Anne-Emanuelle Birn & Theodore M. Brown (Eds.), Comrades in Health: US Health Internationalists, Abroad and at Home. Rutgers University Press, 2013.
Within the medical establishment, health workers are typically viewed as neutral third parties who provide care to patients outside the realm of politics and the dynamics of oppression. Health is predominantly taught, understood, and practiced through a biomedical lens, which emphasizes that disease is caused by biological agents, such as bacteria, viruses, and by individual lifestyle choices, such as smoking and poor eating habits. Comrades in Health: US Health Internationalists, Abroad and at Home exposes the limitations of this narrow definition and expands upon a structural analysis of health that identifies the unequal distribution of power and resources under capitalism as the root cause of disease. Through a collection of writings by or about health internationalists (health professionals whose health work is embedded in struggles against oppression and exploitation both internationally and domestically), Comrades in Health argues that transformative health work must include actions to challenge these dominant structures: political struggle is a requisite for health work, and health care has a critical role in supporting social movements.
The internationalist health movement is attributed to the convergence of social medicine (the practice of addressing health within social and political inequities) and proletarian internationalism (when opposition to capitalism transcends national borders). Norman Bethune and Che Guevara are perhaps the most prominent examples of health internationalists: both applied medicine to support revolutionary liberation movements in China, Latin America, and Africa. Comrades in Health documents the work of other health leftists within the currents of US politics over the past century – those who challenge nuclear armament, engage in the civil rights and anti-apartheid movements, and resist imperialism through independence and liberation struggles. Organizing the book into four generations of health leftists, Comrades in Health emphasizes the role of intergenerational knowledge and mentoring, and builds upon the discourse and practice of our predecessors. While a diversity of themes are covered in the book, this review will focus on the anthology’s contributions in documenting the struggles for social justice and building analysis of the structural determinants of health. The book’s relevance to informing the practice of health workers and activists will be explored, including its limitations in scope of analysis.
The Structural Roots of Ill Health
Vicente Navarro opens the anthology by stating, “Medical care and public health are very political interventions, even though professionals working in these fields may not always be conscious of it” (xi). Health workers who understand disease as biologically - and behaviorally-determined emphasize clinical interventions and health education to modify unhealthy lifestyles. This perspective is often used to justify attitudes among health professionals that patients create the conditions for their illness by making poor choices, a perspective that is similar to victim-blaming and poor-bashing. Anne-Emanuelle Birn and Theodore M. Brown’s brief history of social medicine details the significant body of evidence demonstrating that health is structurally determined: the political, economic, and social orders under capitalism reproduce patterns of poor health along class, race, and gender divides. When resources are distributed to benefit certain groups at the expense of others, the consequences for the latter (poverty, poor living and working conditions, barriers to higher education, etc.) predispose them to poor health and disease. In this way, Comrades in Health challenges the notion that providing health care can be a neutral act: to ignore the politics of health care provision is to replicate the existing power structures of class, race, and patriarchy that marginalize certain groups while privileging others.
For health internationalists, providing individual health care is one small piece of improving health; it is the collective effort to redistribute power and wealth that ultimately leads to change. This is illustrated in Howard Waitzkin’s account of patients suffering from “farmworker’s back” in 1970s California. The crippling injury was caused by many hours bent over a short hoe, which had no productive advantage over the long hoe except that fewer supervisors were needed to spot workers who were not bent over at work. Treating the back injury alone did little to improve the farmworkers’ health; rather, the United Farm Workers union campaigned for improved working conditions until the short hoe was banned by legislation. “Farmworker’s back” was a symptom of economic exploitation, and its treatment included building the collective power of the farmworkers to challenge the root cause.
