Indian Journal of Medical Ethics


Capital is bad for your health

Miran Epstein

Published online first on September 1, 2021.
Nicholas Freudenberg, At What Cost: Modern Capitalism and the Future of Health. New York: Oxford University Press; 2021 March 16; 392 pgs, $26.35 (hardcover) $9.99 (Kindle), ISBN 9780190078621.

Question: What do the major public-health crises of our time share in common?                                                                                         Answer: They are all expressions of a global economic order whose identity is unclear to us or whose name we are too scared to pronounce.

Public health expert Nick Freudenberg’s new book deals with the nature of the pathogen, the pathologies it generates, and the proposed treatment.

The pathogen must no longer be referred to as the “free market” or “neoliberalism”, he says. These post-Cold War anodyne appellations only obscure its identity. It is time to name names and call a spade a spade. The culprit is what he calls modern capitalism, a world system dominated by an increasingly small number of hysterical and ruthless profit-driven, mega-rich, ultra-monopolistic, supra-national corporations dictating to us what we are to produce, desire, and consume, regardless of the human cost. Why hysterical? Because they are trapped in a vicious downward cycle of overproduction hence declining profits, cutting production costs thereby reducing the buying power of the workers and causing further decline in profits, and so forth, made all the worse by an increasingly intense dog-eat-dog competition. Why ruthless? Because in their global race for cheaper workers and richer customers there is no line they wouldn’t cross. If necessary, they would even cut the very branch on which we are all sitting. In fact, they are doing so as we speak. They remove legal obstacles to production and trade, in particular those that were supposed to protect workers, customers, people as such, and the environment. They divert from production to speculation, thereby increasing unemployment, intensifying competition among workers, and driving wages (and profits) further down. They impoverish the state by obtaining tax cuts and subsidies therefrom, and by lending money thereto. They take possession of their debtor’s assets or buy them cheaply. Finally, they conceal or distort their exploits behind the ideological smokescreens of “free movement”, “choice”, “trickle-down”, and divisive identity politics.

In the course of this rampage, these behemoths inflict great misery on us. They destroy the planet. They impoverish the masses and increase economic insecurity. They bring about political and military unrest and instability, massive waves of South-North migration, resurgence of fascism, and intensifying social disintegration at every level. They make us ill — physically, mentally, and socially. However, they also capitalise on our ailments. Take the current pandemic for example, clearly a disaster that carries the fingerprints of a callous antisocial system that favours selfishness over altruism, competition over cooperation, and profit over people. Suffice it to mention the unpreparedness of the welfare systems, primarily public healthcare, following years of “austerity” imposed on them by a tiny-but-powerful tax-averse and privatisation-eager minority and its political shills, the production of vaccines for profit and their inequitable global and local distribution, and the widespread public distrust in the financial conflicts of interest-ridden medical science and political leadership.

The book touches on some of these issues in passing. Its main part — the part concerned with the pathology — is about the calamitous impact of this misanthropic arrangement on what the author calls “the six pillars of health”: food, education, healthcare, work, transportation, and social connections. In these chapters, he explains why and how corporations created a global diet based on ultra-processed products, and how this diet destroys our health and the environment. He demonstrates how the privatisation of education reproduces and widens socioeconomic gaps and stratification, and how austerity stifles the national education system undermining its capacity to deliver on its humanistic promises, and pushing children and families into circumstances that affect their mental and physical well-being. He shows how corporate takeover of healthcare subjects the war on cancer to the profit principle at the expense of the patient, the public, and medical progress. He spells out what the system does to wages, workplace stability, safety and health. He describes how the automotive industry tailors the ways we travel from one place to another to fit its narrow interests, how it bends the safety regulations and how it affects the climate, the environment, and our health. He even draws attention to the disastrous impact of the internet giants on consumption, privacy, democracy, and health.

Most of these well-researched and reader-friendly chapters also present trends of resistance and alternatives to the status quo. However, the author’s therapeutic prescription is outlined in the last two chapters. “Imagine, if you can, a world where the well-being of people and the planet is a priority”, he proposes. Now create a cohesive movement united by this vision, confront the system, its ideas and values, insist on a radical Green Deal, transform the discourse on taxes and regulation, call on the public sector to assume control over the production of scientific knowledge and technology, and create economic alternatives such as workers’ cooperatives.

Surely the importance of these measures cannot be underestimated and must not be played down. But can they alone bring the necessary change? Not sure. On the one hand, they sit well with the traditional social-democratic agenda that has never really sought to challenge the status quo (it is one thing to be critical of privatisation, and a completely different thing to call for nationalisation). On the other hand, the system might turn out to be too fragile to withstand even the reformist ideas of yesterday. Hard to say.

Freudenberg seems to be making every effort to give us the impression that he merely dreams of a reform. He is explicitly critical of capitalism but says nothing about the exploitative-parasitic essence of capital (capital is the profit-driven class, and profit — as a matter of logic — can only be made by somehow making others work for you). Nor does he mention the fact that capital has always been indifferent to benefit and harm to people so far as these were different means to, or different consequences of, its misanthropic end. On the contrary, he only targets “corporations”, “modern capitalism”, “capitalism as practiced” or “the current form of capitalism”. He lobbies for a movement “to modify twenty-first-century capitalism”.

Having said that, it is likely he simply doesn’t want to alienate the American reader who might still be ambivalent about “the American way”. As a matter of fact, his incisive critique of the system strongly suggests he realises that there is no reasoning with capital, not anymore, that there’s no way back, and that we are doomed if we continue as is. In this regard, he joins the glorious pantheon of radical medical sociologists inspired by Friedrich Engels’s 1845 classic, The Condition of the Working Class in England, (1) who have taught us that in our society, illness and suffering are most commonly inflicted by man-made social conditions, in particular class relations and their corresponding modes of production, distribution and consumption. A truly humanistic medicine, so it follows, must be radical. It must point the finger at these conditions and not merely focus on their biological, ecological and social expressions, let alone their clinical manifestations. Most importantly, it must shout from every rooftop and hill that social problems require social solutions and not technological adaptations.


  1. Engels F. The Condition of the Working Class in England. Penguin Classics; revised 1987. 304 pgs.