In the latest issue:

Real Men Go to Tehran

Adam Shatz

What Trump doesn’t know about Iran

Patrick Cockburn

Kaiser Karl V

Thomas Penn

The Hostile Environment

Catherine Hall

Social Mobilities

Adam Swift

Short Cuts: So much for England

Tariq Ali

What the jihadis left behind

Nelly Lahoud

Ray Strachey

Francesca Wade

C.J. Sansom

Malcolm Gaskill

At the British Museum: ‘Troy: Myth and Reality’

James Davidson

Poem: ‘The Lion Tree’

Jamie McKendrick


Jenny Turner

Boys in Motion

Nicholas Penny

‘Trick Mirror’

Lauren Oyler

Diary: What really happened in Yancheng?

Long Ling

Short CutsDave Lindorff

Terms and Conditions

These terms and conditions of use refer to the London Review of Books and the London Review Bookshop website ( — hereafter ‘LRB Website’). These terms and conditions apply to all users of the LRB Website ("you"), including individual subscribers to the print edition of the LRB who wish to take advantage of our free 'subscriber only' access to archived material ("individual users") and users who are authorised to access the LRB Website by subscribing institutions ("institutional users").

Each time you use the LRB Website you signify your acceptance of these terms and conditions. If you do not agree, or are not comfortable with any part of this document, your only remedy is not to use the LRB Website.

