Creating a participatory system of economic democracy in Rojava

Out of repression has emerged one of the world’s most interesting experiments in democracy. And by democracy, what is meant is not the formal capitalist variety of elections every few years in which consumption of consumer products is substituted for participation in societal decisions.

Surrounded on all sides by hostile forces intent on destroying them, in a part of the world that Western pundits claim can only be ruled by dictators, the Kurds of Syria are intent on creating a society more democratic than any found in North America or Europe. This is not simply a matter of creating institutions of direct and communal, as opposed to representative, democracy but, most importantly, democratizing the economy. In the words of the imprisoned Kurdish leader Abdullah Öcalan, “In self-government, an alternative economic system is necessary, one that augments the resources of society rather than exploiting them, and in that way satisfies the society’s multitude of needs.”

The many sides of that equation are explored in detail in Revolution in Rojava: Democratic Autonomy and Women’s Liberation in Syrian Kurdistan,* a study of Rojava’s experiment in radical democracy by three activists who spent months in Rojava studying the society being constructed, and who themselves have been involved in Rojava in various capacities. One of the authors, Anja Flach, spent two years in the Kurdish women’s guerrilla army. Her co-authors are Ercan Ayboga, an environmental engineer, and Michael Knapp, a historian. Although the three authors make clear their sympathies for the Rojava revolution, their book is not hagiographic, but rather a serious analysis of a developing process.

The Kurdish people are split among four countries — Iran, Iraq, Syria and Turkey — and have long suffered persecution in each of them. Their persecution in Turkey is well known; successive Turkish governments have attempted to disrupt organizing, obliterate Kurdish culture and ban the Kurdish language through waves of lethal military crackdowns. Mr. Öcalan escaped Turkey after a military coup that led to hundreds of thousands of Kurds thrown into jail; he and the Kurdistan Workers Party (PKK) he leads were granted asylum in Syria. In the late 1990s, under Turkish pressure, Syria expelled the PKK, and a year later, Mr. Öcalan was abducted from a Greek consulate (a kidnapping believed to be a CIA operation) and has been imprisoned in Turkey since.

But that the Syrian régime found the PKK a useful lever against Turkey for a time did nothing to ameliorate ruthless repression against the Kurds of northern Syria. The Ba’ath Party of the Assad family implemented a policy of “Arabization” against Kurds and the other minority groups of the areas now comprising Rojava. Kurds were routinely forcibly removed from their farm lands and other properties, with Arabs settled in their place. Bashar al-Assad, in contrast to the misplaced hopes that he might institute a thaw upon succeeding his father in 2000, instituted a harsh neoliberalism. Mass privatization, suppression of unions, the shredding of the social safety net and a channeling of investment capital into tourism and away from production had a particularly devastating impact on Rojava.

After the uprisings in Syria against the Ba’ath régime began in 2011, the struggle quickly became militarized. The Kurds avoided being overrun by the Syrian army or the various Islamist forces because of their own organization. Grassroots organizing had been done steadily since the 1990s, and when local government collapsed following the 2011 uprisings, that organizing, a nascent council system and the formation of militias enabled the carving out of an autonomous territory. People surrounded government buildings, demanding the surrender of all arms while guaranteeing the safe passage of all Syrian government officials. This tactic worked, quickly sweeping through all three “cantons” of Rojava. (A canton is a portion of a province, perhaps bigger than a U.S. county or French department but smaller than a U.S. state or a French region.)

The aim here was to create a democratic territory through peaceful means. This takeover was accomplished nearly without bloodshed, although Rojava’s militias have had to repeatedly repulse attacks from Islamic State, al-Qaeda and other hostile forces, as well as fend off the sometimes active hostility of the Turkish government, which has allowed Islamic State terrorists to freely cross the border and re-arm themselves. Sadly, Rojava has also been subjected to periodic blockades and political harassment from the two corrupt parties that control Iraqi Kurdistan, which borders Rojava to the east.

The system of democratic autonomy

The basic units of Rojava’s organization are councils and commissions. These constitute the building blocks of Rojava’s system of “democratic confederalism.” The authors of Revolution in Rojava explain this concept in this way:

“Democratic Confederalism aims at achieving the autonomy of society, that is, a society that administers itself through small, self-governing decentralized units. It entails a permanent social revolution, reflected in every aspect of social structure. All institutions are self-organized and self-administered.” [page 44]

Concurrent with that concept is “democratic autonomy,” which is defined as “the autonomy of the commune” in an “anti-centrist, bottom-up approach.” The commune is the basic unit of self-government, the base of the council system. A commune comprises the households of a few streets within a city or village, usually 30 to 400 households. Above the commune level are community people’s councils comprising a city neighborhood or a village. The next level up are the district councils, consisting of a city and surrounding villages. The top of the four levels is the People’s Council of West Kurdistan, which elects an executive body on which about three dozen people sit. (“West Kurdistan” is the portion of Kurdistan that lies within Syria.)

