Tony Parker, Jane E Ferrie
Health and welfare
rejecting the state in the status quo — examples of an Anarchist approach
For most of the 20th century, all mainstream political parties in Western Europe coalesced around the idea that, ultimately, the state should be the chief provider of social welfare and instrument of social reform. Although Feminist, Anti-Racist, Neo-Marxist, Green and other left-leaning critiques were put forward, particularly in the 1970s,[1] criticism of the welfare state has come predominantly from the free-market right. This has culminated in attacks on the direct provision of welfare by the state in many European countries, and indeed across the world. As a consequence, as attention increasingly focused on defending rapidly shrinking services, criticism of state provision from the radical left has rarely been articulated in more recent years. Even Anarchists, for whom anti-statism, non-hierarchical voluntary cooperation and mutual aid are central to their political philosophy, have mostly held back: possibly through fear of being associated with the free-market attack on what is widely regarded as a general good, possibly because calls for fundamental changes to the status quo-sensationalized by conceptions of terms like ‘social revolution’seem to present a utopian and highly impracticable alternative.[2] In this Diversion we attempt to counterbalance these views, using examples mostly from the UK.
The origins of the modern welfare state can be dated back to the 1880s and the social programmes implemented in Germany by Bismarck. Explicitly designed to forge a bond between citizens and the state and to form a bulwark against socialism,[3] these programmes inspired the UK’s 1911 National Insurance Act, following an admiring visit to Germany by Lloyd George in 1908.[4] Before its more modern incarnation, institutional welfare provision in many European countries had been via Poor Laws, which provided limited funds for the relief of the destitute and were aimed more at preserving law and order than providing well-being.[1] In Britain this provision was increasingly augmented over the course of the 19th century, arguably prompted by the Factory Inquiry Commission Report of 1833. The Report formed the basis of legislation regulating working conditions, particularly the employment of children and its effects on their moral and physical health. Employment in mills of children under the age of nine was prohibited and working hours for those under [18] limited to [12] a day.[5] Other measures included regulations regarding the quality of housing, public health, education and municipal responsibility for the provision of basic services.[1]
The development of the welfare state in the UK in its current form can be dated from the discovery at the end of the 19th century of potentially catastrophic lack of fitness among Army recruits for the Boer War.[6] Implementation of a series of reforms in the first decade of the 20th century, culminated in the National Insurance Act of 1911. This provided free medical treatment for male workers and a permanent increase in the role of the state in British society. World War I again brought the issue of low levels of fitness among recruits into focus. However, effectively nothing was done,[7] and the period between the World Wars, including the Depression of the 1930s, saw increasing documentation of extensive ill health, poverty, malnutrition and bad housing.5,7–[9] During World War II (WW2) the government became further involved in the lives of citizens via the rationing of basic goods, and committed itself to further social provision covering employment, education and benefits. The Beveridge Report of 1942 recommended that health care, unemployment and retirement benefits should be provided via a national, compulsory, flat rate insurance scheme;[10] and, following victory in the 1945 election, the Labour Party developed and implemented Beveridge’s recommendations via a series of Acts that in 1948 brought a National Health Service (NHS) and comprehensive system of social security benefits to all British citizens.