  1. By registering for access to the LRB Website and/or entering the LRB Website by whatever route of access, you agree to be bound by the terms and conditions currently prevailing.
  2. The London Review of Books ("LRB") reserves the right to change these terms and conditions at any time and you should check for any alterations regularly. Continued usage of the LRB Website subsequent to a change in the terms and conditions constitutes acceptance of the current terms and conditions.
  3. The terms and conditions of any subscription agreements which educational and other institutions have entered into with the LRB apply in addition to these terms and conditions.
  4. You undertake to indemnify the LRB fully for all losses damages and costs incurred as a result of your breaching these terms and conditions.
  5. The information you supply on registration to the LRB Website shall be accurate and complete. You will notify the LRB promptly of any changes of relevant details by emailing the registrar. You will not assist a non-registered person to gain access to the LRB Website by supplying them with your password. In the event that the LRB considers that you have breached the requirements governing registration, that you are in breach of these terms and conditions or that your or your institution's subscription to the LRB lapses, your registration to the LRB Website will be terminated.
  6. Each individual subscriber to the LRB (whether a person or organisation) is entitled to the registration of one person to use the 'subscriber only' content on the web site. This user is an 'individual user'.
  7. The London Review of Books operates a ‘no questions asked’ cancellation policy in accordance with UK legislation. Please contact us to cancel your subscription and receive a full refund for the cost of all unposted issues.
  8. Use of the 'subscriber only' content on the LRB Website is strictly for the personal use of each individual user who may read the content on the screen, download, store or print single copies for their own personal private non-commercial use only, and is not to be made available to or used by any other person for any purpose.
  9. Each institution which subscribes to the LRB is entitled to grant access to persons to register on and use the 'subscriber only' content on the web site under the terms and conditions of its subscription agreement with the LRB. These users are 'institutional users'.
  10. Each institutional user of the LRB may access and search the LRB database and view its entire contents, and may also reproduce insubstantial extracts from individual articles or other works in the database to which their institution's subscription provides access, including in academic assignments and theses, online and/or in print. All quotations must be credited to the author and the LRB. Institutional users are not permitted to reproduce any entire article or other work, or to make any commercial use of any LRB material (including sale, licensing or publication) without the LRB's prior written permission. Institutions may notify institutional users of any additional or different conditions of use which they have agreed with the LRB.
  11. Users may use any one computer to access the LRB web site 'subscriber only' content at any time, so long as that connection does not allow any other computer, networked or otherwise connected, to access 'subscriber only' content.
  12. The LRB Website and its contents are protected by copyright and other intellectual property rights. You acknowledge that all intellectual property rights including copyright in the LRB Website and its contents belong to or have been licensed to the LRB or are otherwise used by the LRB as permitted by applicable law.
  13. All intellectual property rights in articles, reviews and essays originally published in the print edition of the LRB and subsequently included on the LRB Website belong to or have been licensed to the LRB. This material is made available to you for use as set out in paragraph 8 (if you are an individual user) or paragraph 10 (if you are an institutional user) only. Save for such permitted use, you may not download, store, disseminate, republish, post, reproduce, translate or adapt such material in whole or in part in any form without the prior written permission of the LRB. To obtain such permission and the terms and conditions applying, contact the Rights and Permissions department.
  14. All intellectual property rights in images on the LRB Website are owned by the LRB except where another copyright holder is specifically attributed or credited. Save for such material taken for permitted use set out above, you may not download, store, disseminate, republish, post, reproduce, translate or adapt LRB’s images in whole or in part in any form without the prior written permission of the LRB. To obtain such permission and the terms and conditions applying, contact the Rights and Permissions department. Where another copyright holder is specifically attributed or credited you may not download, store, disseminate, republish, reproduce or translate such images in whole or in part in any form without the prior written permission of the copyright holder. The LRB will not undertake to supply contact details of any attributed or credited copyright holder.
  15. The LRB Website is provided on an 'as is' basis and the LRB gives no warranty that the LRB Website will be accessible by any particular browser, operating system or device.
  16. The LRB makes no express or implied representation and gives no warranty of any kind in relation to any content available on the LRB Website including as to the accuracy or reliability of any information either in its articles, essays and reviews or in the letters printed in its letter page or material supplied by third parties. The LRB excludes to the fullest extent permitted by law all liability of any kind (including liability for any losses, damages or costs) arising from the publication of any materials on the LRB Website or incurred as a consequence of using or relying on such materials.
  17. The LRB excludes to the fullest extent permitted by law all liability of any kind (including liability for any losses, damages or costs) for any legal or other consequences (including infringement of third party rights) of any links made to the LRB Website.
  18. The LRB is not responsible for the content of any material you encounter after leaving the LRB Website site via a link in it or otherwise. The LRB gives no warranty as to the accuracy or reliability of any such material and to the fullest extent permitted by law excludes all liability that may arise in respect of or as a consequence of using or relying on such material.
  19. This site may be used only for lawful purposes and in a manner which does not infringe the rights of, or restrict the use and enjoyment of the site by, any third party. In the event of a chat room, message board, forum and/or news group being set up on the LRB Website, the LRB will not undertake to monitor any material supplied and will give no warranty as to its accuracy, reliability, originality or decency. By posting any material you agree that you are solely responsible for ensuring that it is accurate and not obscene, defamatory, plagiarised or in breach of copyright, confidentiality or any other right of any person, and you undertake to indemnify the LRB against all claims, losses, damages and costs incurred in consequence of your posting of such material. The LRB will reserve the right to remove any such material posted at any time and without notice or explanation. The LRB will reserve the right to disclose the provenance of such material, republish it in any form it deems fit or edit or censor it. The LRB will reserve the right to terminate the registration of any person it considers to abuse access to any chat room, message board, forum or news group provided by the LRB.
  20. Any e-mail services supplied via the LRB Website are subject to these terms and conditions.
  21. You will not knowingly transmit any virus, malware, trojan or other harmful matter to the LRB Website. The LRB gives no warranty that the LRB Website is free from contaminating matter, viruses or other malicious software and to the fullest extent permitted by law disclaims all liability of any kind including liability for any damages, losses or costs resulting from damage to your computer or other property arising from access to the LRB Website, use of it or downloading material from it.
  22. The LRB does not warrant that the use of the LRB Website will be uninterrupted, and disclaims all liability to the fullest extent permitted by law for any damages, losses or costs incurred as a result of access to the LRB Website being interrupted, modified or discontinued.
  23. The LRB Website contains advertisements and promotional links to websites and other resources operated by third parties. While we would never knowingly link to a site which we believed to be trading in bad faith, the LRB makes no express or implied representations or warranties of any kind in respect of any third party websites or resources or their contents, and we take no responsibility for the content, privacy practices, goods or services offered by these websites and resources. The LRB excludes to the fullest extent permitted by law all liability for any damages or losses arising from access to such websites and resources. Any transaction effected with such a third party contacted via the LRB Website are subject to the terms and conditions imposed by the third party involved and the LRB accepts no responsibility or liability resulting from such transactions.
  24. The LRB disclaims liability to the fullest extent permitted by law for any damages, losses or costs incurred for unauthorised access or alterations of transmissions or data by third parties as consequence of visit to the LRB Website.
  25. While 'subscriber only' content on the LRB Website is currently provided free to subscribers to the print edition of the LRB, the LRB reserves the right to impose a charge for access to some or all areas of the LRB Website without notice.
  26. These terms and conditions are governed by and will be interpreted in accordance with English law and any disputes relating to these terms and conditions will be subject to the non-exclusive jurisdiction of the courts of England and Wales.
  27. The various provisions of these terms and conditions are severable and if any provision is held to be invalid or unenforceable by any court of competent jurisdiction then such invalidity or unenforceability shall not affect the remaining provisions.
  28. If these terms and conditions are not accepted in full, use of the LRB Website must be terminated immediately.