Integrated within the four-level council system are eight commissions — women, defense, economics, politics, civil society, free society, justice and ideology — that work with councils at all four levels; in turn commissions at local levels coordinate their work with commissions in adjacent areas. There is also a ninth commission, health, responsible for coordinating access to health care (regardless of ability to pay) and maintaining hospitals, in which medical professionals fully participate. Except for the women’s commission, all bodies have male and female co-leaders.

Taking with upmost seriousness the full liberation of women (also expressed in the all-women’s militias that fight on the front lines the same as men’s units), the women’s commissions are tasked, inter alia, with adjudicating cases of patriarchal violence and forced marriage. An umbrella women’s movement organizes women across Rojava, taking on activities including educational work, publishing a newspaper, pushing for legislation, and investigating and documenting domestic violence. This work has roots in the 1990s, when PKK women organized door to door. When organizing by men was heavily suppressed after 2004, women organized clandestinely, giving them experience.

Making women’s participation central is of course a glaring contrast with the Islamist groups and the so-called moderate groups of the Free Syrian Army. Every organization in Rojava must include at least 40 percent women. Asya Abdullah, co-chair of the Democratic Party of Kurdistan, Rojava’s largest party, said the revolution is conscious of not repeating the mistakes of the past, in which women’s liberation was often put on the back-burner. She said:

“We’re a still long way from achieving our goals. … But we’ve learned from the failed revolutions in the past. They always said, ‘Let’s carry the revolution to success, and then we’ll give women our rights.’ But after the revolution, of course, it didn’t happen. We’re not repeating that old story in our revolution.” [page 70]

Creating a new justice system

As with many governmental functions, the judicial system has had to be rebuilt from scratch. Peace committees seek consensus through dialogue at the commune and neighborhood levels. The goal is rehabilitation rather than punishment. Most cases are settled in peace committees, but felonies and those cases not adjudicated in the peace committees are assigned to district-level people’s courts. There are separate women’s peace committees that handle cases of male violence against women in which all-women panels hand down decisions.

Parallel to these systems of democratic self-activity is the Democratic-Autonomous Administration. This is essentially a dual government, created primarily for foreign governments. Because Rojava’s councils have been ignored elsewhere, the DAA was created so that world’s governments would have a government they could recognize. Each of three Rojava cantons has a DAA, which includes an elected parliament and ministries that are distributed among the various political parties so that each has at least one minister. These, however, rely on the earlier-established council system and work with the councils. The division of labor between the councils and the DAA has yet to be worked out, nor how to reconcile a dual-government structure.

Civil society associations also play large roles in Rojava. These groups perform educational work, organize grassroots activity and place representatives on the councils. Many of these associations are occupation groups. In contrast to what the Kurdish movement sees as the state existing as a means of extracting profits for favored social groups or classes and inculcating a fixation on authority, civil society is substituted for a state. The authors write:

“The Kurdish movement, in its anti-statism, thus draws on [Antonio] Gramsci’s concept of civil society in proposing to strengthen civil society for the purpose of overthrowing the state. In contrast to the abortive Bolshevist strategy of seizing state power, Öcalan posits, like Gramsci on the ideological, political struggle for civil society, a ‘war of position’ beyond military confrontation. Through empowerment, a civil society tries to free itself from the hands of the state and its religious, economic and administrative structures and so to build a counter-hegemony and to activate individual parts of the society to represent civil society in councils and communes.” [pages 122-123]

Economic development on a democratic basis

This democratic concept extends to the economy. Food and fuel prices are controlled, working conditions are negotiated among several interest groups, workers’ rights are defended and the pursuit of profit maximization is blocked to avoid the destructive tendencies of capitalism. The principals of the “communal economy” are described in this way by the Union of Civil Society Associations:

“The state system exploited the society’s labor power and trampled the rights of workers. Under Democratic Autonomy, civil society associations solve problems according to principles of moral politics and an ecological society. The unity of society is the foundation. These associations hold society together. They ensure the unity that is needed to satisfy everyday social needs. Of course, they do this as part of democratic, communal life. They are how society organizes itself.” [page 124]

Rojava, the authors write, was a “quasi-colony” under the Ba’ath régime. There was an enforced agricultural monoculture with no local production allowed. Oil, gas and agricultural products were shipped out, and canned food and finished products from elsewhere shipped in. Not even trees were allowed to be planted. So although there is much productive farmland, Rojava could not come close to self-sufficiency in food as all farmers were forced to raise wheat or cotton. Farming is now being re-oriented toward local needs so that a much higher percentage of food can be produced locally; this is partly a necessity as the area is often blockaded by neighbors.

