The Political-Economy of Health
Instructional Notes on the Social Etiology of Disease for Public Health Education
Political-economy is a broad theoretical framework that, when applied to the field of health, examines the complex interactions and intersections between the political and economic domains of society and their relevance to the determinants of health. At its core, the political-economy of health advances our understanding that health is not determined solely by biological or medical factors, but is deeply influenced by broader societal and systemic circumstances. The deliberate combination of the two terms elicits the recognition of their inherent inseparability from each other. For health in particular, this framework incorporates a more thorough analysis of the sociocultural, political, historical, and structural factors that influence individual- and population-level health. This contrasts with (or adds onto) more limited conventional frameworks for human health that have prevailed in the past century, which we could describe variously as the ‘bio-behavioral’ model, ‘biomedicine’, or the 'empirical-analytic' traditions of public health, medicine, and the health sciences.
The political-economy of health draws on vast bodies of interdisciplinary scholarship that attend to how the social etiology of disease is shaped by power dynamics, social disparities, material (economic and political) concerns, and historical factors that shape the trajectory of human health. Historically, public health and medicine have been primarily viewed as basic scientific endeavors with only limited conceptions of the complexity of social reality and its impacts on the health of the individual, community, and society.
Despite ostensibly focusing on ‘the public’, public health has been predominantly shaped by administrative conceptions of the public’s health. In its early stages, public health administrators and their methodologies coalesced into a narrow set of interventions and an ethos centered on ‘disease’, ‘sanitation’, and ‘control’. The ‘public’ existed as a body to be acted upon. Such conceptions arose especially in early efforts to find effective responses to mass outbreaks of infectious disease, casualties of war, and in the context of regimes of population control and sanitation put in place by territorial and state authorities in colonial spaces such as the Phillipines and Cuba.
These early foundational perspectives on public health and medicine remained commonplace well into the 20th century. Despite considerable scientific advancements in the basic science of public health and epidemiology, the domains of public health and medicine have still lagged behind in their conceptions of social reality and the social and structural causes of disease. Many of these fundamental conceptions have gone unquestioned even to this day. This becomes especially evident when compared to the progress made by other disciplines in understanding human and social affairs.
Nevertheless, a minority of thinkers - and other disciplines outside medicine and public health - were dedicated to delving into the intricacies of how society, culture, and politics shape human health. Among the earliest European perspectives on the social causes of public health issues, some stem from thinkers rooted in the moral philosophy and social science of political-economy, originating in the works of early social scientists and philosophical critiques of capitalism during the 1800s. Rudolph Virchow (d. 1902), a 19th-century German anthropologist and philosopher, was one such thinker who occupies a notable position in the European tradition on the political-economy of health. In recent years, his contributions have become increasingly better known and recognized as a pioneering influence on this topic. His well-known assertion, "politics is nothing else but medicine on a large scale" has become something of a rallying cry for those advocating for a comprehensive social outlook within the domains of public health and medicine.
"politics is nothing else but medicine on a large scale”
What remains less well-known is Virchow’s commitment to interpreting and identifying the fundamental causes of epidemics and outbreaks he observed in his day within the context of the prevalent political-economic circumstances. Widespread unemployment, governmental failures to provide sustenance during famines that consequently worsened emerging epidemics, and even the substandard quality of housing coupled with overcrowding – all these elements influenced his perception of the transmissibility and susceptibility to disease, factors he not only recognized as exacerbating outbreaks but as examples of ‘fundamental causes’ of disease that we often refer to as ‘upstream’ causes in public health discourse today.
More crucially, he was also not just a theorist but an active participant in the political upheavals of his day and a proponent of political and economic reforms (through the lens of the socialism of his day) - changes he saw as necessary to truly promote human health. He was committed to a larger vision of changing the living and social conditions that he attributed as the root causes of the health of society as a whole, rather than just treating their outer manifestations through medical care for the individual.
Since Virchow’s day, our understanding of the social origins of health, wellness, illness, and disease has undergone significant evolution. Schools of thought influenced by political-economic perspectives on health include sizable subsections of medical anthropology, medical sociology, social medicine, critical public health, psychology, social epidemiology, and others. Gradually, a heightened awareness of these factors has permeated the basic orientation of the disciplines of public health and medicine broadly (for example, through now foundational principles of public health such as the ‘social determinants of health’ or even the recognition that patient level care is only one piece of the puzzle). However, the fundamental perspectives and practices of the field of medicine, their structural arrangements, and the prevailing ideologies animating them frequently remain unchanged despite a century of insights into the complex impact of social, cultural, and historic forces on human health.
