63 Western healthcare has always been capitalistic

At the very outset, we should remember the arguments made in previous chapters, that health professionals have been just as driven by capital markets as any other field over the last century ^[1][2]. As Thomas Foth says, ‘The recent history of healthcare shows that professionals… have demonstrated little resistance to the neoliberal developments’, and ‘any protest that has arisen has not attacked the broader political conditions that made these transformations possible’ ^[3]. So, although health professionals have been more able than others to bury their politics more deeply, and use the functionalist mythology to project an image of altruism and public spiritedness, they are no less embroiled in the messy realities of human function, work and labour, efficiency, and productive social value. But post-professionalism argues that there is something different about the ‘late’ capitalism that we now associate with neoliberalism, globalisation, and digital disruption.

Late capitalism is so called because it deviates from the kinds of capitalism that evolved after the Industrial Revolution. Early forms of industrial capitalism created the belief in the Global North that there was no limit to human growth and flourishing. To achieve this growth, however, enormous human and ecological resources were needed to generate the profits necessary for further growth. Slavery, colonisation, the ‘naturalisation’ of unpaid women’s labour, a new focus on productive work, and, importantly, the creation of an enabling class of professionals trained to ensure the prosperity of the West, were some of the effects of this (see especially Chapters 3 and 4).

Unsurprisingly, perhaps, the belief in unlimited growth and its effects on people and the environment came up against resistance in the 1960s. As a response to this, the ‘late’ capitalism of the last 50 years has increasingly looked to perpetuate the idea of unlimited growth in the commodification of ever more atomistic aspects of social life. By disassembling, disaggregating, and marketising, increasingly granular divisions of human and material existence, late capitalism has turned individual humans into ‘an infinite number of data points… to be divided and sold’ ^[4].

Alongside capitalism’s search for new markets, governmental reforms became increasingly neoliberal. Advocates for neoliberalism espoused that human flourishing could best be achieved if individuals were economically self-interested, with the ideal citizen in a globalised neoliberal world being an ‘autonomous, entrepreneurial, and endlessly resilient, a self-sufficient figure’ ^[5]. The role of the ‘state’, here, ceases to be a welfare safety net against hardship, and becomes an increasingly permissive facilitator of private property ownership, free trade, and free markets ^[6], with the self-regulating free market as ‘the best way to allocate resources and opportunities’ ^[7].

Perhaps the best example of this is the way we now think of bodies in health and illness. Just a few decades ago, people defined health largely as the absence of illness: a simple binary state. Susan Sontag put it this way;

‘Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use only the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place’ ^[8].

By the 1980s, this idea had been replaced by the much more slippery concept of ‘optimal’ health; an amorphous and unachievable goal that gently pushed the expert’s objective diagnosis to the back, and gave primacy to the individual’s beliefs and desires. It allowed the concept of health to be seen as a much more holistic concept, and made it harder for ‘traditional’ disciplines to define. It made health a personal goal, rather than something the healthcare system took responsibility for. It made good health aspirational — for whoever can say that they are in ’a state of complete physical, mental and social well-being and’, note, ‘not merely the absence of disease or infirmity’ Link? And it opened up all of the new dimensions of health and wellness to a new marketplace for goods and services just as neoliberal economic reforms began to take hold. Health could now be individualised, and the social causes of illness pushed to the background, as people were encouraged to make their bodies sites for endless monitoring and improvement.

Crucially, the concept of optimal health has allowed late capitalism to extend its reach into health by finding ways to extract profit from the litany of bodily frailties and imperfections that we are all now encouraged to diagnose and treat in the name of embodied ‘improvement’ ^[9]. The ‘juggernaut of modernity’ ^[10], has re-shaped how we think about bodies in a way that cannot help but influence future physiotherapy, not least because approaches to practice that were once concentrated on relatively discrete populations of ill, injured and disabled people, are increasingly being seen as necessary for all ^[11]; ‘as all citizens grow increasingly responsible for policing their own bodies as a foundational aspect of their well-being’ ^[12].

The ambivalence that people increasingly feel in the face of the ‘avalanche of information, commentaries and analyses’ ^[13], only helps late capitalism because it forces us all to be more reflexive, and take more responsibility for decisions that previously might have been shared; loosening the social bonds ‘through which we gained our identity’ ^[14]. And by being increasingly responsible for our decisions, we can also become increasingly responsible for the costs of treatment and care, further driving healthcare away from its traditional centres of control, opening a marketplace for a thousand new experts and services to match whatever people need. Assuming, of course, you have the surplus time and money to enjoy your newfound freedom ^[15][16][17].

Although ‘attending to oneself is a privilege’, and has been a ‘mark of social superiority, as against those who must attend to others’ ^[18], ideas of optimal health and personal responsibility are quintessentially late capitalist concepts because they are based on the principle of unlimited growth, a concept that only found a home in healthcare when it was realised that health could be seen as an endlessly divisible series of subunits that could be extracted, monetised, and recomposed.

