Social Theory & Health, 2005, 3, (126–143) r 2005 Palgrave Macmillan Ltd All rights reserved. 1477-8211/05 $30.00
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Marx: Capitalism, Alienation and Health CHRIS YUILL School of Applied Social Studies, The Robert Gordon University, Aberdeen AB10 7QG, UK. E-mail:
[email protected] Even though alienation theory is one of Marx’s better known theories, its potential for medical sociology has never been fully explored. This paper seeks to raise the profile of Marx’s theory of alienation in theorizing health and health inequalities. It will do so in three main stages. Firstly, why it is timely to reconsider alienation theory will be discussed in light of recent theoretical debates and wider concerns in medical sociology about embodiment and emotions. Secondly, alienation theory is outlined beginning with the strong materialist, biological, embodied and emotional basis of Marx’s ideas before exploring how alienation arises under capitalism. This section will also deal with how Marx’s theory of alienation is important to his entire oeuvre and not just present in his early work. Thirdly, the paper ends by reviewing examples of health research in the light of the four aspects of alienation that Marx identifies: product alienation, process alienation, fellow being alienation and human nature alienation. Social Theory & Health (2005) 3, 126–143. doi:10.1057/palgrave.sth.8700046
Keywords: Marxism; alienation; health inequalities; theory; capitalism
INTRODUCTION Capital therefore takes no account of the health and the length of life of the workery (Marx, 1990, p. 381).
Alienation is one of Marx’s more famous theories where he attempts to illuminate the lived experiences of capitalism, highlighting the lack of control and self-realization in the labour process. Marx himself throughout his work powerfully comments on how alienation has a variety of debilitating effects on the health of the worker in capitalist society which, ‘squanders human beings, living labour, more readily than any other mode of production, squandering not only flesh and blood, but nerves and brain as well’ (1991, p. 182). Situated in a family of concepts and theories that bring together
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economics, emotions and embodiment alienation theory should have some appeal, whether negatively or positively, for medical sociology. However, in the literature it is largely neglected and under-theorized. This is not just within the general body of medical sociology but also evident, interestingly, in writers approaching health from a Marxist perspective. I seek to address this theoretical lacuna and attempt to highlight the profile of Marx’s work on alienation and how it may be useful in further theorizing health and health inequalities. This paper does so by drawing from classical Marxism (Anderson, 1976) concentrating mainly on the works of Marx and Engels. Falling into three main parts, the paper initially explores why the time is right to consider alienation theory given current concerns with theory generally within medical sociology and medical sociology’s interest with the body and emotions. The paper then proceeds to outline alienation theory. This begins by examining Marx’s materialist ontology highlighting that Marx’s concerns with the body and emotions are evident throughout the whole of Marx’s project, before moving onto what alienation does and does not mean. Finally, the paper looks at the four aspects of alienation that Marx identifies where, by viewing examples from the empirical literature in a Marxist light, the relevance for alienation theory to health and health inequalities is highlighted.