Since 1948, universal state provision of health and welfare has become a given, with the NHS a particularly sacred cow. At the same time, the provision of such services by the state has had its detractors, as exemplified by Friedrich von Hayek who described the welfare state as ‘the road to serfdom’.[11] However, the basic tenets of what is now known as the ‘free market’ critique has arguably not changed significantly since Victorian times. As summed up by one of the foremost proponents of the free market school, Milton Friedman: ‘The scope of government must be limited. Its main function must be to protect our freedom both from the enemies outside and from our fellow citizens, to preserve law and order, to enforce private contracts, to foster competitive markets’,[12] a view which resulted in the involvement of many free market economists from the Friedmanite ‘Chicago School’ in the privatization programme of the military dictatorship in Chile (see Box 1). Various free marketeers built on this with their version of Public Choice theory (that public choice is dictated by individual self-interest) which, in common with the New Right critique, promoted the view that collective choices, like state provision of welfare, are fiscally irresponsible as well as inefficient, uneconomic and ineffective.[1]
Box 1
The privatization programme initiated following the military coup in Chile in 1973 has been a key model for the World Bank’s enforced privatization programmes elsewhere: ‘There has been a growing interest in welfare arrangements in Latin America. The object of the greatest attention has been the Chilean pension system which has been exhaustively surveyed and reviewed ever since the World Bank (1994) recommended it as a model to be followed throughout the Western world and ‘the answer’ to the problem of ageing societies.’[1]
Criticism of state provision has not always come from the Right. Now largely forgotten is the fierce working-class opposition to the 1911 National Insurance Act. Before the Act, low-paid working men, through self-help and mutual aid, had evolved organizations for the supply of medical care and social insurance well in advance of any other insurance system, except possibly that for shipping.13,[14] The working class already had a long history of self-organization. In addition to battling against their employers, this was particularly exemplified by the Friendly Societies which first took shape at the end of the 1600s as the Guild structure broke down and capitalism began to take shape.[15] Mostly composed of skilled workers up to the mid 1800s, this was no longer the case during the second half of the century. Individual ‘Friendlies’ tended to occupy specific niches in the working class hierarchy. Well-known Friendlies, such as the Oddfellows, attracted higher wage earners, whereas unregistered societies catered for the poorer paid.[14] Well before the end of the 19th century, every neighbourhood of every town had its own Friendly, and three-quarters of all manual workers were subscribers.13,[14] Medical Societies widened the coverage. Formed by groups of Friendlies, they also catered for family members, and in Welsh mining communities included everyone from miners to shopkeepers. For example, as late as the 1920s, the local Medical Society in Tredegar (South Wales) included 95% of the population, and indeed the schemes survived the mass unemployment of 1926–40. These were, of course, culturally and politically–as well as economically–largely homogeneous communities.[4] In less integrated communities, irregular or particularly poorly paid employment meant that many working women and men could either not afford to join or found themselves unable to keep up their premiums. It was especially these workers who benefited from the National Insurance legislation.[14]
The Anarchist writer Colin Ward described the Friendlies as classic examples of ‘the tradition of fraternal and autonomous associations springing up from below’.[16] Having resisted attempts at state regulation in 1[793] and the late 1820s,[17] in later years the Friendlies were consistently opposed by the medical establishment. Each of the Societies employed their own doctor, usually elected by a vote of all members, on a contract. This was opposed by the British Medical Association (BMA) which ran a long campaign against the Friendlies, because many saw them as an ‘appalling’ example of doctors being told what to do by their ‘social inferiors’ as well as a brake on their incomes. The advent of the 1911 Act provided the BMA with the opportunity to act, and the pioneering efforts of the Friendlies were undermined when the government fell prey to a powerful alliance between the BMA, big business, and the ‘social reformers’ Beatrice and Sydney Webb.[13] Adolphe Smith, as Special Commissioner for the Lancet for [40] years, famously provided much of the detail for Upton Sinclair’s classic depiction of the degrading conditions in the Chicago slaughterhouses.[18] Less well known is his crucial role in attacking the Friendlies, culminating in his pamphlet The Battle of the Clubs.19,[20] Opposition from the BMA alliance turned the 1911 Act to the doctors’ advantage and their incomes almost doubled within a year of its being passed.[13]
According to Julian Tudor Hart, ‘developments in coal mining areas before the 1911 Insurance Act created a model for local accountability and democratic control, which the Act brought to an end by enlisting doctors as independent contractors to the state’.[4] However, in fact: ‘The medical men’s victory remained for a long time incomplete. Many Friendly Societies managed for two or three decades after 1911 to retain contracts with their doctors on terms that provided them with medical services at lower costs than those paid for by members of the state insurance programme. The members of Medical Associations, too, preserved their superior position into the 1940s, finally giving way before National Health Insurance’.[14] Ward lamented, ‘The great tradition of working-class self-help and mutual aid was written off, not just as irrelevant but as an actual impediment, by the political and professional architects of the welfare state aspiring for a universal public provision of everything for everybody. The contribution that the recipients had to make to all this theoretical bounty was ignored as a mere embarrassment–apart, of course, from paying for it’.[16]
Although predating Anarchism, the Friendlies, locally organized, freely federated, based on self-help and mutual aid and, importantly, independent of the state, followed closely the basic tenets of Anarchism.21,[22] The idea of ‘The Servile State’[23] deliberately inducing dependence through its control of employment, health and other provisions was central to working class opposition to the 1911 Act: not only from the Friendlies, but also from working class Syndicalists and their associated national daily.[24] It was an argument that was to resurface again in opposition to the introduction of the NHS and universal state welfare provision after WW2.