In late September​ , AmerisourceBergen, one of the world’s biggest pharmaceutical distribution companies with revenue of $150 billion, was fined $260 million by the US Food and Drug Administration for emptying pre-filled glass syringes of expensive cancer drugs and reloading the drugs, in slightly smaller doses, into cheap plastic syringes before distributing them to oncology centres. For years, the company allegedly pocketed the profits obtained by creating and selling 10 per cent more pre-dosed syringes in this manner. Prosecutors claimed that because the refilling process was not conducted under sterile conditions, it led to ‘floaters’ and bacterial contamination, putting at risk the health of thousands of cancer patients with compromised immune systems.

Earlier this year, the Justice Department filed a lawsuit, based on evidence from a whistleblower, against UnitedHealth Group, the largest provider of subsidised private medical insurance for the elderly, accusing it of overcharging the government by more than $1 billion, by claiming patients were sicker than they actually were.

The FBI estimates that fraud, both private and public, accounts for up to 10 per cent of total US healthcare expenditure, or about $350 billion, of the annual $3.54 trillion that Americans spend on healthcare. The scale of medical fraud in the UK is still small by comparison, but some of the companies that have paid huge fraud fines in the US – including UnitedHealth, McKesson, Celgene and the Hospital Corporation of America – are becoming increasingly involved in NHS privatisation schemes, in accordance with the government’s wishes.

The Health and Social Care Act pushed through by Andrew Lansley as health secretary in 2012 was intended to increase privatisation, outsourcing, inter-regional competition and ‘marketisation’ in an already strained system. There is little sign that it is improving services or reducing costs, but private firms see profits to be made.

My wife and I flew to the UK last summer to see our daughter receive her DPhil at Oxford. On arriving, I found myself increasingly short of breath. Within a few days I was having difficulty, for the first time in my life, walking up gentle slopes or climbing a flight of stairs. A private doctor whom I consulted found my blood oxygen level to be only 91 per cent – a reading one might expect of a person suffering from pneumonia. He also detected fluid in my right lung and swelling in my ankles. He referred me to the John Radcliffe Hospital’s ambulatory assessment unit the next day. For the time being, he said, I could forget flying home.

After years of negative articles in the US media about overworked doctors, cursory exams and brusque support staff, I wasn’t expecting wonders from the NHS. But my experience was quite the opposite. Doctors, nurses and other staff displayed care and patience and answered my many questions, even at the end of long, busy workdays. My first shock, however, was the lack of an admissions gatekeeper to demand my insurance card, co-pay etc. Such ‘wallet biopsies’ are the first ‘procedure’ conducted in any US doctor’s office or hospital – even in the ER. Instead, I was simply directed to the fifth-floor AAU.

I was given innumerable blood tests, diuretics administered by IV-drip to dry out my lung, an X-ray, CT scan and echocardiogram, not to mention a hot lunch. In addition to staff doctors I was seen by both a cardiologist and a pulmonologist, who together delivered the verdict that I was suffering probable congestive heart failure. They said I could stay there for treatment, but suggested the better plan (to avoid a huge hotel bill) would be to get me stabilised so I could safely fly home to Philadelphia to be seen by specialists there. In five days they brought my blood oxygen level back up to 98 per cent.

The only mention of payment came when an administrator arrived in the waiting room on the second day and politely asked for my passport number and insurance card, ‘if you have insurance’. I said I was covered by Blue Cross through my wife’s job as a university professor. ‘Oh, Blue Cross,’ he said. ‘Well, we’ll bill them, but they won’t pay us anything.’ I asked why not. ‘We don’t have codes for the tests run or the doctors involved. We just bill by the day, and they don’t accept that.’ But he said I shouldn’t worry as the cost of my NHS care ‘won’t be that much’. In the US, every procedure, every medicine – even an aspirin – is separately logged and billed, at exorbitant rates.

I shudder to think what would happen to a British tourist without excellent travel insurance suffering a similar health crisis in the US. Steffie Woolhandler, a professor of public health at the City University of New York and co-founder of Physicians for a National Health Program, says an uninsured person arriving at a private US hospital ER with a similar blood oxygen level and complaining of shortness of breath ‘would probably be turned away since it would not be considered a life-threatening condition’. In some states, she said, they might be advised to go to a public hospital – found these days only in the largest cities. Even then, someone with no insurance might only be stabilised and sent away.

