By Jennifer Cohen
To work toward health justice, we must recognize health as a function of (1) capitalist economic development processes, including (2) gendered and racialized divisions of labor. Together, these heighten the contradiction between the profit motive and the domestic and global requirements of public health. This contradiction is also evident in the ways (3) markets can misallocate inputs to health (e.g., hand sanitizer, personal protective equipment for medical practitioners) and how most people obtain health (e.g., as “consumers”).
Health justice requires acknowledging that the capitalist organization of work establishes and reinforces health disparities.
First, the premise of capitalist economic development is capital accumulation through profit maximization and cost minimization. As evidenced historically (e.g., colonization and slavery) and currently, labor costs are minimized by combining exploitation, a class relation, with oppression, or intersecting social hierarchies. The gendered and racialized division of labor reflects both history and the ongoing pursuit of cost minimization.
Profit maximization typically demands cost minimization, and the lowest costs to capital are those it does not pay for at all. Hence capital seeks the lowest labor costs through gendered and racialized divisions of labor — from the level of the household, where women are disproportionally responsible for the unpaid reproductive labor that sustains current and future generations of workers, to the global movement of capital as it searches for low labor costs.
Abundant historical evidence demonstrates that beneficiaries of global capitalism have shaped the economy to meet their desires at the cost of well-being for the majority of the population of any country: women, racial and ethnic minorities, the disabled, and LGTBQIA folx. Even the most cursory consideration of the global economy in historical context reveals health injustices associated with the pursuit of economic growth.
Colonization and slavery are but two historical examples that have generated and reinforced disparities in health. Disparities persist through the gendered and racialized division of labor of paid and unpaid work. Hence, the way in which capital organizes both production and reproduction — historically and at present — combines exploitation with systems of oppression. Together these structure health injustices.
For example, the gendered and racialized patterns of impact from COVID are utterly predictable for reasons that have very little to do with the virus itself and a great deal to do with the capitalist organization of work. The impacts include mortality and morbidity, as well as social determinants of health, such as employment, especially among Black women; income; and time-use.
Health justice requires recognizing the gendered and racialized division of labor in the provision of care — including health care.
Second, feminist [radical] political economy highlights how gendered and racialized divisions of labor are present across work activities, not just in work for pay. I lay out this argument in depth in a recent publication, in which I show how capital accumulation depends on the oppression of women in paid labor, and how all paid labor (not just women’s) depends on women’s unpaid work. Production and reproduction depend fundamentally on women’s work and therefore on their health. It is a well-documented phenomenon that, compared to men, women tend to manage households with more children, older people, adult children, and extended family members. Their households also tend to have fewer income-earners. Put simply, women support more dependents and their households are more dependent on women’s earnings, both of which likely contribute to women’s sense of being under pressure. In other words, gender roles contribute to stress.
The points above hold for women broadly, but the case of health care workers, the suppliers of care (70% of whom are women) and of nurses and midwives in particular (85% of whom are women), merits particular attention. Protecting health care workers’ health has direct and indirect benefits for families, households, communities, health care systems, and population health. However, it has not been a priority, in part because of cost-minimization strategies.
The pressure nurses are under to provide care outside of the hospital and to support family members has implications for the capacity and stability of health care systems, and is particularly concerning for public health care systems, which exist to care for the underserved and marginalized. The gender division of labor in the household can act as a constraint on the quality and quantity of care supplied by women practitioners.
A qualitative study with Black women working as nurses in a public hospital in Johannesburg demonstrated social and economic dependence on women’s health even prior to the pandemic.
Q: Tell me a little bit about stress at work and stress at home.
A: What can I say? At work, there’s not stress like bad stress. (emphasis in original)
— Auxiliary nurse (R1I29), 34, single mother of three.
Nurses share a belief in the conventional wisdom that nursing is a stressful occupation, and therefore they expect stress at the hospital. In contrast, the “bad stress” noted by the nurse quoted above comes from stressors that appear to have origins outside of paid work. But despite the appearance of two separable, distinct sets of stressors (one from the hospital and one from the home) nurses’ stress outside of paid work tends to be directly connected to aspects of that work, such as shift scheduling, nurses’ pay, and geographic constraints. The demands of nursing combine with gender norms and the economic realities of dependency to contribute to chronic stress among nurses. When a stressor is widely shared among workers in a particular occupation, it suggests the stressor is in fact associated with their paid work. It is an occupational concern.
Health justice requires reconsidering how markets allocate inputs to health and how people obtain health.
Third, on the demand side, an “ability-to-pay” market-based framework for allocating health resources reinforces health inequities, because people with the lowest incomes are the least able to obtain not only care, but even basic preventive resources like hand sanitizer, during the pandemic. In a genuinely welfare-maximizing world, the people who should have the best access to hand sanitizer are those least able to wash their hands, e.g., the homeless. Instead, during the pandemic, we saw price gougers hoarding and reselling sanitizer to the highest bidders. The pandemic spotlights this troubling dynamic, but misallocation persists outside of pandemic context. In the face of existing inequities, “responsibility for health” can hardly be assumed to lie with the individual when the market system does not provide access to inputs to health.
Jennifer Cohen, PhD Economics, is Assistant Professor of Global and Intercultural Studies at Miami University, USA and Joint Researcher with Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.