For those already attuned to this imperative, as well as for those with a newfound awareness, the lack of recognition of the social origins of health underscores the urgency of redoubling efforts to integrate understandings of the political-economy of health into these disciplines. It motivates incorporating this framework as a fundamentally inseparable part of curricula addressing the study of health and society. For those positioned to effect such change, a few fundamental considerations are outlined below:
In practice, incorporating perspectives informed by the political-economy of health leads to the recognition that both health and healthcare are embedded within particular social and structural contexts. Elaborating the nature of this context leads to numerous political and social implications for how health and healthcare are tended to and motivates the need to more deeply understand the specific character of the political and economic realities that shape the health of populations. On one hand, it demands a degree of ‘systems-level’ thinking and entails the capacity to adeptly identify and critically engage with the underlying ideologies that not only ‘structure the structures’ of society but also shape processes of thought and knowledge at their most fundamental level within oneself and the communities around us.
On the other hand, this does not imply that every scholar or practitioner in the field of health must attain expertise across all dimensions of these extensive topics, nor does this dictate an exclusive focus on macro-level perspectives in our work and scholarship. Rather, it means that we can draw upon a more comprehensive range of conceptual tools to orient our work at whatever level we engage in.
Let’s explore an example. Let’s say the object of understanding for our work/scholarship was analyzing the efficacy of hospital care. Employing a framework informed by the political-economy of health prompts an awareness that hospitals as institutions do not exist in a vacuum independent of the historic, economic, and political circumstances that shape and structure their operation. This awareness reshapes what questions one asks, the modes and methods and kinds of studies you would use to explore these questions, and the bodies of theory you would engage with.
With this in mind, it would be hard to imagine gaining a comprehensive understanding of the institution of the hospital without recognizing, for instance, the political and economic forces of neoliberalism that have, in the past few decades, reshaped the fundamental operations and imperatives of hospitals, the ideologies and notions of health motivating their aims and directives, and their interactions with other social and economic entities. Even as the core question (“efficacy”) may remain, how one goes about this research shifts at a fundamental level. This is the nature of adopting a more comprehensive framework at the root of your learning. How would an understanding of the historic contexts of hospitals and other biomedical institutions as social ‘entities’ within specific periods of history, subject to distinct social and economic forces that shape their expression in society, change how you would think about such a research endeavor?
A natural set of questions would follow from adopting a political-economic framework for this topic; some more fundamental ones include:
whether healthcare ought to be a profit-producing enterprise subject to conventional economic forces
whether or to what extent citizens should be responsible for their own health and not for that of others
whether or not there is or should be any shared framework of collective responsibility for health of populations,
what means are there to achieve ‘collective health’ and should these be pursued through state or market interventions, scientific activity, and/or collective action?
However, these are only the beginning, only a few of the ways one’s program of research might change.
On a fundamental level, adopting a political-economic perspective of health encourages researchers to consider critical perspectives that illuminate how these overarching systemic configurations structure and influence human affairs, extending from individual and social interactions to community and societal dynamics. This approach naturally highlights a range of topics and themes that take on greater significance as a result, such as deeper consideration of the role of the State and State power; one’s perceptions of the role of history in shaping present circumstances; the role of culture, human agency, and social movements; the influence of social roles, classes or identities (whether race, sex, gender, religion, etc.); or more generally how socio-politically determined 'givens' shape social reality.
Rather than simply fixating on one or another notable concept taken to be the way to integrate political-economy of health into one’s work, this change occurs on a more fundamental level. Scholars and practitioners in the field of human health must build the capability to draw upon a growing and ever-more consistent body of knowledge informed by the vast implications that come from a more robust understanding of social reality and from integration of the political-economy of health as a theoretical framework. We must become more skilled at articulating how these factors intervene in human health in tangible and intangible ways, especially how they explain, produce, and reproduce the disparities and inequalities that counteract our resolve to promote health and wellness in society. Most importantly, this should motivate not just new understandings of how these disparities arise, but what can be done about them. After all, our understanding of social reality is not just some matter of fact - with us as distinct observers separate from what is known - rather, as social beings, we are active participants in and recipients of the very context we seek to study. Our awareness alone reshapes that which we study, but also prompts further action about what must be done.
As social beings, we are active participants in and recipients of the very context we seek to study. Our awareness alone reshapes that which we study, but also prompts further action about what must be done.
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