Comrades in Health also gives insight into the ways in which capitalist structures are reproduced in health care delivery. Waitzkin describes its consequences in the contradiction of medical maldistribution wherein, despite plentiful resources in the US, the majority of health workers, facilities, and quality services are concentrated in areas with higher levels of personal income and economic enterprises. Other contributors to the book explain the impacts of maldistribution on under-serviced communities, including the rural south, the Bronx, and Harlem – conditions that are analogous to Canada’s rural and northern communities, Aboriginal reserves, and urban working class neighbourhoods. Even Canada’s publicly funded health care system cannot mediate the effects of maldistribution, and chronic underfunding of these communities is ongoing despite the wealth in our country. In the chapter “Health and Human Rights in Latin America, and Beyond,” Alicia Ely Yazmin labels this neglect as a marker of social exclusion akin to other human rights violations, arguing that health cannot be understood as charity, but must be considered a human right and public good to which everyone is entitled access.
Comrades in Health extends the critique of capitalist medicine to the increasing reliance on corporations (including the pharmaceuticals industry) and humanitarian aid agencies to fund health care. Capitalist health interventions often emphasize highly specialized and technical medical care, and thus become opportunities for private profit and corporate investment, thereby detracting from the radical political and economic change needed to address the root causes of ill health. As Birn and Brown describe, “Much of global health work today addresses diseases that are a consequence of poverty yet, ironically, tries to do so without examining or questioning poverty’s underlying structural determinants, particularly as they pertain to the accumulation of private wealth” (305). Contributor Paula Bravemen depicts the shift in the World Health Organization and US in the 1990s towards the measurement of health inequities as a technical exercise comparing health between individuals, rather than between privileged and marginalized groups. As a result, efforts to reduce health disparities were de-politicized, stripped of their social justice imperatives, and diverted resources away from addressing political and economic inequities. The contributions from Health Alliance International, Doctors for Global Health, and Michael Terry and Laura Turiano describe common struggles to resist co-optation into the neoliberal and conservative agendas of funders, which sees transformative health work eroded into service provision. This dilemma is faced not only by health workers but is a continuation of the struggles all activists and organizers confront when maintaining their autonomy within the non-profit industrial complex.
Although Comrades in Health provides critical insights into the political economy of health, its analysis of the other structural determinants of health is not as clearly articulated. The editors note that the work of health leftists may include opposing other forms of oppression and exploitation, as in the cases of the civil rights movement and opposition to US imperialism; however, the book does not offer further discussion beyond naming racism and other forms of discrimination that impact health. Waitzkin’s discussion of “farmworker’s back” focuses on economically exploitative relationships on the farms but overlooks the racist structures that restrict the ability of these farmworkers to obtain other employment, such as residency status and education. The singular focus on political economy in the structural determinants of health can reinforce existing politics of exclusion based on race, gender, and other forms of oppression. Notably, the absence of Indigenous self-determination and feminist movements in Comrades in Health limits its scope of analysis and is a missed opportunity to learn from the experiences of these health internationalists, particularly as these movements continue to be on the frontlines of social justice struggles in the US and Canada. For example, struggles for Indigenous political, cultural, and environmental rights, particularly in relation to control over health care provision, bring important insights into decolonizing practices and alternatives to capitalist models of health care delivery for health workers. Broadening the analysis of the structural determinants of health ensures that we continually challenge our own assumptions and privileges, rather than replicating the oppressions we are working to dismantle.
Health Care as an Instrument of Social Justice
From its analysis of the structural roots of ill health, Comrades in Health offers us alternative strategies and visions for transformative health work. Terry and Turiano maintain that, “Choosing to work with the poor and treating each patient with dignity is in its own way a political act, but it is not enough” (235). For health internationalists, the strategies and objectives of health work are social justice oriented rather than medically dominated – liberating rather than prescriptive. Beyond providing health care as an end in itself, it has the potential to be applied as a strategic tool for collective change.
