Medicine sits where fear meets trust, and Big Pharma - the companies that make up the Medical Industrial Complex - know that.

In this video, I explain how the 1910 Flexner Report, written in the USA at the peak of an era of toxic capitalism, reshaped medicine, why big pharmaceutical companies gained power as a result, and how the NHS is now at risk of becoming a profit gernation machine rather than a care system.

This is not about denying science. It is about asking who benefits from today's model of healthcare and why prevention, public health and social care are being sidelined.

We need a politics of care, not a politics of profit.

This is the audio version:

This is the transcript:

I want to talk about a subject which is much discussed in my household, and that is the relationship between  fear, medicine, 'Big Pharma' or big pharmaceutical companies, if you want to put it that way, and the NHS and how these things have been framed deliberately by neoliberal capitalism to produce health outcomes which are now frankly contrary to our well-being.

Let's be clear. The framing of this is very much around fear and the fact that capitalism uses it as a sales tool. Medicine sits in the place where fear meets trust, and this has been known for a long time, in fact, it underpinned a report that I want to talk about, which was written as long ago as 1910. The report in question was called the Flexner Report, named after the person who wrote it, and the report was pivotal in the history of medicine because it quite literally reshaped healthcare. Most especially, it let Big Pharma capture it for gain.

Now, for a long time, and let's be clear about this, the NHS held out against that. The Flexner Report was written in the USA and had its biggest impact at first in the USA and Canada. But now, we in the UK are also at massive risk from the impact of Big Pharma on what happens inside the NHS, partly because of the choice of our politicians, who seem to believe themselves totally in hock to the big pharmaceutical companies, and partly because those companies have, in any case, captured the medical-industrial complex of this country and turned it against our well-being by literally pursuing profit above healthcare. Those are the issues I want to talk about.

Now, when we talk about fear in this issue, we talk about illness creating inelastic demand for healthcare. Patients will pay anything for hope once they're ill. They also face great insecurity at that moment, and by and large, lose their ability to decide. That's why advertisers amplify insecurity as a mechanism for increasing their sales. Finance prices risk into everything, but markets are quite different. Markets, when it comes to healthcare, monetise fear.

This is structural and not accidental, and this is how big pharmaceutical companies are now working to turn fear about health into profit streams.

Medicine, as far as they're concerned, has become the perfect market. Patients cannot judge treatment quality. They're not qualified to do so. Decisions are made urgently, and are very often emotional. Illness cannot be delayed. Once it arrives, it's there right in front of us, affecting us, or our loved ones. And doctors hold trusted authority, but they and the services that they can deliver are in restricted supply. That combination creates enormous pricing power for Big Pharma, even within the NHS.

And none of this is by chance; that's my point. The history I'm talking about goes back to that Flexner Report written in 1910, and this was no neutral product. It was commissioned by the Carnegie Foundation, a charity. So you might think, well, surely it was promoted for well-being. Hang on a minute. The Carnegie Foundation was, of course, funded by big industry at a time when, in fact, America was going through an exceedingly toxic period of capitalism, where big industry was trying to capture the entire well-being of the States for the benefit of a few people, and that report was a part of this process.

What it did was review all the activities of US and Canadian medical schools. What it said was, they did not come up to scratch. They needed to be reformed. They needed to be based on the logic of the big pharmaceutical industry.

As a result, many institutions were closed.  Training was centralised in elite universities, and notice that word, 'elite'.  And laboratory science, and not care, judgement or remedies not requiring prescriptions, became the dominant form of medical supply.

The logic of medicine changed. You went to see a doctor to come away with a pill, a treatment, or something else that required continuity of care by the medical profession using the products of the big pharmaceutical industry. The Flexner Report was, in this sense, a complete turning point.

Now, let's not pretend that there was no good that came from this; clearly, some did. Scientific method did strengthen some parts of medicine, undoubtedly, and dangerous quackery, which had been heavily seen in the 19th century, was reduced as a result. That  was progress. Let's be clear. I don't dispute that.

And medical training did improve to some extent. Public trust, as a consequence, also grew in doctors to the point where we know doctors  have frequently been amongst the most trusted professions in the UK and elsewhere. Modern clinical medicine emerged from all this. None of that can be denied.

But political economy always asks one question, and that is: who gained? After all, everything within political economy is about how power is used to allocate resources, and in this case, what we need to ask is, in a sense, who lost, because that is how we can identify the winners.

Community-based medical traditions vanished as a consequence of the Flexner Report. They were treated as old hat, irrelevant, to be considered outside the medical system. Those ideas that had sometimes worked incredibly well were no longer seen or recommended.

In particular, there were other losers.  Medical schools that served women and Black students were closed, changing the balance of power in medicine in a way still not restored. This bias is still there.

