Monday, June 27, 2016

Capitalism and Democracy: Shaping the American Enterprise and Our Health

One faces the future with one's past. Pearl S. Buck (born 6/26/1892)

The Smithsonian’s National Museum of American History has assembled a major exhibition on the “American Enterprise,” which “…chronicles the tumultuous interaction of capitalism and democracy that resulted in the continual remaking of American business—and American life.”

I visited the exhibit just after being part of a Congressional Briefing on health equity where I made the point that the dominant worldview in the United States has led to policies and systems that systematically disadvantage some population groups while advantaging others; contributing to health inequities. Using the Triple Aim of Health Equity as the framework, I challenged congressional leaders to embrace a worldview that is based on community good and social justice rather than on individual needs and market justice. It was with that mindset that I entered the “American Enterprise” exhibition.

From the first to the last display I saw contrasting and conflicting worldviews impacting not just our health but the evolution of American business and democracy. During the “Merchant Era” (1770 - 1850s) when there was abundant land and vast natural resources fueling economic opportunities, the population was mostly rural. During that time, Thomas Jefferson saw the future optimally tied to farming, not factory work, while Alexander Hamilton favored an economy based on industry.

Those differing perspectives have persisted throughout the development and evolution of our economy and society. In the “Corporate Era” (1860s – 1930s) industrialization and business expansion brought major economic growth and social change to the United States, including massive immigration, financial crises, and labor/management confrontations. Business and political leaders “disagreed over the power of big business and whether it endangered the balance between private gain and common good.”

Industrialist Andrew Carnegie argued that competition was good for the country, while Supreme Court Justice Louis Brandeis was concerned that the rights of common citizens would be abridged by the wealthy few. Likewise, President Theodore Roosevelt championed the government’s role in controlling the negative aspects of unbridled big business. In anticipation of a more interdependent world, President Woodrow Wilson suggested the ideal of social responsibility and social cohesion.

In the “Consumer Era” (1940s – 1970s) “production boomed and consumerism shaped the American marketplace. Innovations in technology, expansion of white-collar jobs, more credit, and new groups of consumers fueled prosperity. Business and political leaders claimed consumerism was more than shopping: it defined the benefits of capitalism. This era marked a high point of American productivity and a high standard of living. But it ended with many Americans questioning the promises of consumer capitalism.”

Contrasting worldviews became starker during this time. Economist John Kenneth Galbraith opined that an unregulated marketplace resulted in “private opulence and public squalor.” Philosopher Ayn Rand contended that individuals thrive best in a free and unregulated marketplace. Labor and civil rights leader A. Philip Randolph argued that equality of opportunity could not be left to the marketplace.

In the “Global Era” (1980s – present) the pace of change has rapidly accelerated. Computers, smart devices, and “big data” have affected all aspects of life. There is increased global interdependence expanding markets and opportunities for some while eliminating traditional stability, employment, and safeguards for others.

While some of the debate around the role of government and free enterprise has existed since the founding of our country, the debate now has global ramifications. Economist Milton Friedman advocated for a limited role for government in the American economy while Secretary of Labor Robert Reich argued that access to opportunity was the right of all American citizens.

After two hours in the “American Enterprise” I was acutely aware that the differing worldviews that have jousted with each other over our economy also impact health. Given that socio-economic conditions are the greatest determinants of health, that wasn’t a surprise but I had never seen it articulated so clearly. I also realized that there is no “best” or “perfect” worldview. Every worldview by itself is inadequate for developing the policies and systems needed for everyone to thrive. That’s why the debate that has been going on in this country for 240 years is so crucial. That’s also why it’s essential for those of us in public health, who have a worldview that embraces advancing health equity and optimal health for all, need to be engaged in the debate.  And that’s why the questions that we have framed around the Triple Aim of Health Equity need to be part of every conversation:

Who is at the decision/policy-making table, and who is not?
Who is being held accountable and to whom?
What are the health and equity implications of any decision?
Who is benefiting and who is left out?
What values/worldviews underlie the decision-making process?

As I headed back to my hotel, I wondered how this museum visit would influence the speech that I was to give in five days at the Minnesota Rural Health Conference. The tension between capitalism/economy and democracy/community seemed like a theme to be explored especially as it relates to rural communities. Those tensions reminded me of a statement in "Racism and the Economy" by farmer, poet, and essayist, Wendell Berry – a statement that ultimately framed my speech: “Cultivating Health Equity and Optimal Health for All In Resilient Rural Communities – How the Dominant Worldview of Society Impacts Health.”

“A proper community, we should remember also, is a commonwealth: a place, a resource, an economy. It answers the needs, practical as well as social and spiritual, of its members - among them the need to need one another. The answer to the present alignment of political power with wealth is the restoration of the identity of community and economy."

Ed