What is a critical disease policy
Why disease cannot be cured without politics
A conversation with the medical sociologist Hans-Ulrich Deppe
"Illness cannot be cured without politics," was the title of your book, which was still considered provocative in the 1980s. Today there is heated debate about health policy - however, the debate is mostly reduced to the costs of the health system. What do you mean, Mr Deppe, as medical sociology, by health policy?
I understand health policy to mean the political regulation of how society deals with illness and health. Illness and health cannot be limited to scientific knowledge, but are mediated historically and socially. And how society deals with it depends on the respective political power constellation. In Germany, health policy is largely reduced to disease policy and, with increasing economic pressure, it even congeals to a policy of cost containment. Your actual goals, life extension and improvement of the quality of life - and not only for individual, but for everyone - get out of sight. There are currently many individual health policy projects, mostly empirical studies. This includes the organization of medical institutions, the quality of health care, the importance of individual illnesses, the behavior of the insured and the sick, the remuneration of doctors, and competition with medical institutions. What is missing is the overarching perspective social orientation. Let me use a metaphor to describe it: There are currently many well-developed individual trees in health policy, but what the resulting forest looks like - or should look like - is unknown and is not addressed.
Health policy is not just an empirical survey and theoretical analysis, it is the content of numerous real social movements. I am thinking of the self-help movement inside and outside the health system, of social movements that deal, for example, with the environment, nutrition, sporting activity from the point of view of healthy living conditions. Not to be forgotten in this context are groups that provide important help from here in the Third World.
You described medical sociology as the “metabolism between medicine and society”. So it not only has the individual actor - whether doctor, patient or health insurer - in view, but this complicated network of relationships. What essential insights into this metabolism has medical sociology produced in recent years?
Poverty makes you sick - this is the brief, striking finding that has been clearly proven by numerous studies. Over the past thirty years, medical sociology has contributed to shedding light on these relationships with empirical studies: it has been established not only in industrialized countries, but worldwide that the lower the average income of the population, the higher the disease, and that in almost all societies the lowest social strata have the most frequent and the most serious illnesses and that life expectancy falls significantly as income falls. In more recent studies it has also been shown quite well that within the rich countries, those with the best life expectancies also have the smallest differences in income. It is about the degree of polarization in a society.
Medical sociology, along with other scientific disciplines, has developed into what is now known as health science. The development comes from the USA and is called public health there. In addition to medical sociology, health policy, health economics, nursing science, social medicine, etc. Public health is about the question of which social conditions and which social behavior make you sick. Are there certain social risks and social conditions such as environmental, working and living conditions, family constellations that cause illnesses or exacerbate certain illnesses? And how does society react to such findings?
Is prevention anchored as a political goal somewhere?
Prevention is a traditional social demand, but it was given considerable impetus at the end of the 1970s by the World Health Organization because it placed health promotion at the center of its activities. As early as Article I of the 1948 Constitution of the World Health Organization says: Health is a fundamental human right. And the WHO defines health as physical, psychological and social well-being. In Germany, we have an enormous amount of catching up to do in terms of prevention and health promotion, even if this idea has been anchored in the German Social Security Code since 1988. Prevention must continue to be an issue so that there is a rethinking process in health care. (...)
The German health system is considered to be particularly resistant to reforms and difficult to control. Can medical sociology offer scientific tools to regulate health care?
Yes, medical sociology can contribute a lot here. Until the so-called Seehofer reform in 1993, the German health system was considered to be resistant to change, but changes were possible all at once under economic pressure. Our health system is heavily legalized and bureaucratised - in a positive and a negative sense. That is why it is resistant, and there are also certain dynamics of its own. If you ask, for example, what medical sociology can contribute to this, then I will start from the scientific side: First of all, we need data on the state of health of the population and the care facilities - so we need reliable health reporting. Germany has some catching up to do here, that's one thing. But we also have to interpret these figures and incorporate them into policy advice. So today medical sociologists work in almost all institutions of the health system. Let me just mention the report just submitted by the Advisory Council for the Concerted Action in Health Care "Needs-Based Approach and Efficiency" as an example of the necessary cooperation by medical sociologists. It is not only about economics, but also about objectives in the health system, health promotion and prevention, but also about quality assurance and quality management - genuine medical and sociological issues!
Given the economic pressure, the question of social justice in health care will have to be re-asked. How will this affect the lower social classes?
If - as explained above - there are more and more serious cases of illness in the lowest income groups, then that means for the health insurance companies: The highest expenses are incurred by those who pay the lowest contributions. For these two economic reasons, the low-income count among unpopular members of the health insurance. In the course of the competition between the health insurances, the insurances tried to woo away the young high earners, who get less sick, with lower contribution rates. The companies naturally supported this because the employers pay 50 percent of the contribution. The risk structure compensation between the health insurance companies must therefore urgently be adapted to these requirements. From the point of view of social justice, there should even be a competition for the chronically ill. It should be worthwhile for the health insurers to keep seriously ill people, but also to pursue targeted prevention.
In an international comparison, do you see signs that the discussion about the commercialization of all areas of life has reached its limits, that citizens are instead demanding a discussion about the common good, about "common sense"?
The neoliberal wave started in the United States and came to us on the continent via Great Britain. In the USA and England, neoliberalization was pushed through more radically than on the continent, where a certain resistance has developed. The US has the highest health care spending in the world. They have exceptionally high administrative costs. It is also striking how extremely socially unequal health care is there. There is already talk of a mess of unsuccessful deregulation. In England we can observe that the economization of many areas of life and the abandonment of state regulatory competence has led to a polarization within society up to the dissolution of social structures and social norms of responsibility. Against the background of various crises - whether these are accidents in privatized areas of society or failures in agriculture - many Britons have the impression that the common good has lost control of society. The social bureaucracies in Europe are by no means too expensive compared to the USA. Interestingly, your administrative costs are rather low. They make a major contribution to social stability.
Medical sociology is inconceivable without the dawn of the 1968 era. Did the 68ers fail with their approaches to critical medicine, which does not regard the patient as an object, but focuses on the subject?
No, on the contrary: The critical and social medicine that developed in the context of the 1968 movement set things in motion. She discussed the connection between social conditions and illness. She has dealt with questionable authoritarian structures in the healthcare sector. She has criticized the fact that the patient is only perceived as an object. It should not be forgotten that this movement dealt with medicine under National Socialism for the first time in the Federal Republic of Germany.
I think that the stronger perception of the psyche, i.e. the subject of the sick, can be traced back to the 68 movement. It is not only the laboratory and thus scientific medicine that decides on health and illness, but also people's moods, fears, compulsions and feelings. Until 1967 there were no socially recognized psychosomatic illnesses. In 1967, psychosomatic illnesses were included in the catalog of benefits of the statutory health insurance. Since then, they have also been paid and socially recognized as a disease. Recently, the psychotherapists have been included in the medical care. In this context, one should also remember once again the statement made by Alexander Mitscherlich, the Frankfurt psychoanalyst. He said: "Medicine without knowledge of the imagination is veterinary medicine".
The combination of biology and economy can lead to fatal consequences if the image of man is reduced to the "homo biologicus" and the "homo oecomicus". I do not want to refer to the specific experiences of our history here, because today these relationships are presented in a different light, under different political conditions. But I think it is the task to become aware of this development and to influence health policy in such a way that the community is protected from an uncontrolled and self-determined combination of biology and economy.
The interview with Hans-Ulrich Deppe was first published in: »Research Frankfurt. Science magazine of the Johann Wolfgang Goethe University «, No. 03/2001.
Published in express, magazine for socialist company and trade union work, 1/02
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