The city of Qamishli in Syrian Kurdistan

The councils, already in existence, organized the economy to prevent a collapse after Rojava’s liberation. Price controls, measures against hoarding food and medicine, agricultural diversification, planting fruit trees, and building grain mills and industry were implemented and are ongoing projects. Rojava’s economic underdevelopment is seen locally as a disadvantage and an opportunity. It is the latter because, the authors write, it “allows the traditional social collectivism of the Kurdish people to be channeled positively to build a new, alternative economy.” [page 197]

Much of this new economy rests on cooperative enterprises. Cooperatives are required to be connected to the council system; independence is not allowed. Cooperatives work through the economics commissions to meet social needs. Much of this cooperative production is in agriculture or small shops but there are plans to create more industry to meet local needs. Thirty percent of all coop proceeds must be given to local self-government administrations. And this is seen as a route to eliminating unemployment. The authors write:

“The cooperative system is solving the problem of unemployment. ‘Through the communes and cooperatives and the needs-based economy,’ explains [Afrin University chair] Dr. [Ahmad] Yousef, ‘each person can participate in production in his own way, and there will be no unemployment. Where communes are established, it will become clear that unemployment is a result of the capitalist system itself.’ ” [page 206]

Such a system can’t work without an educated population:

“To ensure that society is able to make decisions about the use of water, soil, and energy, information about the society’s needs are taken out of the hands of the experts and socialized. Education is critical for this purpose. ‘We school the people in how cooperatives can form a social economy,’ says [Union of Kurdish Communities leader Cemil] Bayık. ‘We are establishing economics academies to advance this.’ ” [page 207]

Surrounded by a hostile world

All this is at odds not only with the existing institutions and state organizations surrounding them, but with the capitalist powers as well. How can Rojava’s experiment possibly survive in a such a hostile world? The authors of Revolution in Rojava strongly urge the building of Left support sufficiently strong to influence North American and European governments. The people of Rojava, the authors stress, are in need of material support from the West at the same time they are acutely aware of the dangers of a U.S. embrace.

The idea that Rojava’s acceptance of Western aid is a “betrayal” is called “naïve” by the authors, drawing parallels with Republican Spain of the 1930s. Describing Rojava as an “anti-fascist project,” they note that the capitalist West turned its back on the Spanish Revolution, allowing fascism to triumph.

The danger of U.S. material support, of course, can’t be underestimated, given that a communal economy oriented toward people’s needs rather than private profit is anathema to U.S. corporate and government power, which have teamed up to throttle many a revolution attempting to transcend capitalism or simply assert independent development. Moreover, the U.S. wrongly classifies the PKK, which seeks to implement the same system as their fellow Kurds in Syria, as “terrorists” and has long supported Ankara’s scorched-earth repression of Kurds.

In the short term, material support from the West is needed if Rojava is to successfully defend itself from Islamic militants and the Turkish government. Syrian (and Turkish) Kurds, who see their model as one that can be expanded across Syria and the entire Middle East, have their eyes open to the narrowness of the path that must be thread through these contradictions. Nor are their eyes closed to their unsolved problems of pollution, water, waste management, and the stop-gap use of diesel generators that is causing serious environmental problems.

The book ends on an optimistic note, readapting Rosa Luxemburg’s famous phrase to declare the future is “communalism or barbarism.” Although brief discussions of Thomas Jefferson, Luxemburg and Gramsci (who was no opponent of the Bolsheviks) are poorly argued and their views misstated, this is at most a minor irritant in a work ably presenting the first comprehensive study of Rojava’s inspiring experiment in mass-participation democracy. Revolution in Rojava is an excellent introduction to a revolution that is not yet well known but should be.

* Ercan Ayboga. Anja Flach and Michael Knapp (translated by Janet Biehl), Revolution in Rojava: Democratic Autonomy and Women’s Liberation in Syrian Kurdistan [Pluto Books, London 2016]

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Dump the kid and get back to work

The presidential campaign season is well underway in the United States, and never in human history will more money be spent to say less. And only 16 more months to go.

A perennial favorite of the worst electoral system money can buy is the race among the candidates to be the most in favor of motherhood and apple pie. Not actually do something to make it easier to balance personal life and work, of course, but to send endless platitudes into the void. To put this in context, here is the complete list of all the countries in the world that do not provide paid maternity leave for women workers:

  • Papua New Guinea
  • United States of America

The International Labour Organization reports that 183 countries and territories on which it has information provide cash benefits to women on maternity leave; the two listed above do not. The ILO report, “Maternity and paternity at work: Law and practice across the world,” found that although not all countries reach its standard of at least two-thirds of pay for at least 14 weeks, almost half of the world’s countries do, including 25 of the 29 developed countries in which ILO researchers were able to make an assessment. [page 19] (Canada, Iceland and Slovakia are the others.)