Perhaps more widely known than the Friendlies, the Peckham Health Centre, which operated from 1926 to 1950 in South London, provides an example of what has been described by Ward as ‘a laboratory of anarchy’.[25] The Peckham Experiment, essentially an investigation into the nature of health, was located in a purpose-built centre in which doctors observed families interacting in a social setting. The Experiment concluded that health is much more than an absence of disease, and identified the crucial role played by environments.[26] Initial findings of high levels of ill health among its artisan participants[27] were unexpected and used as illustrations of what would later be described as the clinical iceberg.28,[29] In spite of a film (Box 2) commissioned by the Foreign Office and featuring a visit by Clement Attlee, the Labour Prime Minister, the Peckham Health Centre was refused admission to the newly formed NHS and closed its doors in 1951. The grounds of refusal went to the core values of the project. According to David Goodway, ‘It was concerned exclusively with the cultivation of health, not the treatment of disease. It was based not on the individual but entirely on the integrated family. It was based exclusively on a locality, having no ‘open door’. Its basis was contributory, not free. It was based on autonomous administration and so did not conform to the lines of administration laid down by the Ministry of Health’.[30] In a lecture to the London Anarchist Group in 1946 Scott Williamson, one of the founders, described the nature of the administration: ‘I was the only one with authority, and I used it to stop anyone exerting any authority!’ Other sources noted that ‘In the social environment of Peckham there are no guiding planners, no cliques, no closed doors, no hierarchies’.[31] Possibly Peckham’s autonomous administration was its biggest Achilles heel, highlighting a wider problem of general hostility to any initiative originating outside the state and anti-statist in its philosophy.[30]
Box 2
The Peckham Health Centre (1948) http://peopleshistorynhs.org/museumobjects/film-the-centre-1948/
In the same journal in which Ward had celebrated the Peckham Health Centre,[25] his friend the Anarchist general practitioner, John Hewetson, reviewed a book about the experiment recently published by the Centre’s founders. Criticizing the book as a difficult read, Hewetson, nonetheless, expressed his view that: ‘There has never been a comparable sustained attack on the problem ‘what is the nature of health?’ as carried on by Scott Williamson and his helpers’.[32] During WW[2] Hewetson was editor of an Anarchist paper, which was generally published under the title Freedom but came out during the war years as War Commentary for Anarchism.[33] In June 1946, Freedom Press published a booklet by Hewetson Ill Health, Poverty and the State.[34] By the time Hewetson first came to write his booklet, the Beveridge Report had been in print for a couple of years.[10] Research for the booklet was undertaken between two spells in prison towards the end of the war, first as a conscientious objector and subsequently for ‘seducing members of the Armed Forces from their duty’.[35] His job as Casualty Officer at Paddington Hospital had given him ‘full run of the library, which was above my department’. Back in prison, he wrote the booklet on ‘loo bumpf and things of that sort’. Unfortunately it was not included with his belongings when he was released. However, ‘I knew more or less what it all was and rewrote it’ (John Hewetson unpublished interview 1987).
Building on foundations laid by earlier writers from Frederick Engels to Jerry Morris, and debate that stemmed back to the Factory Report of 1833, Hewetson set out his case against the health and social welfare acts being prepared by the government.[34] Two months before the booklet’s publication he had written: ‘When the Beveridge Scheme was first published … we pointed out that it made no attempt to eliminate poverty, only to insure against its worst effects. As such, its effect was actually to stabilise poverty, by seeking to make it just tolerable. The same criticism must be brought against the scheme of July 5th 1948’.[36] Similar remarks in the booklet itself underscored his fundamental objection to the post-war reforms and led him to conclude that, in terms of the abolition of poverty, ‘These reforms will be as ineffective as those introduced in 1911’.[34]
Although Hewetson grudgingly admitted some virtues in Beveridge–the universality of the scheme in particular–his concerns were not limited to its failure to tackle poverty as the underlying cause of ill health. Above all, ‘Yet another step has been taken along the road that ties the population to the State. Such measures were a substantial factor in securing the stability of the Fascist regimes … and the Soviet Union. Such societies owe their pernicious effects to the fact that they encourage the irresponsible dependence of individuals on the state. The fact that the alternative, under capitalism, is destitution … does not make the Liberal-Socialistic alternative a sound proposition’.[36] Hewetson felt it was ‘not within the province of the capitalist state to “suggest measures for the relief of poverty”-much less for its abolition’. His solution like that of others, for example Alan Hutt and Clara Zetkin,8,[37] was social revolution, but via the abolition of the state rather than its supposed ‘withering away’. Although Hewetson’s alternative was lacking in detail, he was a strong advocate of Kropotkin’s stress on mutual aid as the central factor in evolution. He saw Darwinian evolutionism as being inspired by Malthus’ Essay on Population, and viewed its subsequent development as a very explicit celebration of tooth-and-claw capitalism. For him, as for Kropotkin, the possibility of an Anarchist society was already obvious in the long past of voluntary civil society.21,[38]