What has made the influence of late capitalism even more pervasive, however, has been the confluence of neoliberal political economies, with globalisation and digital disruption ^[19]. Anthony Giddens — who originally coined the term ‘globalisation’ — has suggested that no other civilisation has remotely approached the level of interdependence we now experience ^[20]. (It is chillingly prescient, given the COVID pandemic, that Bryan Turner commented in 2008 that, ‘The deregulation of global markets as a consequence of the neoliberal policies of Reagan and Thatcher will have the unintended consequence of bringing about the globalization of disease’^[21].) Giddens sees globalisation as ‘a fundamental restructuring of the basic institutions of the societies in which we live’ (ibid), working by drawing power away from the ‘old’ nation states and re-siting it in the hands of global corporations, whilst at the same time pushing services closer to local communities, encouraging devolution of power and local cultural autonomy ^[22].

But although neoliberal economic reforms and globalisation have profoundly affected almost every sphere of society, from banking to music production; architecture and accountancy; religion and self-help; manufacturing, tourism, and journalism; social media, education and writing; leisure and work, health care remained largely immune. In part, this may be because, ‘to realize a neoliberal agenda in health care, it was first of all necessary to transform hospitals and healthcare services into economic entities’ ^[23]. And this took time, not least because the earlier ideas of healthcare needed to shift from personal value to economic cost, and from a culture of idiosyncratic service to one of predictable, risk-managed, standardised processing.

Health professionals took time to naturalise this shift, and still many resist, but the key may now have been turned by digital disruption because it provides the tools to take medicine’s reductive logic to its logical conclusion, and create an infinite number of ways to disassemble and reassemble a person’s health and, in doing so, create an enormous market for the sale of personal goods and services to rival any of the gold seams, coal fields, or oil reserves of the last two hundred years.

From ‘hospital at home’ ^[24], and the hospital without walls, that prioritises ‘surveillance and early intervention’ ^[25][26]; deep learning systems to aid diagnosis ^[27]; AI-based exercise machines ^[28]; robot-assisted surgery, personal care, and rehabilitation ^[29][30]; the ‘molecular politics’ of wearable health tracking technology ^[31][32], whose ‘target is habits of moving, eating and drinking, sleeping, working and relaxing’ Lindner P. Molecular politics, wearables, and the aretaic shift in biopolitical governance. Theory, Culture & Society. 2020;37:71-96.[/footnote], and offers ‘improving daily productivity’ ^[33]; work routinisation and disintermediation are rapidly becoming everyday features of contemporary healthcare.

The reaction from orthodox health professionals has been mixed. A number of writers are now suggesting that the rapid pace of change in healthcare has revived forms of medical paternalism that neoliberals and critical theorists had both sought to tackle over the last half century^{[34][35][36][37][38]}. But other initiatives, like the drive for evidence-based practice, the pursuit of precision medicine and novel genetic therapies, and attempts by medicine to be seen as more holistic, through the biopsychosocial model, may well reflect an attempt to shore up medicine’s historic base in the face of post-professional reform.

Because the health professions command such high levels of power and prestige, some of the most profound reforms have often come quietly, without fanfare. Some of the changes show, however, just how deeply the logics of late capitalism have penetrated healthcare. In Thomas Foth’s critique of the nursing process, for instance, he shows that nurses’ use of a systematic assessment of the patient’s problems and resources — a process very close to the evidence-based, problem‐solving, and decision‐making process used by physiotherapists — leans heavily on accounting and cybernetic practices common to industrialisation ^[39]. The ideals of an instrumental, ‘objective, transparent, rational, and comprehensible’ approach, reducible to the kinds of ‘means-ends analyses’ of inputs and outputs, links every action of the nurse (or therapist) to ‘discrete sections each measurable and linkable to monetary value’ (ibid). The work of the therapist seemingly continues as before, but now ‘health itself is conceptualized as a profit/loss situation, and the patient as human capital in an expense account’ (ibid). (Max Weber famously argued that the vaunted objectivity of bureaucracies and modern science-based professions, meant they were often unable to engage with the basic humanity of the other’ ^[40].) In contrast to the image portrayed by professions like medicine (and by extension, physiotherapy), these professions can be ‘cold, impersonal and anonymous’ social forces, lacking a sense of public responsibility. Such values make them ideally suited to the market-driven ethos of neoliberalism ^[41].)

In a similar vein, Arseli Dokumacı has questioned the taken-for-granted obviousness of medicine’s adoption of quality of life (QoL) as a guiding framework. Dokumacı, Arndt and Bigelow and others argues that healthcare measures like QoL speak directly to the emerging managerial and corporate culture in healthcare (ibid; ^[42]), and focus on the ‘lack of correlation between the amount or type of care provided and the level of improved health’ ^[43]. QoL places much more emphasis on the consumer’s voice, and increasingly holds professionals to account for poor productivity, service quality, and value for money. Rather than being an earnest attempt to improve care for patients, then, the adoption of QoL has been seen by some as a way for medicine to share in some of the spoils of late capitalism and align the profession with new neoliberal market ideologies (ibid).