To Live and Die in America
Class, Power, Health and Healthcare
Robert Chernomas & Ian Hudson
The Future of World Capitalism Series
London: Pluto Press, 2013
Paperback. xi + 232p. ISBN 978-0745332123. £17.99
Reviewed by Jeffrey H. Bloodworth
Gannon University (Erie, Pennsylvania)
Appalachian Emergency Room: Or Why the United States Mystifies Marxists
Tragedy makes good comedy. Indeed, Saturday Night Live made itself into a cultural icon (partially) based on this formula. In the mid-2000s, SNL featured a skit, “Appalachian Emergency Room” that put this aphorism to the test. In this sketch, random Appalachians wandered into their local hospital with bizarre and strangely acquired afflictions. For example, in a 2004 episode Ben Affleck played a trucker who suffered from a ferret bite to his crotch, an injury he acquired when he fed his pet while naked. The bit was funny, because it rang true. The wealthiest and most dynamic nation on earth is also home to a lot of poor and unhealthy people. In the face of this tragic paradox—sometimes all one can do is laugh instead of cry.
“Appalachian Emergency Room” reveals a certain truth: poor Americans only see a doctor in times of trauma. This reality partially explains why the American healthcare system exists in a state of semi-permanent crisis. Though the US spends more, as a percentage of GDP, on healthcare thanCanada and Western Europe, it boasts comparatively pitiful outcomes. Twenty-ninth in life expectancy and forty-sixth in child mortality rates, Americans scarcely receive a proper return on their healthcare spending. 
Everyone, from political elites to policy intellectuals, realize the absurdity of the situation—everyone that is except most Americans. Indeed, a recent Gallup Poll 73% of Americans reported they were “satisfied” with their healthcare. Robert Chernomas and Ian Hudson don’t understand this dissonance. The University of Manitoba economists devoted their new work, To Live and Die in America to this very conundrum. There is much that is right with this book. Unfortunately, the authors’ hidebound Marxist framework turns a promising work into an incoherent mess.
Critiquing the US healthcare system is the domestic policy equivalent to assessing North Korea’s Kim Jung-un. Since we know it is bad and the reasons for this are so painfully apparent, writers must say something fresh and novel. Give the authors some credit in this regard; they offer a new perspective. Downplaying the biomedical and behavioral approaches to understanding health, illness, and chronic disease, Chernomas and Hudson claim that political economy explains America’s poor healthcare system and its god-awful outcomes.
To the authors, the “cause” of illness is much more complicated than the biomedical school that holds genes, viruses and bacteria responsible for illness. Moreover, they also dismiss the behavioral approach. To them, blaming “self-destructive” habits of smoking, sedentary lifestyles, and unhealthy eating choices for poor health outcomes is simple-minded. They argue for a political economy explanation that embeds the behavioral approach in the context of how an “economy operates, [and] an individual’s place in it.”  In other words, poor Americans develop bad health habits because they live in a certain social context: so far, so good.
The authors’ discussion of the biomedical, behavioral, and political economy approaches to understanding health comprise the best portion of this book. That an individual’s health and disease occur in a larger social context is undoubtedly true. Bombarded by advertising and living in a nation that largely fails to tax junk food, America’s working poor gobble Cheetos, guzzle soda, and get fat. Unfortunately, the authors’ political economy approach purports to explain much more than that reality. And this is where their argument goes awry; their monocausal and obsessive focus upon “class conflict” as the ultimate and only explanation for the nation’s health outcomes undermine the entire work.
This is a book that is simultaneously interested in and oblivious to history. The authors aim their initial chapter at a commonly held myth that modern medicine, via vaccines and cures, is wholly responsible for the transformation in life expectancy. They argue, effectively, that higher incomes and improved living conditions, nutrition, and public safety measures led to these advances. Chernamos and Hudson betray their ahistorical groundings when they blame early industrialization entirely for the living conditions that rendered people susceptible to infectious disease in the first place. Perhaps, industrialization witnessed a profound and broad-based collapse in living conditions, which in turn spawned what they term a “casual Holocaust” . They offer no proof whatsoever for this claim. Nor do they feel compelled to explain their bombastic comparison of early industrial life to the horrors of Auschwitz.
The authors’ misuse of and inattention to history and context continually damage what are, at times, sound arguments. For example, they correctly wonder whether the roots to “chronic disease,” cancer and heart disease, are found and exacerbated by the “interaction of distress, fat, cholesterol, tobacco, chemicals, and economic inequality” . This supposition is wholly fair. For decades, researchers have wondered whether chronic disease is a result of people living long enough to develop these ailments, or were they causally linked to the proliferation of chemicals in our everyday lives. Regrettably, the authors never establish a contributory correlation between ever-present and cancer causing chemicals and the spread of chronic disease. To them, since cancer-causing chemicals exist and chronic disease flourish the two are linked.
Even more damaging are the authors’ extraordinary generalizations. They claim, “The unique US healthcare system is not a result of any genuine expression of the will of the people” [p.168]. This statement quite literally begs for validation, proof and further explication. Since national health insurance legislation has been met with stiff political resistance one could assume that, at least, a staunch minority of voters embrace the basic contours of the present system. Apparently, if the “people” opt for bad or incorrect policies then their will must not be genuine.
The authors are much more interested in their will than that of the American people. Indeed, they assume that the US should follow and mimic Canada and Western Europe. Chernamos and Hudson commence their book with an interrogation of “American exceptionalism” and claim that, “People in the United States exhibit a certain indifference to the rest of the world” . In these bookends, they reveal their work’s fundamental error and assumption.
Nearly two hundred years ago Alexis de Tocqueville traveled to the US and discovered how significantly the infant republic deviated from West European norms. Struck by the contrast, the Frenchman coined the term, “American exceptionalism.” For decades this idiom was employed by academics to explain the nation’s unique political evolution. Starting with the Bush administration, however, conservatives co-opted the term as a way to express America’s superiority.
The authors and conservatives both misunderstand de Tocqueville’sterminology. For better or for worse, the United States has deviated from certain political and cultural norms that make Western Europe a relatively coherent region. Nevertheless, specialists should discard the concept. Once upon a time, the US and Western Europe possessed remarkable similarities in their ethnic stock, cultural values, and political norms. Today, America’s NATO allies remain cultural cousins. However, the influx of African, Latin American, and Asian immigrants and the passage of time has made the US and Western Europe into more distant relatives. Thus, when Chernomas and Hudson constantly compare American healthcare or even passport ownership rates to those of Europe and Canada, it is no longer an apples to apples comparison.
In contrast to Western Europe, Americans are more parochial and they possess a substandard healthcare system. However, America ain’t Sweden. It is far larger, more diverse, more economically dynamic, and far less equal than its West European cousins. In terms of egalitarian norms and civilized behavior, West European society very well might be superior to the United States. Culturally similar yet increasingly distinct, conservatives and radicals should recognize the difference and discard this comparative framework.
If Saturday Night Live aired, “Laplander Emergency Room” nobody would laugh. In this skit, efficient Norwegian physicians would attend to healthy Laplanders while doctor and patient discussed plans for their government mandated 5-week paid vacation. Pleasant social democracies lack the raw material (and human tragedy) necessary for good sketch comedy. Marxists, social democrats, many liberals, and this reviewer surely desire a healthcare system (and society) closer to the Norwegian model. Unfortunately, Americans only mimic Scandinavians when they shop at IKEA. To Live and Die in America is a well-intentioned book premised on a fallacy; don’t bother reading it.
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