ALIENATION THEORY – WHY HERE AND WHY NOW? There are two main reasons why Marx’s alienation theory can be of use for understanding health and health inequalities. The first reason is that there is a general discussion about theory within medical sociology with tensions concerning the sub-disciplines empirical and positivistic leanings (Scambler, 2002) and constructionist versus realist perspectives (Williams, 2003a). Secondly, within medical sociology there has been a growing use of theories and concepts of the body and emotion in assisting a deeper understanding of health. Firstly, relating to theory, there are concerns relating to both the general level and use of theory within medical sociology. As Scambler et al. (2003, p. 2) note there are very few health and health-care-related journals that promote theoretical debate often instead preferring to publish more empirically inclined work. Within areas such as health inequalities much of the mainly positivistic epidemiologically orientated research on health inequalities has recently come under critical fire for being limited in its explanatory power whether theoretically or philosophically (Forbes and Wainwright, 2001; Wainwright and Forbes, 2000). Further to this point, Social Theory & Health
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Williams (2003a, pp. 43–50) provides a useful critical overview of the state of theoretical play within contemporary medical sociology, identifying three main theoretical currents and their respective weaknesses: neopositivism (useful for prediction but limited in explanation), interpretivism (usefully elucidates personal narratives but limited in understanding the wider world) and post-modernism/post-structuralism (at worse, provides only a circuitous relativistic impasse). There is also a apparent shift away from post-modernist/social constructionist theories to more material theories, particularly Bhaskar’s critical realism (Williams, 2003a) or a combination of critical realism and neo-Marxism (Scambler, 2002). It is as part of this ‘realist shift’ that I present this paper,1 and it is with Marxism being a one of critical realisms antecedents (Bhaskar, 1989) that I believe that it is timely to reappraise alienation theory. Also, on a more general level adequate theorizing of alienation is missing within the broader literature on health and health inequalities. For example, the recent collection The Sociology of Health Inequalities (Bartley et al., 1998) had no mention of Marx, Weber or Durkheim! Interestingly, even among those writers approaching health from avowedly Marxist perspectives, alienation is also noticeably absent in any depth. In Navarro’s otherwise highly cogent critiques of capitalism, alienation is mentioned but only in passing with no real development. So for example, Navarro (1978, p. 84) correctly states that, ‘[a] continuous process of alienation and frustration is created by the capitalist system that reflects itself in despair and frustration’, but does not extend nor develop the point further. Also commenting on capitalism’s influence on health and healthcare, Doyal and Pennell (1979) draw on Marx’s more economic and structural writings but do not include alienation, while Blane (1987) draws on labour power theory but omits alienation in his Marxist-orientated discussion of health. And among writers who have dealt more explicitly with alienation or Marx’s views on human nature, such as Me´sza´ros (1972) or Geras (1983), there is little or no relation of alienation theory to health. Secondly, there are the embodied/biological and emotional ‘turns’ within (medical) sociology. An ageing population, increases in levels of chronic illness, late modern uncertainties and feminist and disability rights political activism have (rightfully) increased awareness of the body within (medical) sociology. Further, (medical) sociology can, as urged by Benton (1991), Williams (2003b) and Williams et al. (2003), help to go beyond reductionist approaches of understanding the biological and the body and develop a more rounded and fruitful view of the biological and sociological in relation to health and health care. In tandem with an increased focus on the body there has been an awareness of the salience of emotions to health. Freund (1990, Social Theory & Health
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1998), for example, has argued that emotions are experienced somatically thereby leading to a host of physical illness and symptoms. There is also, of course, the major, but much debated contribution, of Wilkinson (1996) who has brought attention to the influence of indirect psychosocial factors in health inequalities. Here, it is not the direct material factors but rather relative disadvantage and the emotional responses of shame and distrust associated with living in a socially divided society that are the causes in the great cleavages in health across society. Alienation theory speaks to these embodied and emotional concerns. At the heart of Marx’s philosophy is a biological material ontology that starts and proceeds with an understanding of a sensuous human relationship with nature and, within alienation theory, there is an understanding of the emotional and physical pain that life in capitalist society can bring.
THE ALIENATED BODY As outlined above, issues concerning the body, biology and emotions are current concerns with medical sociology and so it is appropriate to begin by considering Marx’s material embodied ontology and the role of labour. This will provide the basis on which to build a summary of how the body is addressed in Marx before more squarely considering alienation theory before commenting on how issues relating to the body and alienation are not just a passing youthful phase, as so often characterized, but a theme throughout Marx’s work. It is in the early works of the 1844 Manuscripts, The German Ideology and The Holy Family that we find Marx laying down his ideas on sensuous biological human nature identifying that humanity ‘as primarily a physical and biological being, is a dependent part of nature’ (Callinicos, 1983, p. 97). This theme of a sensuous biological human nature runs through the entire oeuvre of his work – a point I will expand on later. Here one finds Marx settling his accounts with and displaying the philosophical influences of Hegel and Feuerbach. As has been outlined many times and elsewhere (for greater details see, Arthur, 1986; Rees, 1998) – though, importantly for the task at hand, without any meditations on health – Marx moves away from Hegel’s idealism and Feuerbach’s lack of history to place humanity in a living sensuous historical and material world. Human beings stand as natural living biological beings in an interdependent relationship with nature requiring to fulfil the basic requirements of eating and sleeping and doing so by engaging in their natural biological disposition to collectively labour. And it is from that interdependent relationship with nature and that natural biological Social Theory & Health
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disposition of collective reflective labour that all else flows – relating to other human beings to meet shared needs thus creating the basis of social interaction and society2 (Geras, 1983). Right from the outset then Marx firmly and unambiguously recognizes that humans are biological beings existing in nature with certain biological needs and certain unique genetic abilities that separate humans from animals in meeting those needs: To say that man is a corporeal, living, real, sensuous, objective being with natural powers means that he has real, sensuous objects as the objects of his being and of his vital expression, or that he can only express his life in real, sensuous objectsy Hunger is a natural need; it therefore requires a nature and an object outside itself in order to satisfy and still itselfy A being which does not have its nature outside itself is not a natural being and plays no part in the system of nature (Marx, 1977, p. 136–137, quoted in Foster, 2000, p. 77, emphasis in Marx).
