises the question of whether alienation is part and parcel of capitalism and therefore present for all or only afflicts those being left out. 126

We see the current polycrisis of income and wealth inequalities, employment insecurity and precarity, and housing and food insecurity resulting from excessive capital accumulation at the expense of social reproduction fitting into Wright’s concept of economic oppression. The following section considers the concepts of capital accumulation and social reproduction in greater detail.