Offline: Defending the left hand of the state

Abstract

On Jan 14, 1992, Le Monde published an interview with the French social scientist, Pierre Bourdieu (1930–2002). Bourdieu drew a distinction between what he called the two hands of the state. The left hand represented those ministries that “are the trace…of the social struggles of the past”—notably, health and education. The right hand was symbolised by “the technocrats of the Ministry of Finance”. Bourdieu had lived through a decade of Margaret Thatcher and Ronald Reagan, and the influence their policies had had on politicians in France. He concluded that he was seeing one of the greatest reversals of human civilisation—“the failure of the state as the guardian of the public interest”. When asked how the public might respond, he cited ancient Egypt. When Egypt passed through a crisis in its state, the country's rulers, losing respect for the public interest, embraced corruption. The public, in despair, turned to religion. Bourdieu argued that after a decade of “neoliberalism”, the public had rejected the state, “treating it as an alien power to be used so far as they can to serve their own interests”. Bourdieu dedicated the final years of his life to uncovering the malign absurdities of neoliberalism on human wellbeing. He showed how neoliberalism undermined the state and the state's responsibilities to its citizens, including the state's responsibility to provide health care. Yet, in mainstream medicine and public health today, few people talk about the connections between neoliberalism and health. Even the most radical public health document of this generation—the Commission on Social Determinants of Health (2008)—held back. Neoliberalism is not a synonym for capitalism. It is a specific form of capitalism, an intensification of capitalism, a political project to reinvent the state and deliver ever greater power to economic elites. As with all forms of capitalism, the market is judged the superior mechanism for the allocation of resources. Neoliberalism then takes a unique turn. It does not endorse a small laissez-faire state. Instead, it demands an interventionist state, one that clears away all obstacles to the market. If markets don't exist, the state creates them (carbon trading). The state will create new spaces for markets to flourish, supranationally (the European Union's single market) and subnationally (decentralisation of power to cities). Neoliberalism is typified by the deification of individual responsibility, privatisation, deregulation, and reregulation—management of the public sector according to private sector principles. For 40 years, neoliberalism has become deeply embedded in our political, economic, and social institutions. Most insidiously, the neoliberal perspective has infiltrated Bourdieu's left hand of the state. Medical and scientific institutions have warmly adopted the neoliberal project. Their Presidents and Provosts, Rectors and Deans, have become its advocates, deploying arguments of realpolitik, economic necessity, and material instrumentality to justify their policies and actions. The rewards—financial and honorific—buy their collusion. Yet one can find examples across the entire scope of medicine and public health to illustrate the harms of neoliberalism to human health. What can be done? First, consider Bourdieu's evidence and arguments. Ask, do they have resonance today? At a moment when we observe the importance of race, gender, class, and power in shaping health, the answer is surely affirmative. Second, conduct empirical studies of the effects of neoliberalism on health and the determinants of health. Too few of such studies are being done, at least partly because funders are indifferent. Finally, when evidence shows harm, construct critiques to resist, counter, and provide alternatives. Our modern times of austerity, precarity, and insecurity make Bourdieu's analysis of immediate importance. In October, the 40th anniversary of the Declaration of Alma-Ata will be celebrated at a conference in Kazakhstan. A new declaration will be launched to resituate the principles of Alma-Ata in an era of sustainable development and universal health coverage. The original declaration claimed health as a social goal demanding the full commitment of political and economic sectors. Alma-Ata was a manifesto defending health equity and issuing a warning against the dawn of a neoliberal epoch. Bourdieu argued that neoliberalism was not inevitable. A renewed Alma-Ata declaration offers the opportunity to stand against neoliberalism and to insist on the strengthening of the left hand of the state.