However, this is not to reduce humans to being biologically determined or to collapse the social into biology. On the contrary as Arthur (1986) and Rees (1998) argue humans do not simply exist as part of nature but rather are in a more complex dialectical relationship with nature, where Marx ‘conceives of nature and human beings as a totality, but not one in which either side of the contradiction can simply be reduced to the other’ (ibid., p. 72). The contradiction comes about because even though humans are in nature human consciousness, as Creavan (2002, p. 138) notes, is ‘a qualitatively distinct part of nature, by virtue of its power to reflect upon and transform nature in the service of human needs, and because it must still encounter the world as an objective power, as a set of circumstances which confront and constrain thought and action from without’. How this contradiction is resolved is through the mediation of labour between the human mind and the natural world (Arthur, 1986). It is labour that constitutes humans’ ‘species-beings’, the defining attribute that separates the human animal from other animals.3 That labour, though, has distinct qualities for humans within Marx’s writings, and this is explored next. As indicated in the preceding passage, human labour is reflective, an ability that is not witnessed in the behaviour of animals, even though there may, at certain times, be certain similarities: A spider constructs operations which resemble those of the weaver, and a bee would put many an architect to shame by the construction of its honeycomb cells. But what distinguishes the worst architect from the best of bees is that the architect builds the cell in his mind before he constructs it in wax. At the end of every labour process, a result emerges which had already been Social Theory & Health
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conceived of by the mind of the worker at the beginning, hence already existed ideally (Marx, 1990, p. 284).
Labour is also an embodied activity deploying human’s natural powers in relation with nature. So, for example, in Capital I we find Marx describing labour as a: yprocess between man and nature, a process by which man, through his own actions, mediates regulates and controls the metabolism between himself and nature. He confronts the materials of nature as a force of nature. He sets in motion the natural forces which belong to his own body, his arms, his legs, heads and hands, in order to appropriate the materials of nature in a form adapted to his own needs (Marx, 1990, p. 283).
There are many other examples of Marx referring to the essential embodied quality of human labour throughout his work, but space limits a fuller consideration of this element here, though the sections in Capital I on The Working Day (Marx, 1990, pp. 340–411) and Machinery and Large-Scale Industry (Marx, 1990, pp. 492–642) provide many examples of the centrality of embodiment to Marx’s ontology in his later works. In addition to being embodied labour is also emotional. The production of objects during labour is an objectification of human species-being, of essential human nature. Humans as they work invest a certain amount of self into what they are doing and on completion there is a satisfaction or reward in what has been produced and a replenishment and enrichment of self in seeing the labour complete (Ollman, 1976). As humans work, they call on their concentration, their ability to solve problems and, perhaps most importantly, creativity to bring about the creation of an object: It is in this manner that he ‘puts his life’ into his objects, the latter expressing in what they are the character of the organic whole to which they and the living person who made them belong (Ollman, 1976, p. 142).