Stockholm (photo by Sharon Hahn Darlin)

Stockholm (photo by Sharon Hahn Darlin)

The geographic region with the best results is Eastern Europe/Central Asia, where 88 percent of countries exceeded the ILO maternity-leave standards and every one at least equaled the standard. [page 18] This result isn’t surprising, as these countries were mostly part of the Soviet bloc. Women on maternity leave in the Soviet Union received full pay up to 112 days, partial pay up to 18 months, and unpaid leave from 18 to 36 months, according to a Max Planck Institute for Demographic Research paper. Maternity-leave benefits achieved during the communist era in countries such as Poland, the Czech Republic, Slovakia and Hungary have largely been retained.

That doesn’t mean all was well; women workers in the Soviet Union from the 1960s on earned about 70 percent of what men did, and industries with the highest concentrations of women tended to be those with the lowest pay. Then again, that is not much worse than today in the United States, where women earn 78 percent of what men earn. Canadian women earn about 74 percent of what Canadian men take home.

Leave for both parents

Of course, there is more to family-friendly work policies than conditions of maternity leave. Only about half of the world’s countries provide paternity leave. Although the ILO has not established a standard for paternity leave, the organization encourages it. The “Maternity and paternity at work” report says:

“Research suggests that fathers’ leave, men’s take-up of family responsibilities and child development are related. Fathers who take leave, especially those taking two weeks or more immediately after childbirth, are more likely to be involved with their young children. This is likely to have positive effects for gender equality in the home, which is the foundation of gender equality at work.” [page 52]

One way of encouraging gender equality is to provide for parental leave, where either parent can take it, or in the case of countries such as Sweden and Norway, some of the parental leave must be taken by the father. The ILO’s report says:

“As countries move toward greater gender equality in their legislation and policies, most countries are setting out parental leave as a shared entitlement, where either the mother or the father has the right to take parental leave and the parents determine the allocation of leave themselves. Countries adopting this approach include Albania, Cuba, Estonia, Finland, New Zealand, Uzbekistan and many others. …

“Sweden was the first country to grant men and women equal access to paid parental leave in 1974. Few men took parental leave, however, so, in 1995, Sweden introduced a non-transferable ‘daddy’s month’ and extended this leave to two months in 2002, with pay at 80 percent of income. Norway also has a non-transferable leave period of 14 weeks to encourage men’s take-up of childcare responsibilities. Germany and Portugal too provide non-transferable allocations of paid parental leave for fathers.” [page 62]

More help in difficult times

In contrast, in the United States, parental leave is a privilege attached to your job, just as with health care (where health care is far more expensive than every other developed country. Only 9 percent of companies in the U.S. offer paid maternity-leave benefits, down from 16 percent in 2008. Lest we pin this reduction on the ongoing economic crisis in which the world has been mired since 2008, the ILO report found that several European countries, along with others such as Chile and El Salvador, actually increased the levels of government support to families, and in 2010 Australia introduced paid universal parental leave for the first time. [page 28]

Those countries that already provided generous benefits haven’t reduced them. Sweden provides 480 days of paid parental leave, prenatal care through free or subsidized courses, and allows parents pushing infants and toddlers in prams and buggies to ride for free on public buses. Norway provides 49 weeks of paid parental leave at 100 percent of income or 59 weeks at 80 percent of income.

The only legal requirement in the U.S. is the 12 weeks of unpaid leave provided under the Family and Medical Leave Act — if you can’t afford to be without a wage, too bad. A Senate bill with 19 sponsors, the Family and Medical Insurance Leave Act, has been introduced that would provide up to two-thirds of pay for 12 weeks, capped at $4,000 per month, paid for by contributions by employers and employees. By contrast, most countries that provide paid parental leave do so through government benefits.

No Republicans have offered to co-sponsor this bill, and not one of the 17 candidates vying for the Republican Party nomination is in favor. The Family and Medical Leave Act was bitterly opposed by George H.W. Bush when he was president, who vetoed it twice, and his son, current Republican establishment favorite Jeb Bush, shows no more inclination to align actions with rhetoric. When governor of Florida, Jeb Bush’s big initiative was to privatize the foster-care system, which handed big profits to corporations, and which took “a pretty well-functioning system and blew it to bits,” according to one case worker.

When “the market” is allowed to decide social questions, it shouldn’t be a surprise that corporate profits, not human needs, are the priorities.

Ding Dong! Thatcherism and sexism are alive

I have a deep ambivalence over the playing of the song “Ding Dong The Witch Is Dead” to commemorate the death of Margaret Thatcher. I can well understand the desire to rebel against orders by the British right-wing establishment that everyone must celebrate the prime minister’s “accomplishments,” but the exercise in this form is nonetheless deeply sexist.

Surely there are plenty of political epithets to be hurled at her memory that reference the disastrous policies of her reign. Ronald Reagan was just as awful, but he wasn’t denounced as a witch at his death, was he? Clearly, few of those who took part in the campaign to have the song played on the BBC’s music-chart program stopped to think about the sexism inherent in branding a woman a “witch.” Yes, even when we are talking about someone as horrid as Margaret Thatcher.