The book documents insights gained from health leftists who adapt alternative health models, often with socialist roots, to the US context. Susan Gross Solomon describes John Kingsbury’s attempts in the 1930s to transport the Soviet Union’s model of socialized health care to the US. H. Jack Geiger gives a compelling account of his journey as one of the founders of the Community Health Centre movement in the US based on South Africa’s model, in which “nutritious food, sanitation, and shelter were medicine” (172). Victor and Ruth Sidel explain how they translated the model of “barefoot doctors” (community health workers) from the People’s Republic of China into a Community Health Participation Program in the Bronx. In the youngest generation of health internationalists, Razel Remen and Brea Bondi-Boyd studied community medicine in Cuba in order to bring these skills to under-served communities in the US. The lessons from these health internationalists underline the importance of building relationships among progressive groups internationally, both as a means of fostering an exchange of knowledge and skills, as well as a means of strengthening networks of allies working from multiple fronts in common social justice struggles.
Health work has a critical role in supporting social movements, which includes a long history of medical solidarity with communities in struggles against hegemony and imperialism. While medical aid in military conflict features more prominently in our understanding of health internationalists, Comrades in Health draws out less well-documented work of health leftists within the medical arms of radical social movements. The political analysis and tactics of these contributors deepens our understanding of the ways in which health work can be used as a tool to organize communities in social justice struggles. Drawing on their own histories and experience, these diverse contributions include Geiger’s account of the Medical Committee for Human Rights, (which provided support and care for civil rights workers), Waitzkin’s medical support for the United Farm Workers union clinic system, and Mary Travis Bassett’s involvement with the Black Panther Party health centres. A common reflection among these health internationalists is that solidarity with liberation struggles is necessarily precluded by political activism against domestic structures that propagate capitalist and hegemonic policies. This is saliently captured by Bravemen’s account of her solidarity work with the revolutionary Sandinista government in Nicaragua, which did not need her medical services, but rather her political activism to protest US involvement in the war against the Sandinistas. In “Medical Internationalism and the ‘Last Epidemic’, Bernard Lown describes his experiences leveraging his credentials and privilege as a physician to publicly condemn nuclear armament (134).
Action against the structural determinants of health necessitates work outside of clinical practice. Comrades in Health attempts to portray the different faces of health work, such as political advocacy, movement-building, education, and research; however, the health leftists featured in this anthology are predominantly physicians or have other professional affiliations. Their overrepresentation reinforces class structures within health and privileges the work of professionals over those in other fields. People such as community health workers, as well as activists who do not have professional health training but provide care and advocate for the health of their communities, are excluded. Seiji Yamada writes, “medicine reproduces class relations and the world of medicine is particularly hierarchical” (258). The editors themselves reflect on the role of privilege (male, white, physicians) in giving some health leftists a greater ability to be outspoken. The skills, perspectives, and analysis of health workers and activists outside of the health sector are critical in challenging the structural determinants of health. Until these voices are actively sought and included, radical health work cannot truly move out of the terrain of clinics and hospitals.
Bringing These Lessons Home
As an anthology of four generations of health activists, Comrades in Health serves as a repository of intergenerational knowledge, radical ideas, and alternative approaches for the political development of generations to come. The book offers relevant lessons not only for those working in the health sector, but for all activists and organizers. As the very nature of the work of health leftists threatens the most powerful and wealthy sectors of society, a common theme is the persecution and repercussions from professional associations, the state, or funders who attempt to co-opt and control transformative health work. This experience is echoed by many health leftists and activists and resonates with my own struggles to merge my two worlds as an activist and health professional. Working in a climate that is reluctant to acknowledge, much less act on, the structural harms that cause disease, where even “advocacy” has become too political a word, the silencing of opposition to the status quo eliminates opportunities for meaningful discussion and change. Nonetheless, a legacy of the health internationalists has been to push mainstream health discourse towards more progressive directions: where previously community health centres and community health workers were seen as radical notions, they are now integral parts of health care delivery in many jurisdictions. Though Comrades in Health offers no easy answers for health internationalists, it helps to sustain our work by providing a space for meaningful discussion of the ideas and struggles of our predecessors and paves the way for us to build on their successes.H