The discussion so far has concentrated on Marx’s ontology identifying and highlighting its biological basis and the importance that reflective labour plays in the being of the human species being in terms of labour providing a realization of self. However, as Marx develops in his analysis, with the historical arrival of capitalism this vital and defining creative attribute of humanity is distorted, ripped away and therefore alienated. Capitalism denies humans the self-realizing qualities of their labour where the individual sees a positive affirmation of self in the object of labour, but instead sees a power that is more powerful and utterly alien. For Marx (1977, p. 63) capitalism creates a society where the ‘devaluation of the world of men is in direct Social Theory & Health
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proportion to the increasing value of the world of things.’ It is in this ‘world of things’ Marx notes in his concept of commodity fetishism that there is a dialectic of appearance and essence where there is an obscuring of the social relationships that actually produce an object. Reflecting on the importance of this Marxian concept for contemporary consumer society Billig (1999), following McRobbie (1997), argues contra post-modernist musings that objects or commodities are not playful free-floating signs removed from any real basis but are rather the outcome of a whole host of human activity (biological and embodied, I would add) and their relationships with each other. Thus, alienation theory can also assist in reminding us of the ‘beneath the surface relationships’ that exist within capitalism, and the essence of exploited and alienated human activity that lies beneath the reified appearance of commodities. Capitalism, then, deforms basic human nature to labour. This results in the productive activity that should be a pleasurable and rewarding experience becoming the source and cause of all that is wrong in life. This is alienation which Marx (1977, p. 66) outlines as being: The fact that labour is external to the worker, i.e., it does not belong to his intrinsic nature; that in his work, therefore he does not affirm himself but denies himself, does not feel content but unhappy, does not develop freely his physical and mental energy but mortifies his body and his mind. The worker therefore only feels himself outside his work, and in his work feels outside himselfy the spontaneous activity of the human imagination, of the human brain and the human heart, operates on the individual independently of himy it is the loss of self.
The passage above is probably the most succinct summary of alienation and its effects that Marx provides. From this passage, the affects of alienation on the worker on a variety of related and interweaving levels can be deduced: alienation can affect the worker’s health physically and mentally in terms of exhausting the body and the concentration of the mind required to work, but also emotionally – a point developed in depth later – in terms of the frustrating, unfulfilling dehumanization that alienated labour brings. Importantly, under capitalism alienation does not stop at the front door as an experience that is left behind at the end of the working day. The home, the private space, only gives the illusion of a ‘haven in a heartless world’. Alienation weaves through everything in life, where, as Ollman (1976, p. 202) states: ‘The life activity of the alienated individual is qualitatively of a kind. His actions in religion, family affairs, politics and so on, are as distorted and brutalised as his productive activityy There is no sphere of human activity that lies outside these prison walls.’ Increasingly the deluge of consumer Social Theory & Health
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goods and consumer lifestyles that rushes into our homes makes the family home ‘a unit of consumption not an emotional haven’ (Cox, 1998, p. 60). These consumer goods and lifestyles – even the rise of ‘reality TV’ – offer only a fleeting illusory private solace against the dehumanising experiences that we encounter in our public lives. One of the effects of alienation as identified in the preceding discussion is emotional. This requires a note of caution as reading alienation as being only ‘psychological’ or a question of ‘feelings’ can lead to an abuse of the theory taking it away from its materialist home and placing it in an idealist context. In so doing understanding how human beings are affected by social organization is lost and instead alienation becomes a matter of individual consciousness ‘repairable’ on an individual rather than societal basis. This idealist take on alienation is found in the writing of Blauner (1964), for example, who essentially gives primacy to the subjective experience of alienation, ignoring the objective conditions that initially create alienation. In tracing the emotional influence on health that arises out of alienation, it is important to follow Marx’s ontology in that the ‘mind’ and the ‘body’ are not separate either/or categories, but are dialectically related to each other, akin to what Freund (1990) refers to as ‘mind–body unities’. To shorthand a debate that is expounded at greater length (see Williams (1998, 2001) for more on this point), I read emotions as being both biological and social with social and economic structures having the ability to deeply and traumatically affect the functioning of the physical body. Freund (1990) argues that emotions are expressed physically in neuro-hormonal and muscular skeletal forms and that these expressions are strongly influenced by social structure, particularly social position, all of which impact upon health: ‘External’ social structural factors such as one’s position in different systems of social hierarchy or various forms of social control can influence the conditions of our existence, how we respond and apprehend these conditions and our sense of embodied self. These conditions can also affect our physical functioning (Freund, 1990, p. 461).