What does her gender have to do with her policies? And can it truly be said sexism is a thing of the past because a woman became head of the government of one of the world’s most powerful countries? No more than it could be said that racism is a thing of the past in the United States because Barack Obama is president.

Prime Minister Thatcher imposed misery on millions of Britons; her defenders’ demands that no ill be spoken of her rightly deserves contempt. What mercy did she show to working people? But although the prime minister was powerful and notoriously impervious to opposition — I still have a vivid memory of her reacting to being showered with derisive laughter from the Labour benches during a Prime Minister’s Question Time session with a fierce stare that unmistakably said, “You are very lucky I can’t have you all killed or I surely would” — women as a group do not possess privileges.

Statue of Alice Nutter, English woman accused of witchcraft. (Photo by Graham Demaline.)

Statue of Alice Nutter, English woman accused of witchcraft.
(Photo by Graham Demaline.)

Unequal pay in the workplace, unequal opportunities, expectations of shouldering most of the burden of child care, violence at the hands of male partners, violence at the hands of men in general, sex trafficking, under-representation in governments and legislatures, difficulties being taken seriously, social and institutional discrimination — and this does not exhaust the list.

Social expectations are not separable from that list. Although most of those denouncing the prime minister as a “witch” likely think of themselves as making some sort of political statement, they are really just demonstrating their absorption of the sexism that permeates the world.

When we drill to the bedrock, branding Prime Minister Thatcher a “witch” has much to do with her not conforming to gender “norms.” She may have made her family’s breakfast in the morning, but there is no denying her ruthlessness and cold-heartedness in advancing her political career. Such behavior may or may not be liked in a male politician, but would not be seen as “abnormal behavior” in the way it often is in a female political leader.

An easy example are Bill and Hillary Clinton — she was portrayed on countless occasions as secretly possessing male genitalia and mercilessly ridiculed for supposedly being overly aggressive. Yet are her political positions, or her admittedly ambitious climb to political heights, in any way different than her husband? No — yet she is routinely mocked in ways her husband never has to endure.

If you don’t act ‘feminine’ you are a witch

The cultural history of “witch” is nothing to take lightly. A United Nations research paper reports that “more than 100 women are tortured, paraded naked or harassed … every year” in India’s Chhattisgarh state alone. Rita Banerji, founder of the 50 Million Missing Campaign, reports that more than 2,500 women were branded as “witches” and killed across India in the past 15 years.

In Ghana, there are six witch camps where women accused of witchcraft are banished, forced to live in wretched conditions to escape the near certainty of enduring torture, beatings and lynchings should they leave. The anti-poverty group ActionAid reports:

“Women who do not fulfil expected gender stereotypes, for example if they are widows, unmarried or cannot have children, are vulnerable to being branded as witches. … Some camps, for example Gnani, have male residents who have been accused of wizardry. However most of the camps contain only alleged witches and the total number of men in the camps is far lower than the number of women. This is because men are generally less vulnerable than women as they are economically better off and more able to resist physical violence. This illustrates that vulnerability is a key underlying factor in witchcraft accusations. … Though both men and women can be accused of witchcraft, the vast majority are women, especially the elderly.”

The UN research paper, written by Jill Schnoebelen, reports witchcraft accusations occur on every continent. These accusations often follow a pattern:

“The poor can be accused of jealousy-induced witchcraft, and the well-to-do can be accused of practising witchcraft to acquire wealth.”

A report in the Australian non-profit news Web site Global Mail, detailing mass accusations of witchcraft in Papua New Guinea, notes that communities stressed by the arrival of multi-national mining companies are scapegoating women:

“[T]radition has in places morphed into something more malignant, sadistic and voyeuristic, stirred up by a potent brew of booze and drugs; the angry despair of lost youth; upheaval of the social order in the wake of rapid development and the super-charged resources enterprise; the arrival of cash currency and the jealousies it invites; rural desperation over broken roads; schools and health systems propelling women out of customary silence and men, struggling to find their place in this shifting landscape bitterly, often brutally, resentful.”

The beneficiaries of oppression

These patterns were seen during the centuries of “witch” burnings across Europe and North America. In Germanic states, women were targeted as witches in order to take their wealth for benefit of states and well-connected individuals, while in the British Islands witch hunts mostly targeted poor peasant women, accused by wealthy individuals who were part of local power structures. The Inquisition peaked during a long period of famines, unrest and declines in population; women were systematically excluded from wage work in part to force them to bear children that would replenish the supply of workers in an era of falling population and in part to enable the sustainability of the male wage worker through enforced housework.*

Although witch hunts are today a relic of the past in those cultures, the underlying social forces driving them have not faded into history. As Fran Luck, host of the Joy of Resistance Multicultural Feminist Radio program, writes:

“[T]he oppression of women (and other oppressed groups) is not ‘an accident’ or a vestige from another era, but is an active process from which someone/someones are benefitting now!”

