HEALTH AS A COMMODITY
It is necessary to contextualize how the market acts to regulate everyday life activities to understand how our society has achieved vast health disparities. In his text The Great Transformation, Karl Polanyi discusses the ethics of our capitalist market system through the lens of the connections of markets and social goods. In this text, Polanyi argued against the ideas of neoliberal economics by articulating that our society’s idea of a free market is a social fact, created and maintained by social institutions and regulations; the “free market” is not reflective of human nature or fact but is instead an ideology. Polanyi’s perspective shows us that market structures (which are conglomerates of relationships) are both real and socially constructed; therefore, we can visualize them.
The neoliberal school of thought, broken down into 3 assumptions:
- “That markets are the best and most efficient allocators of resources in production and distribution
- That societies are composed of autonomous individuals (producers and consumers) motivated chiefly or entirely by material or economic considerations
- That competition is the major market vehicle for innovations” (Coburn 2000, 138).
As Coburn (2000) summarizes, the idea of choice and precisely the “right” to choose is a defining characteristic of neoliberalism. However, how neoliberalism constructs the idea of “choice” is not representative of choice in our society. Choice cannot exist if every individual does not have the equal opportunity to choose; this is how neoliberalism propagates inequality. While individuals may be considered “consumers,” not every individual has the same access or ability to consume due to structures present in their present or historical environments that hinder upward mobility.
How “regulation” ties into neoliberalism
Another critical characteristic of a neoliberal market is that it is “unregulated.” Because neoliberalism values individual choice and views humans as only looking out for their self-interests, the unregulated market is tied with the idea that “the pursuit of individual self-interest [is] the innate motivation of human nature.”
Conversely, the regulated market, which Polanyi argues can mitigate inequality, acknowledges that humans are “social animals” that “define and realize themselves in relation to others” (Block & Somers 2014, 30).
The key difference between these two views on the market centers around human nature (whether it is innate and driven by the individual) or is the result of cultural and societal relationships. It is important to emphasize that no market represents the “fact” of human nature; this idea is contrary to neoliberal ideology. Instead, all markets are ideologies: social structures that humans create and employ.
The following chart aims to describe the differences between regulated and unregulated markets; further, it provides some context for the following examples on the process of deregulation.
Because market structures are real (they impact individuals’ lives) and social (humans create them, so they are not the result of human nature), we can visualize them. This process can reveal how structural violence functions. Visualization of the neoliberal aspects of our market can show how the ideology contributed to making the structures that perform violence on populations more invisible by dismantling larger and more apparent structures that were put in place to mitigate violence.
An example of these processes of deregulation occurred in the Reagan presidential era. During the Reagan era, the government disassembled large programs because Republican policy favored the idea of the “ideal” free market with no measures of regulation. These policies directly contributed to the rise of inequality in the United States. The top 1% increased their wealth gap (specifically, the share of income going to the top 1% increased from 10% in 1981 to 23.5% in 2007) (qtd. In Block & Somers 2014, 19-20).
The graph below is a visual example. During Reagan’s presidential term (1981-1989), the Gini coefficient jumped an astounding 0.3; this is arguably the most significant jump in income inequality in the United States history (limited to documentation). The Gini coefficient measures income inequality on a scale from 0 to 1, with 0 indicating perfect equality and 1 indicating total inequality. For contextualization, Australia had a Gini value of 0.344 in 2014, Finland had a Gini value of 0.274 in 2017, and South Africa had a Gini value of 0.63 in 2014 (statistics from the World Bank).
The Market as a Social Fact, Big Pharma, and Health as a Commodity
“We thus find ourselves at a crossroads: health care can be considered a commodity to be sold, or it can be considered a basic social right. It cannot comfortably be considered both of these at the same time” (Farmer et al 2003, 174, 175).
Paul Farmer, an American anthropologist and physician, is a critical voice linking neoliberal ideologies to health inequalities. In his chapter Listening for Prophetic Voices: A Critique of Market-Based Medicine, Farmer calls for “prophetic voices” in medicine to speak out against neoliberal health ideologies. Farmer’s nod to our capitalist market system’s ethics, which enables health insurance, care, and medication to be purchased, is a nod towards the inequalities driven by neoliberalism.
Neoliberal views on the market influence how society views health; the chart below aims to outline how different ideologies view health and its components. Think about how the United States currently operates with health through your experiences.
Neoliberal mindsets actively inhibit the idea that “place” can be of significance to health, as they see living conditions and environments that individuals inhabit as choices that individuals make in regards to the market, rather than acknowledging that health is a product of one’s environment that one may not have “choice” over. This “choice” that I am referencing here could be, for example, housing prices that inhibit those with lower incomes from seeking healthier environments. Or, it could refer to segregation as produced by HOLC redlining that inhibited the growth of specific neighborhoods. In summary, health in the United States is under the neoliberal mindset’s control, deeming it a commodity rather than a right.
I argue that adopting Polanyi’s mindset about the market’s role in regards to health is one step towards making structural violence more visible.
His ideology allows us to see that health can and should be seen as an attribute of the population rather than an individually determined characteristic that is able to be purchased through market transactions (that are not necessarily available to and accessible by all). In order to explore this further and provide examples as to how and why neoliberal mindsets of health are furthering structural violence in the United States, I will discuss the history of drug regulation in the United States to demonstrate how the market is a structure that is both real and social. This history, depicting the story of the rise of Big Pharma following neoliberal deregulation, has led to the opioid epidemic in the River wards. I, alongside other anthropologists, argue that neoliberalism’s commodification of health constitutes a form of structural violence.