One criticism of what has been discussed so far is could be that it only applies to Marx’s so-called earlier works (though I have made reference to his ‘mature’ works) and that this youthful humanistic concern is dropped in crossing a philosophical Rubicon to a focus on economics and science on the other side of maturity. This particular reading is most evident in, and associated with, the writings of Althusser (1969), who sought to remove the subject from history and to read in Marx an ‘epistemological break’ where Marx dispenses with the human problematic of his early years in favour of a scientific problematic in his later work (Callinicos, 1990, p. 271). Giddens Social Theory & Health
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(1981) too identifies in Marx a separation between the two periods of his writing, whereby the mature Marx is economically reductive to the point of denying human agency (Callinicos, 1999, p. 106). I see no distinction between the early and mature works of Marx, but rather view them as a sequence where the ideas expressed in the early works are an embryo for the later work and that ‘Marx’s Capital is inconceivable without its ontological underpinning in the 1844 Manuscripts’ (Arthur, 1986, p. 144). As Rees (1998, p. 71) points out, the later works, particularly Capital, are the practice of the arguments that are rehearsed in the 1840s works. This tradition of reading Marx in this manner is fully and elegantly explained and developed by Arthur (1986), Ollman (1976) and Me´sza´ros (1972). To summarize so far, in Marx we can see the human body depicted as being part of nature but qualitatively different in that the human body can reflectively and socially labour on nature to meet its needs. This ability to labour forms a core attribute of human nature in that it defines the human species apart from other animals, but also for the individual human unalienated labour provides a deep emotional replenishment through the objectification of self. Under capitalism, however, that essential characteristic is inverted and humans are unable to consciously and creatively shape the world in the way they want. Essentially, capitalism removes and lessens control over labour. This key element of the lack of control and its influence on health will appear repeatedly in the next section that links alienation theory to health, by outlining the four aspects of alienation identified by Marx: product alienation, labour process alienation, fellow human being alienation and human nature alienation. In the course of this, examples from the literature are used. However, this is not meant to imply that the research mobilized here is in itself anyway Marxist or the authors have Marxist leanings but that there is something within the research that supports the case presented here.
PRODUCT ALIENATION Unalienated labour provides humans with a sense of self-realization and affirmation of species-being. The enrichment of self found in unalienated labour is reversed in alienated labour where there is a ‘one-sided enrichment of the object’ (Ollman, 1976, p. 144). This occurs because in capitalist society despite it being the worker who produces objects in their work, whether it is circuit boards on a computer in traditional manufacturing or the smile on their face in the service sector, for example, they do not own that object. Rather the object is owned or perceived to be controlled by the capitalist. Social Theory & Health
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Importantly, for Marx ownership does not necessarily mean legal ownership but effective ownership of the product. Therefore, the maker of the circuit board may never own the computer for which she constructs parts and the service worker who smiles may perceive her smile as not being of her own but as owned by the company for which she works. This results in the object becoming something over which the producer has no ownership and therefore considers alien and potentially something that confronts the worker. Further to that point, under capitalism the object a worker produces can begin to dominate her. The creative power, that vital aspect of humanity’s natural disposition, is permanently lost to the worker during the capitalist alienating production process. All that creative power, the energy, thought and consideration that it requires to make something vanishes into the object of alienated production, which in turn is not replaced by other revitalising creative power generated by the satisfaction gained by completing a task. Instead, the worker receives only money with which they can purchase other commodities that themselves are the object of someone else’s lost alienated creative power. Therefore, there is no sense of achievement or satisfaction in labour in capitalist society – it is a one-way process of the worker drawing out and giving away sometimes quite deep life affirming aspects of self in order to receive no equal or greater