Accusations of witchcraft are no more separable from the cultures in which they arise than is the treatment of women in advanced capitalist countries. In the global North, the mass media and popular entertainment endlessly parade women as objects of pleasure for men, with serious consequences for women who refuse to conform. The oppression of women, as with the oppression of People of Color, national hatreds and similar chauvinisms, is woven into social fabrics, fostering social divisions.

That an individual woman such as Margaret Thatcher rises to a position of power in itself does nothing to alter those social fabrics. She is part of a system, not an individual deus ex machina, no matter how personally ambitious. The neoliberalism imposed by Margaret Thatcher, or Ronald Reagan, or Augusto Pinochet, is a natural consequence of the centralization of power and wealth, the beneficiaries of which have the ability to have their interests maximized above all other interests and to disseminate their ideologies through a multitude of institutions.

It did not take a “witch” to impose such policies, nor could one have imposed such policies if they weren’t already desired by the most powerful corporate interests. By denouncing a “witch,” opponents of Thatcherism not only blind themselves to the reality of the larger system of which it is a component, they actively promote the individualist ideology that maintains that system and the sexism that forms one of its longest-lasting components.

* This paragraph relies on Silvia Federici, Caliban and the Witch: Women, the Body and Primitive Accumulation [Autonomedia, Brooklyn, New York, 2004]; Maria Mies, Patriarchy and Accumulation on a World Scale: Women in the International Division of Labour [Zed Books, London, 1988]; Barbara Ehrenreich and Deirdre English, Witches and Nurses: A History of Women Healers (second edition) [Feminist Press at City University of New York, 2010]

The high cost of private profit in health care

The United States spends huge amounts of money on health care. But it is only in comparison to other countries that the magnitude of health care spending becomes clear. Because the U.S. health care system is designed for private profit rather than public health, the U.S. spends an extra $1.15 trillion per year beyond what it would otherwise.

If that total astounds you, you are not alone. When I first began making calculations to determine excess spending in health care, the figures were so large that I had difficultly believing them and performed the calculations over again. The result was the same.

The excess spending on health care is not only growing, it is growing much faster than the rate of inflation, in concert with overall health care spending. For instance, the annual average of excess spending for the period of 1990 to 2000 was $685 billion. For the period of 2001 to 2010, the annual average ballooned to $1.15 trillion.

And despite all that extra spending, U.S. residents have poor health results in many key indicators, in comparison to the world’s other advanced capitalist countries. Still more amazing, 51 million people in the U.S. are without health insurance, while all other peer countries have universal care. This is the system that millions of U.S. citizens believe is the best in the world thanks to the world’s most developed public relations and misinformation industries.

The rest of the world is quite in disagreement, to the point that even the harsh austerity-minded Conservative prime minister of the United Kingdom, David Cameron, has repeatedly had to deny (whether or not sincerely I will leave to others) any intention to emulate the U.S. system as he attempts to impose changes on the country’s National Health Service.

U.S. health care is by far the world’s highest

Let’s do a bit of digging under the surface of numbers. First off, an explanation of where the $1.15 trillion in annual excess spending comes from. I calculated the number by first obtaining total health care spending per capita* of the three largest economies within the European Union (France, Germany and the United Kingdom) and of Canada, the neighbor of the United States. I then averaged the numbers for the years 2001 to 2010 (the latest for which full statistics are available) as compiled by the Organisation for Economic Co-operation and Development (OECD), the club of the world’s advanced capitalist countries and the largest developing countries.

The composite average of Canada, France, Germany and the U.K. for 2001 to 2010 is US$3,479 per capita per year. That number is less than half of the U.S., which had by far the world’s highest health care spending at $7,325 per capita per year. The differential was then multiplied by 300 million, the approximate U.S. population during the past decade. If you prefer a different measure, the U.S. spent 17.4 percent of its 2009 gross domestic product on health care expenditures, again the world’s largest by a wide margin. The average of the 34 countries of the OECD is 9.6 percent.

And if that is not enough, here is one more astounding comparison: Not only are out-of-pocket expenses by U.S. health care consumers higher than in any of the four comparison countries (no surprise there) but per capita government spending in the U.S. is higher than in any of the four comparison countries. Those four have varying versions of what U.S. right-wing ideologues venomously denounce as “socialized medicine” — health care systems either run or closely regulated and supervised by a federal government paid for through taxation — and yet each government nonetheless spends less than does the U.S. government on a per capita basis.