Preventive approaches were most definitely sidelined. What we saw was that those things that have been known for centuries, even millennia, which actually prevented the onset of disease, were not mentioned anymore.

As a result, we've got the rise of  things like ultra-processed food. In fact, nutrition, sanitation, and environmental causes of ill health were all downgraded within the medical system, or even ignored, despite the fact that, as medical history proves, these three things were the biggest contributors to the improvement in health in the 19th century in the UK and way beyond. Nothing did more for healthcare in this country than did the laying of sewers.

Natural  therapies, meanwhile, were marginalised. Heliotherapy, for example, sunlight treatment, which so heavily influenced  the design of hospitals and schools for a long period of time, was literally pushed aside. Once common as a treatment,  which was highly effective for TB and rickets, this was now ignored. The cost has been enormous. One of the things that sunlight is incredibly good for is cancer patients, but nobody now talks about that. That's not because sunlight stopped working. It's because laboratories and pharmaceutical companies defined what was legitimate, and that's where we now are.

But most especially, what the Flexner Report brought in was an era where medicine moved from providing cures to the management of disease. Now, disease is different from illness. Illness is real. It's the symptoms you suffer. It's the consequences of those things that you feel within your body. Disease is the description that is applied to that by the medical model. They are actually quite different. And chronic disease, which can simply be a name describing a syndrome for which there is actually no known cure, became a revenue stream for Big Pharma.

Drugs managed symptoms and not causes. Lifestyle and environmental cures for illness were ignored, hence our ignoring ultra-processed foods now, and the identification of disease requiring treatment was the new priority of all medicine, and it still is. That is what your GP is rewarded for if you go to see them in surgery. If they can tick a box saying that they have identified a disease that you have, they literally get paid. That is the incentive that they have now. It was created in 1910.

Prevention was, as a consequence, underfunded, and it again, still is. Your GP is not rewarded for preventing you from getting ill. They're only rewarded for identifying why you might be ill and giving that illness the name of a disease.

Care became treatment, and not therefore health, and that was the basis of the profitability of Big Pharma; they knew that. Healthy people are not customers of that industry, but like all industries, they want more and more customers. In other words,  managing illness became their marketplace. Identifying disease became the product that they sold, and pills were the solution which they wanted to peddle. Big Pharma is a business seeking to grow, and this model let it do just that.

So who funded Flexner, and why did it matter? The Carnegie Foundation funded the study, and the Carnegie Foundation was a charity, so you might think all is well and good, but  Andrew Carnegie funded that charity and Andrew Carnegie got his wealth from somewhere. It was from industrial Capitalism, and we are talking about an era when industrial capitalism was dominated, as was financial capitalism in the USA, by a very few people. They were literally creating monopoly situations to extract profit from the people of that country, which gave rise to the goal of the first US president to have the name  Roosevelt. This was Teddy Roosevelt, the man who was president just after the turn of the 19th century into the 20th century, before the First World War, who literally had to set out to break the power of these capitalists, so pernicious was it.

This report, funded by Andrew Carnegie's Foundation, aligned medicine with industrial science for a reason. Pharmaceutical manufacturing was, at that time, emerging. Standardised medical practice would create drug markets, which it needed to be profitable, and none of this was accidental. Standardisation of medical practice was created at scale because that scale created an opportunity for profit for the industrial complex that became the medical-industrial complex, which we are still subject to when it comes to healthcare.

As a result, medicine also became exclusive. Entry to the profession became restricted. For a long time, it was hard for a woman to get in. Elite universities dominated training, and the training system that they provided was dominated by what Big Pharma also, in turn, required them to do.

The supply of doctors was constrained.

Professional authority was centralised, and those who questioned it were normally punished, as they still are, by the way. It is the easiest way to lose your license to operate as a doctor to say that Big Pharma is wrong with regard to the way in which it suggests patients be treated.

And patients became dependent. The subjects of the doctors, not the patients of them.

This, of course, was effective at one level. For a while this worked particularly well, especially as new treatments were found. Things like penicillin and other antibiotics. We saw advances as a result, and we saw advances in other areas. Treatment of heart disease, for example, clearly made progress, but it was exclusive, and exclusivity plus fear equals pricing power, and then Big Pharma enters the scene,   not just in the USA and Canada, by the way, but also here too, because Big Pharma creates our drugs.

They protect them using patent law. The consequence is that they create continuing income streams because a monopoly is effectively created by that patent. Now, I'm not arguing that this shouldn't exist for a while. There has to be a reward on their effort. But when a great deal of drug creation is actually funded using government grants, the right to hold a patent to grant monopoly has to be questioned.

In the USA,  insurance systems also guaranteed payment to pharmaceutical companies and became a system of guaranteed income return in its own right. There is a whole industry of healthcare insurance, whilst hospitals became corporate assets.