creativity in return, or as Marx (1977, p. 63) states quite literally, ‘the worker puts his life into the object’, with the object retaining that life and stealing it from the worker. This ‘putting of life into the object’ is especially so for work that requires emotional labour and this is elaborated on below. Hochschild’s (1983) work on ‘emotional labour’4 provides a good example of the relationship between a worker’s product becoming alien, hostile and something out of their control and consequent poor health. Hochschild focuses generally on how the shift towards a service sector economy has led to workers relying not just upon their physical or mental labour but increasingly on their emotional labour. This is where the workers’ actual emotions become ‘transmuted’ to serve the needs of capital and the particular industry in which they work, the end result being that smiles and expressions of care, for instance, become products and the property of the company and not the individual (Hochschild, 1983, p. 198; Hughes, 2003, p. 7). Hochschild (1983, p. 8) herself notes that for the workers she interviewed their smiles, ‘were seen as an extension of the make-up, the uniform, the recorded music, the soothing pastel colors of the airplane de´cor, and the daytime drinks, which taken together orchestrate the mood of the passengers.’ The service sector may not have existed to the same extent in Marx’s day when extractive and heavy-manufacturing industries were Social Theory & Health
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dominant. However, this does not mean that the service sector and its particular negative emotional impacts on workers health are not amenable to a Marxist analysis. One fundamental point that Marx makes about capitalism is that is a constantly revolutionizing system that is always seeking out new frontiers, new markets and new ways of working, thereby becoming unendingly dynamic, assembling and reassembling and of course melting all fixed and frozen relationships into air to ensure that profit is realized (Berman, 1999). Therefore, it is fundamentally wrong to regard Marx’s writings as only relating to heavy industry as he himself recognized that capitalism is in constant reconfiguring flux. So for Marx the type of industry is not of prime importance but rather the relationship between people. Callinicos (1989, p. 127) summarizes this well, when he comments that, ‘[t]he fact that much of this labour now involves interacting with other people rather than producing goods does not change the social relations involved.’ This situation is exemplified when the air stewardesses in Hochschild’s study complain that they no longer feel that their smiles, the welcoming caring emotion that company training demands that they contribute to their work belong to them but rather to the airline for which they work. The ramifications of emotional labour on health are quite considerable. As Williams (1998, p. 754) commenting on Hochschild observes that, ‘The Managed Heart, for example, is replete with references, to the ‘human costs’ of emotional labour, from ‘burnout’ to feeling ‘phoney’, ‘cynicism’ to ‘emotional deadness’, ‘guilt’ to self ‘blame’’.
LABOUR PROCESS ALIENATION Allied to the above point concerning how having no or little control over the object of production can result in alienation, is also the issue of having little control of the actual process of production. As Ollman (1976, p. 141) suggests, product alienation and process alienation are on a par with each other, both being intimately related to that essential abuse of the creativity of human nature under capitalism. The labour process under capitalism becomes one where the worker – and this can be in a variety of locations (eg: shop worker or academic) as Ferguson and Lavallette (2004) indicate – loses control over workplace organization, which has potential negative ramifications for the worker both physically and mentally (Cox, 1998). The result is that the worker loses sight of her natural disposition to labour and ‘as soon as no physical or other compulsion exists, labour is shunned like the plague’ (Marx, 1977, p. 66). Social Theory & Health
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In Capital I and III Marx provides many examples of how process alienation affects the health, the bodies and the minds, of the workers. So in Capital I Marx (1990, p. 548) rails against how: Factory work exhausts the nervous system to the uttermost, it does away with the many-sided play of the muscles, and confiscates every atom of freedom, both in bodily and intellectual activity.
Further in Capital III Marx (1991, p.179) states: The contradictory and antithetical character of the capitalist mode of production leads it to count the squandering of the life and health of the worker, and the depression of his conditions of existence, as itself an economy in the use of constant capital, and hence as a means of raising the rate of profit.