Despite the massive transfer of money to private insurance companies by employers and employees, on a per-capita basis government health care spending by itself in the U.S. is higher than total health care spending in Canada.**

The authors of the paper “Why is health spending in the United States so high?” (a supplement to an OECD statistical report) attempted to draw conclusions from a mass of data on health care expenditures:

“It does not have many physicians relative to its population; it does not have a lot of doctor consultations; it does not have a lot of hospital beds, or hospitals stays, when compared with other countries, and when people go to hospital, they do not stay for long. All these data on health care activities suggest that U.S. health spending should be low compared with other countries.”

The reason that spending is anything but low is because of the high prices extracted throughout the system. The costs of a range of medical procedures or surgeries are much higher in the U.S. than elsewhere, as are pharmaceutical prices. The authors write:

“Overall, the evidence suggests that prices for health services and goods are substantially higher in the United States than elsewhere. This is an important cause of higher health spending in the United States.”

The OECD is an organization that is representative of the world’s most powerful capitalist countries, so the report does not inquire into underlying causes or in any way challenge the economic system that leads to such results; it merely reports facts and figures. Those facts and figures, however, give us a useful starting point. The wasteful spending on health care are subsidies for pharmaceutical manufacturers, hospital-chain operators, insurance companies, managed-care companies and medical-products manufacturers. Money flows to those corporate entities directly from your pocket and indirectly from you via government spending.

Each U.S. citizen’s annual share of wasteful, excess spending on health care — excess spending that goes into the coffers of some of the country’s largest corporations among the many industry profiteers — amounts to $3,846. Business leaders, their lavishly funded think tanks and pressure groups, and the public-office officials who represent them continually assert that private enterprise is always more efficient. It would seem that the efficiency lies in extracting money and wealth.

Government more efficient because goal isn’t private profit

Noting that “high administrative costs and lower quality have also characterized for-profit HMOs” (health maintenance organizations funded by insurance premiums that supervise health care), a Journal of the Canadian Medical Association article provides the following figures for the percentage of revenue that is diverted to overhead:**

  • For-profit HMOs: 19 percent
  • Non-profit plans: 13 percent
  • U.S. Medicare program: 3 percent
  • Canadian Medicare: 1 percent

In contrast to the rhetoric so often employed, government is far more efficient at delivering health care than the private sector. (This is also true in retirement plans, where the U.S. Social Security program’s overhead is much lower than mutual-fund managers or other financial-industry enterprises.) An important reason is that the government does not skim off massive amounts of money for bloated executive pay nor does it need to generate large profits to enrich financiers.

Such large expenditures also flow from a lack of competition. Few people in the U.S. have a choice of insurance provider, which is dictated by their employer, and insurance companies and HMOs frequently limit choice of doctors, and often deny coverage so as to maximize profits. A company that has stock traded on exchanges is legally required to maximize profits above any other consideration; it is no different because health care happens to be the product.

A few summers ago, I found myself in a debate with a Canadian woman who was critical of her country’s health care system. I acknowledged that Canadian health care is not perfect, but then gave the example of a friend who had recently died in his 50s of a heart attack because his insurer decreed that he did not require medication for his weak heart and he could not afford it on his own. Does that happen in Canada?, I asked. She replied with silence.

As in any other mature industry, most market share has consolidated into a few hands, a condition that is known as an “oligarchy.” Although competition in younger or more fractured industries does result in price reductions, when an industry is reduced to a small number of dominant corporations, price competition is usually a casualty.

Health care constitutes several industries — insurance, pharmaceuticals, hospitals and medical equipment, among others — and each adds to the cost. Giant pots of government money are involved, always a lucrative source of private enrichment. And insurers have people over a barrel because health insurance comes through their employer, who make deals with a single insurer, take it or leave it.

Health care provision also has unique attributes that further inflate costs. In “The high costs of for-profit care,” by Steffie Woolhandler and David U. Himmelstein (the Journal of the Canadian Medical Association article quoted above), the authors write:

“Why do for-profit firms that offer inferior products at inflated prices survive in the market? Several prerequisites for the competitive free market described in textbooks are absent in health care. First, it is absurd to think that frail elderly and seriously ill patients, who consume most health care, can act as informed consumers (i.e., comparison-shop, reduce demand when suppliers raise prices or accurately appraise quality). …

“Second, the “product” of health care is notoriously difficult to evaluate, even for sophisticated buyers like government. … By labeling minor chest discomfort “angina” rather than “chest pain,” a U.S. hospital can garner both higher Medicare payments and a factitiously improved track record for angina treatment. It is easier and more profitable to exploit such loopholes than to improve efficiency or quality.

“Even for honest firms, the careful selection of lucrative patients and services is the key to success, whereas meeting community needs often threatens profitability. … [For-profit] hospitals duplicate services available at nearby not-for-profit general hospitals, but the newcomers avoid money-losing programs such as geriatric care and emergency departments (a common entry point for uninsured patients). The profits accrue to the investors, the losses to the not-for-profit hospitals, and the total costs to society rise through the unnecessary duplication of expensive facilities.”