Private equity now buys care providers because they are so profitable, and drug pricing has been detached from cost.  Many drugs which cost very little are now priced at a great deal. Right now in the UK, the example is aspirin. You have to pay a fortune to buy aspirin in this country right now, and yet it is an incredibly cheap drug to produce, but that's because Big Pharma mysteriously has it in short supply.

Now the USA shows the logical outcome of all of this. Let's be clear. It is a provider and user of technology-rich medicine, but it has morally poor outcomes, and the NHS was meant to be and did provide another model for a very long time and thank goodness for that.

Public healthcare socialised risk.

Costs were controlled.

Doctors were meant to serve patients and not shareholders, although that has never been entirely true with regard to GPs.

Prevention became rational policy because the state saw the benefits.

There was a macro dimension to healthcare, which justified spending on issues like vaccination and care in the community.

Social security also removed fear. It meant that people were not frightened of ill health; therefore, they tackled it and dealt with it, and healthcare was, as a consequence, seen as infrastructure and not as a commodity.

This is exactly what I argue for here and on my  Funding the Future blog, which you should be looking at if you're not a reader.

But none of this is easy, and what is more, all of it is threatened. The NHS is being undermined by Big Pharma right now and by the political choices of people like our Health Secretary, Wes Streeting. Flexner improved science by all means, but it also narrowed imagination everywhere. Medicine is now driven by algorithms. It is laboratory-centred. It is pharmaceutically focused. Doctors are incentivised to literally prescribe; that is their role. They're not encouraged to think, and in fact, medical training does not encourage anyone to think; it is not, in that sense, an academic discipline at all. It is more like an apprenticeship. Profit has followed fear, and anybody who challenges that within the NHS is, as I've already noted, punished; you could well lose your license.

As a consequence, the NHS has changed. We, too, have lost medical judgment: public health, sunlight as treatment, perception of diet as a cause of ill health, treatment of the environment as a threat, and we've also lost the relationship between healthcare and social care, which we once had. Indeed, we did once have a Department of Health and Social Security in the UK to link those two together, but they are now miles apart in terms of their political treatment.  We gained pill dependency as a consequence, and that is not neutral.

Big Pharma controls medicine here, too, now. Not least, through training and control of university curricula. Doctors must follow their prescriptions, literally, or they cannot work. By the back door, the NHS is a Big Pharma profit generator as much as in the USA. We are a replica of them in this sense.

So what should change? Look, we need to go back and ask real questions about why we have a healthcare system. What is illness, and what causes it? Is the primary question to ask? We need to understand that, actually, we are not looking at healthcare as pills, but we need to ask about healthcare as wellness. We need to look at what it is that causes that illness in the first place, and here the primary fault lies with our policies around ultra-processed food, and frankly, a lack of physical well-being.

But having dealt with that issue,  we still need to regulate pharmaceutical monopolies. We need to expand medical education so doctors can actually think for themselves and imagine outside the box of pills that they've got in front of them, that there might be other solutions that a patient needs, including a referral for enhanced social care within the community, supplied by the government, and they don't need to be treated with pills instead.

We need to integrate environmental and lifestyle care inside the NHS to ensure that we look at the whole person.

We must protect the funding for public healthcare systems.

And we must literally always imagine that we are looking  at illness and not disease because disease is just a label, but illness is real and the thing from which people suffer.

We also need research into cures and not just the management of disease that generates profit. The two are quite distinct. We have forgotten what cures look like; that is not what Big Pharma does. It doesn't look for them because management of disease is what makes profit for them, and that is a big problem. As  a consequence, we need to rethink all these things as part of a politics of care and not a politics of profit.

So was Flexner pivotal? Yes. It was the moment when medicine became industrialised. It was when industrially funded philanthropy aligned with corporate opportunity. It was when professional medicine became dependent upon pharmaceutical supply chains. It was the point at which Big Pharma founded its institutional basis. The Carnegie Foundation drove that reform, and those who funded industrial capitalism gained a vast new market in disease as a consequence.

Fear does drive profit when care is privatised. Flexner did reshape medicine as a result. Big Pharma has captured that opportunity. The NHS did show a humane alternative, but it no longer does. It too has been captured via the back door of Big Pharma, training, and algorithms, and all of that is wrong.

We need a public healthcare system to manage all risks and not just disease. If we can provide care, we can afford to do so. The real constraint is resources and not money, but we have got resources available, but we are not employing them for the right purpose. And as a consequence, we are being denied resources in terms of training, skills, and experience to see how medicine could now be so much better than simply being disease management most of the time.

We need to talk about health. We need to talk about wellness. We don't just need to talk about disease , and we've forgotten that for far too long now, since 1910, in fact. And we need to rethink the whole issue again because that legacy has now lasted too long. That's what I think.

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