There are many other examples where Marx highlights how process alienation and its affect on the bodies and minds of workers result in, as Ollman (1976, p.138) summarizes, ‘stunted size, bent backs, overdeveloped and underdeveloped muscles, gnarled fingers, enlarged lungs and death pale complexions.’ Particularly, there is much invective concerning the treatment of women and children who, for instance, who endure ‘insufficient nourishment, unsuitable food and dosing with opiates’ (Marx, 1990, p. 521). Interestingly, many of Marx’s descriptions on the effects of the terrible conditions of women working in the clothing industry (eg, Marx, 1990, pp. 364–365) are almost identical to those made by Naomi Klein (2000, p. 215) concerning the exploitation of female labour in ‘developing’ nations today (Harman, 2000). One highly useful example from the empirical literature that illustrates the effects of process alienation is that of Whitehall I and Whitehall II studies of Whitehall civil servants (Marmot et al., 1997, 1999). Forbes and Wainwright (2001, p. 810) have commented, but do not develop further, that the evidence and results from the studies appear ‘to be directly related to the Marxian concepts of alienation and exploitation’. The research has identified that among civil servants of differing ranks there are decidedly different experiences of health that appear to relate to how much control a worker has in their workplace. Looking more squarely at the studies a picture of how process alienation is at play can be established. In both studies, there is a clear social gradient in mortality (Marmot et al., 1984) and morbidity (Marmot et al., 1991). In these studies we see how a worker’s health is affected by the extent of their control (examples being, choosing what to do at work, in planning, or in deciding work speed) within their working environment (Bosma et al., 1997), and how on a variety of measures the Social Theory & Health
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health, whether physical (for men and women) or mental (mainly for men), is influenced by the position or rank that they hold within the organization (Martikainen et al., 1999). This chimes very much with the alienation that arises out of the labour process where ‘[i]nstead of developing the potential inherent in man’s powers, capitalist labour consumes these powers without replenishing them, burns them up as if they were a fuel, and leaves the individual worker that much poorer’ (Ollman, 1976, p. 137).
FELLOW HUMAN BEINGS ALIENATION This aspect of alienation takes us away from the ‘immediate sphere of workplace relations’ (Rees, 1998, p. 90) and into the wider corrosive effects of alienation in its extension into society. Other humans cease to be fellow humans but are transmuted into ‘extensions of capitalism’ (Ollman, 1976, p. 144), and we are aware of them only by the objects, the commodities, they produce – the consequence of commodity fetishism with its obscuring of the social relations that lie behind production. This can lead to seeing others as a source of competition, for example, for better work or more favourable conditions within a workplace (Ollman, 1976, p. 207). Marx is making the point here that fellow human alienation creates antagonistic divisions between both the worker and the capitalist and between the worker and other workers. This is a society that is rift with division, cutting into that important characteristic of human collectivity, where people encounter fellow humans only as the objects of their production or as superiors or inferiors. Discussion of a society that is divided, or lacking in social cohesion, draws me to the, sometimes rancorous, debate surrounding Wilkinson (1996) and his psychosocial perspective – though space here limits a full Marxist analysis and comments should be regarded as a preface to work needing to be developed subsequently. The debate surrounding Wilkinson has been well rehearsed elsewhere (eg, Szreter and Woolcock, 2002) but the nub of the debate centres around whether it is the negative emotions created by perceptions of inequality and lack of social cohesion (Wilkinson, 1996) or structural material factors such as unequal distributions of resources, and lack of investment underpinned by historical and political trends (Lynch et al., 2000) that adversely affect health. There have been calls by commentators external to the two camps (eg, Szreter and Woolcock, 2002; Williams, 2003b) that there must be some common ground and that both perspectives are in some ways useful. Perhaps alienation theory can provide a solution to this impasse as it offers an understanding of how negative emotions emerge and impact on health due to lack of social cohesion Social Theory & Health
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and the negative emotions that it engenders. Marx (1978, p. 35) himself5 noted the negative emotions – albeit in the context of a materialist analysis of wages – social division engenders in Wage, Labour and Capital: Our desires and pleasures spring from society; we measure them, therefore, by society and not by the objects which serve for their satisfaction. Because they are of a social nature, they are of a relative nature.
Materialists should not shy away from acknowledging the important role that emotions play in poor health as emotions are one of the ways in which poor material circumstances are experienced. Alienation theory provides that linkage between the material and the emotional with the material circumstances and negative emotions being bound up dialectically with each other. Lynch (2000, p. 1003) argues for a similar understanding of negative emotions where he sees them as, ‘consequences of contextualized real-world living conditions’. Viewed from the perspective of alienation theory Wilkinson’s thesis then, could be seen as an exploration of the negative emotional effects of a divided alienated society but an exploration requiring a fuller historical materialist basis.