One of the examples Hewetson did touch on was the mutualism in Anarchist village collectives during the Spanish Civil War.[38] Often cited as a prime example of Anarchism in practice, the integrated health system created by the newly formed anarcho-syndicalist Health Workers’ Union during the 1930s Spanish Civil War[39] is only one example of many autonomous mutual aid healthcare projects around the world: more recent projects in South America being among some of the better known. Examples there include: the [800] community health centres, municipal clinics and hospital of the Mexican Zapatistas; and the health programmes created by indigenous organizations such as the Confederation of Indigenous Nationalities of Ecuador and the regional Indigenous Councils in Colombia.[40] Associations of the piqueteros (unemployed) in Argentina have organized preventative health centres, supplied their members with free medicine and eyeglasses[40] and occupied and taken over (‘recuperated’) private clinics.[41] In the USA, the Common Ground Health Clinic, part of a mutual aid collective set up to fill the vacuum left by the state in the wake of Hurricane Katrina, still provides primary care services for the local community.[42] In common with the Friendlies and the Peckham Health Centre, these initiatives have come under attack by the state either directly or via attempts to incorporate them into the state apparatus and by so doing destroy their independence and bury them in bureaucracy. In Chile for example, during the Pinochet dictatorship, land occupations were used to create autonomous squatter settlements. These carried out everything from food production to health groups at the same time as having to resist massive and brutal attempts by the dictatorship to destroy them. This resistance, in which women played a vital role, contributed to ending the dictatorship. However, for the women ‘the transition from dictatorship to democracy was a disaster’. Centre left politicians and middle class professionals invited the squatters’ organizations–the Commando of United Residents and the Settler Women’s Movement–to participate in multi-sectoral bodies. They then proceeded to marginalize them and the end result was their disintegration.[40] Initiatives (elsewhere) across the globe have been similarly neutralized by non-governmental organizations or indeed USAID in its role of guardian of US foreign policy interests.[43],[44]
Given the ongoing, seemingly inexorable, transfer of public services into the hands of private profiteers, maybe now is the time to revisit and re-evaluate the possibilities afforded by these and the many other examples of self-organized approaches to health provision. Possibly Hewetson’s call to tackle poverty, as the underlying cause of ill health, by social revolution is the only approach that will root out inequalities rather than merely minimize their effects. Market forces and competition have invaded every aspect of people’s lives and are now systematically perpetuated by national and international institutions, including those that govern health and welfare. Maybe Anarchists and other advocates of working class self-organization ‘from below’ should spend less energy defending the state and the status quo and be more vocal advocates of viable alternatives?
We are not arguing of course that schemes like the Friendlies, Peckham Health Centre and autonomous self-organized projects, such as those referred to in South America, could, will or can of themselves end poverty. They are, however, clear examples of effective collective self-help past and present. They may also, perhaps, be the seeds ‘of the new society within the shell of the old’.[45] A vision of social revolution arising from such seeds could even ground any liberatory revolutionary project in the actual lived experience of ordinary people.
Conflict of interest: None declared.
[1] Pierson C. Beyond the Welfare State? The New Political Economy of Welfare. 2nd edn. Cambridge, UK: Polity Press,1998.
[1] Pierson C. Beyond the Welfare State? The New Political Economy of Welfare. 2nd edn. Cambridge, UK: Polity Press,1998.
[1] Pierson C. Beyond the Welfare State? The New Political Economy of Welfare. 2nd edn. Cambridge, UK: Polity Press,1998.
[1] Pierson C. Beyond the Welfare State? The New Political Economy of Welfare. 2nd edn. Cambridge, UK: Polity Press,1998.
[1] Pierson C. Beyond the Welfare State? The New Political Economy of Welfare. 2nd edn. Cambridge, UK: Polity Press,1998.
[2] Hill M. Fragments of an Anarchist Public Health: Developing Visions of a Healthy Society. 2012. http://anarchiststudies.mayfirst.org/node/301 (18 November 2016, date last accessed).
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