At What Cost: Modern Capitalism and the Future of Health

Book Title: At What Cost: Modern Capitalism and the Future of Health

Authors: Nicholas Freudenberg

Publication Information: Oxford, UK, Oxford University Press, 2021, 406 pp., $29.95, hardcover

Dr Freudenberg is Distinguished Professor of Public Health at the City University of New York Graduate School of Public Health and Health Policy, Director of the CUNY Urban Food Policy Institute, and founder of Corporations and Health Watch. He is well known for his work studying the influence of corporations on public health (book spoiler alert: he generally doesn’t consider it a good idea). His other books include Lethal but Legal and one of the classics in urban public health, Cities and the Health of the Public, which he coedited with Drs Sandro Galea and David Vlahov.

The book opens with a chapter titled “The Changing Face of US and Global Capitalism” and the body of the book deals with the influence of capitalism on major areas of our life, divided into sections: Food, Education, Health Care, Work, Transportation, and Social Connections.

The book presents a clear point of view and ultimately a balanced perspective. In doing so this is a more powerful and thought-provoking book than one simply calling for the end of corporate medicine in America. The author acknowledges the growth of capitalism as part of US health care, and in some cases, perhaps even its necessity. Yet the case studies in these above chapters illustrate clearly some simple truisms. When profit is a primary motive, then capitalist enterprises in the social sphere are at best used for financial gain, or at worst an incidental line of business that can be discarded when profits run dry. The moral and practical tussle would seem to be between catering to the market (the foundation of capitalism) and engaging in public good, a thread running throughout the book. Health in the United States is a prime example, being a tussle between caring for patients by individuals who should have no financial incentive (physicians and other providers), and those who would make a profit based on that health care (insurance companies). In my opinion, this has reduced health care providers to being more akin to shopkeepers who profit based on what they sell, than school teachers who get paid a fixed amount to educate the children in their classrooms. It is a peculiarity of the US health care system that when a system designed specifically to maximize curative interventions fails to deliver adequate prevention and public health, we are shocked and dismayed. One suspects Dr Freudenberg would not be shocked. He provides excellent examples from cancer care, that dissects the relationship between overlapping interests within this field: those stricken by disease, those seeking to cure, those seeking to profit. He notes that in a rational system, medical science and those who govern it would in fact be the driving forces, and, for example, lead to better and more equitable treatments for cancer and other conditions. He notes with dismay that in the US system, corporate/capitalist interests have usurped this authority, and not always to the end of the public’s health.

The reader is confronted with the inescapable truth that making a profit off the poor is difficult to do; thus capitalism may be an imperfect tool to solve issues that do not yield immediate or foreseeable profit in conventional terms. This is consistent with the overall theme of the book, namely that unfettered capitalism does not achieve the aims of public health. What it does accomplish—short term financial gain and incidental benefit to health—is neither effective nor replicable (the Unitd States being quite alone among industrialized countries to resist socialized health care).

The author’s case studies in other areas of health are equally robust. This is a thoroughly researched book with decades of experience to back it up. If anything, occasionally the approach is too academic; for the casual reader, there may be too much data presented before getting to the crux. This stands in contrast to the types of popular works that make a provocative point first, then layer in the supportive information.

This book serves several audiences, even without occupying the type of pop-culture bookshelf space that others might: teachers and students of health policy within schools of public health, medicine, or other health sciences; individual chapters would also make fine reading material for family medicine journal clubs (the entire book may be a stretch).

This is an important contribution to the literature on the topic, and I look forward to more of Dr Freudenberg’s thoughts on the future of health care, health policy, and the intersection between private corporations and public health.