HUMAN NATURE ALIENATION The first two aspects of alienation – product and labour – are arguably tied in very closely to the actual moments of production whether in the worker’s relationship with the object she produces or in the organization of the work process in which she finds herself. The second two – fellow humans and, under present discussion, species nature – relate to wider social manifestations of alienation. The final aspect of alienation relates to what it is to be human and what separates humans from animals, in that humans have the ability to labour on nature to progress humanity as a whole. This is human’s all important defining ‘species-nature’. Alienated labour, for Marx, under capital with its relentless pursuit of profit prevents humans from carrying out that fundamental aspect of human existence. As Cox (1998, p. 51) succinctly puts it,’ [w]e have the ability to consciously plan our production, to match what we produce with the needs of society. But under capitalism that ability is reversed by the anarchic drive for profits’. Putting the preceding point into a health context, the natural human instinct to be social and further the health interests of other humans is alienated by capitalism. Consistently, it can be seen that in a variety reports, for example, from Engels (1987) observations in the 1840s to The Black Report (1980) to Shaw et al. (1999), working class bodies are consistently Social Theory & Health
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prone to chronic illness, early mortality and increased morbidity. However, in the time between Engels and Shaw et al. capitalism has advanced considerably but yet those health differentials remain. Dorling et al. (2000, p. 1551) make a similar point after analysing spatial and temporal distributions of health and poverty in London after updating’ Booth’s 1896 survey they conclude that not much has really changed concerning, ‘patterns of inequality in inner London and on the relationship between people’s socioeconomic position and their relative chances of dying.’ The resources exist to bring about a reduction in heath inequalities, for example, as Mitchell et al. (2000) point out 11,509 lives a year could be saved if various (moderate) reforms – reductions in wealth inequality, child poverty and unemployment – were implemented. This is one of the many dialectical contradictions that capitalist society creates – the simultaneous presence of the means to solve a problem that affects the lives of so many members of its society, but yet is incapable of putting the two together. Part of this contradiction is that capitalism by its very definition alienates labour in order to exist, thus negating the health of the workers that reproduce capitalism in every generation. The only way to ultimately resolve this contradiction is to remove or negate capitalism (a negation of the negation, so to speak).
CONCLUDING REMARKS The case that has been pursued here is that alienation theory is an absence within the wider theoretical framework of medical sociology, but given current theoretical trends, such as the ‘realist’ turn away from postmodernism and wider concerns within medical sociology relating to the body/biology and emotions, a reappraisal is timely. What Marx’s alienation theory can give is a theory that articulates the experience of real natural biological humans, without collapsing of the social into the biological, in a society that inverts human creativity and the ability to purposefully transform nature for the collective good into a painful and fragmented opposite. It also reminds us, at the very least, that the commodities that fill the supposedly leisure centred world of late/high/post-modernity are the actual outcomes of the activity and relationships of real people involved in an exploitative harmful system of production. Acknowledgements As ever I thank my colleagues Phil Sutton and Stephen Vertigans for their invaluable guidance and helpful comments on the various drafts that this Social Theory & Health
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article went through. Also, I thank Peter Freund for his support and encouragement as well as June Wells and Lydia Lewis for their assistance at various stages. ENDNOTES 1 There are a great deal of areas of convergence and divergence between critical realism and classical Marxism. It is not my intention here to explore that issue here but see Creavan (2000, 2002) and Callinicos (1993) for a Marxist perspective on critical realism. 2 For what kind of multi-layered dialectical real world that Marx sees emerging out of human labour see Geras (1983), Creavan (2000) and Sayers (1996). 3 A passionate debate exists as to whether or not classical Marxism is human centred, see Foster and Burkett (2001), and Foster (2000) for more discussion on this point. 4 Hochschild (1983, pp. 3–6) actually begins by referring to Marx and capital by comparing Marx’s (1992) analysis of the brutal conditions of 1860s English working class life especially for children in the wallpaper industry with the apparently benign pleasant working experiences of American air stewardesses in the 1980s. Quite interestingly, Hochschild (1983, p. 5) continues by commenting that the difference between the historical working class child and the contemporary air stewardess are not separated by polarity but rather degree and that there is ‘some unexpected common ground’ between her approach and Marx. In many ways, I would argue, Marx’s theory of alienation is a spectre haunting Hochschild’s work! 5 Both Wilkinson (2001) and Marmot and Wilkinson (2001) also make passing reference to Marx’s awareness of the psychosocial aspects of inequality.
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