U.S. fares very poorly in a comparison of national systems

In the spirit of comparison-shopping, here is a brief examination of the five countries under discussion, the United States and the four comparison countries.

  • German health care system: Everybody is covered. Workers pay eight percent of their gross income into a “sickness fund,” a nonprofit insurance company; employers pay the same amount. These contributions account for almost all money in the system. Workers choose among 240 sickness funds. There are no deductibles. Everything, including drugs, is free for children younger than eighteen. The government regulates all insurance companies closely.
  • French health care system: Everybody is covered. Workers pay 21 percent of their income into a combined retirement and national health care system; employers pay about half that amount. Payroll and income taxes largely fund health care. There are no waiting lists for elective surgery or to see a specialist. Doctors’ fees are negotiated with medical unions, while hospital fees are regulated. Patients with one of 30 long-term and expensive illnesses pay nothing for care.
  • British health care system: Everybody is covered. The National Health Service is funded by income taxes, employs physicians and nurses, and owns most of the hospitals and clinics. The service also pays directly for all health care expenses, with prescriptions and dentistry being the two exceptions. There are sometimes long waiting lists, which are commonly attributed to there being no restrictions on services, particularly hospitalization.
  • Canadian health care system: Everybody is covered. The federal government sets standards; provincial and territorial governments administer the system. Medically necessary hospital, physician and diagnostic services are free, although most dental care and prescription drugs are not covered. Services are primarily through private providers. Long waiting times for specialists are a problem, with reduced government payments cited as an underlying cause.
  • U.S. health care system: 51 million are not covered. Coverage is through an employer (of which the employee pays a portion), or through own purchase of private insurance, but most can’t afford to do so. Insurance companies frequently dictate what, or if, services will be provided. Coverage generally requires out-of-pocket expenses and includes a “deductible” before payments begin. Patient bankruptcies due to inability to pay bills are common.

Another weakness of the U.S. health care system is that is based on the concept of a “family wage” instead of a “social wage.” That is both cause and effect — unlike other countries where health care is a right, in the U.S. health care is a privilege, and the large disparities in the ability to obtain it reflects the canyon-like inequality there and also aggravates social inequities. Not only because health care is tied to an employer, giving a boss more power over employees, but because a family’s health care coverage is tied to the person who has the job that provides it — usually the man in a traditional family. But it could be any one person in a non-traditional family or within a gay or lesbian household.

Universal health care systems are gains of movements

Feminist pioneer and theorist Kathie Sarachild of the influential group Redstockings, in a July 4 interview on the Joy of Resistance: Multi-cultural Feminist Radio program, summarized this concept. She said:

“The family wage is another way of saying this old idea that men should support the family. [U.S.] society is built on the idea that men should get higher pay than women because men would support the family and women would stay home and take care of the children. … Even though there were always women who worked, they received less pay than men did because of this family-wage concept. …

“A lot of [the European social wage] came out of socialist and communist theory. … The labor movement and the feminist movement in [Europe] have been able to win a social-wage system, which pays to raise the next generation [through universal health care and paid leave when a child is born instead of being dependent on an employer to pay a ‘family wage’ to the man].”

Nationalized health care becomes part of a basket of social benefits, including more vacation time, life-long education and elder care that liberates working people from dependence on an employer. A shorter work week would also bring benefits, Ms. Sarachild said:

“If the work week were shorter … there would be more jobs. There’d be less unemployment because the work week is shorter so there are more paid jobs. There would be more time at home for the father and mother to be with the child. …. [With the introduction of a] social wage, the unfair family wage would not be necessary. … [Women] are not as dependent on the man, and both of you are not so dependent on the employer.”

The lower wages of women in the “family wage” system boost corporate profits on the backs of women, Joy of Resistance host Fran Luck points out, and many women are forced to stay in bad relationships because they would lose their health care.

For men and women, the price of private profit is enormously high: 22,000 people die and 700,000 go bankrupt per year as a result of inadequate, or no, health insurance in the United States.*** The U.S. ranks among the bottom five of the 34 OECD countries in per capita doctor consultations, hospital beds and average length of stay in hospitals,**** and is well below average in life expectancy and infant mortality.

The country’s people pay more than $1.15 trillion per year on top of what they should pay to swell corporate profits and executive and Wall Street wallets — in return, we receive worse coverage. That is the price of capitalism.

* OCED figures. Spending per capita in U.S. dollars adjusted to create purchasing power parity.
** Steffie Woolhandler and David U. Himmelstein, “The high costs of for-profit care,” Journal of the Canadian Medical Association, June 8, 2004, pages 1814, 1815.
*** T.R. Reid, “No Country For Sick Men,” Newsweek, Sept. 21, 2009, pages 43-44.
**** “Why is health spending in the United States so high?,” OECD report, page 5.