The cost of my NHS care, if provided in the US, would easily have topped £10,000, I’m told, assuming it could have even been provided on an outpatient basis as in Oxford. For inpatient treatment the bill could easily be treble that.

Allyson Pollock, the director of the Institute of Health and Society at Newcastle University, a fierce critic of the privatisation of the NHS and the adoption of US-style business practices, says the idea of free and equal care at point of delivery for all patients ‘still exists because it is provided by the doctors, nurses and staff, if only because of the survival among them of an NHS culture that says people have a right to healthcare, even as that right is being undermined by the government’. NHS hospitals can now generate up to 49 per cent of their revenue from private patients (it used to be 2 per cent): diverting, potentially, almost half their beds and staff.

A huge problem with market-driven medicine is colossal bureaucratic waste. According to a recent paper in the Annals of Internal Medicine, the US will this year devote a whopping $1.1 trillion – 31 per cent of total healthcare spending – to administrative costs. The study estimates that half of that amount – more than $500 billion – could be eliminated simply by switching to a Canadian-style single-payer system, and even more with an NHS-style government-run system.

Most of the $1.1 trillion is spent on billing patients, seeking reimbursement from insurers and supplying paperwork required by insurers and the government to determine the suitability of procedures and to prevent fraud. And yet that anti-fraud paperwork doesn’t help much: remember the $700 billion a year wasted on fraudulent claims, most of which go undetected. Much of the fraud is committed by insurance companies.

Mark Button at the University of Portsmouth says that fraud in the NHS is growing apace with privatisation. ‘If you give organisations and individuals a situation where there are opportunities to increase fees and revenues through fraud, you’ll get more fraud,’ he says. ‘The other problem is that a government that has an interest in promoting marketisation isn’t interested in exposing that fraud.’

As the US demonstrates, when the profit motive is introduced into a health delivery system, ways of gaming the system and outright fraud schemes are easier to devise, and they are a far more profitable business to engage in than treating patients. ‘The capitalist market model doesn’t really work in healthcare,’ Button says, ‘because the consumer has real difficulty making rational decisions based on quality and costs.’

Inequality of care based on assets and insurance coverage is the norm in a market-driven health system. The UK spends $4000 per person to provide care for every single citizen (and people like me). Americans currently spend more than $10,000 per person on healthcare annually, but even with the implementation of the Obama administration’s controversial Affordable Care Act, 27 million people, or about 9 per cent of Americans, remain uninsured and can’t usually afford to see a doctor. And because of the high cost of the care provided through Medicare and Medicaid (taxpayer-funded but heavily privatised) and the high premiums for mandatory private insurance, a majority of US voters last year elected politicians who vowed to eliminate the ACA, cut back on Medicaid funding, and take subsidised health insurance away from between 20 and 30 million more of their fellow citizens.

Healthcare systems don’t work like a free market; the profit motive sucks out money that should be spent on healing people; and the social consequences of privatising healthcare, in terms of inequality of access and treatment, are things no decent society should tolerate. The US has the highest priced and least equitable healthcare of any developed nation. And we don’t even have the best statistics on life expectancy or infant mortality rates to show for it. We’re not even close.

Send Letters To:

The Editor
London Review of Books,
28 Little Russell Street
London, WC1A 2HN

Please include name, address, and a telephone number.


Vol. 40 No. 1 · 4 January 2018

I have worked in the UK with asylum seekers and undocumented people for many years, and as such I was interested to read Dave Lindorff’s account of his experience of the NHS as a foreign visitor (LRB, 30 November 2017). It should, however, be pointed out that not everyone is allowed access to NHS treatment. Over the past five years the government has implemented numerous policies to prevent the hundreds of thousands of people who live in the UK without a visa from getting NHS care. Often this is no fault of theirs since they were brought here as children and are now adults, or have had their asylum application wrongly rejected by the UK Border Agency (30 per cent of rejections by the UKBA are overturned by judges).

It is true that some NHS medical services are still available to all free of charge: emergency intervention in A&E to save a life, or treatment of communicable diseases such as HIV and tuberculosis. However, non-emergency medical treatment, while it might (or might not) be provided at the discretion of a local NHS trust, will be billed to the patient if they do not hold a current visa. People who don’t have visas are rarely in a position either to buy the insurance that Lindorff had, or to pay the government’s NHS surcharge of up to £200 for every visa application (on top of the cost of the visa itself, which can be in excess of £1000). Usually the surcharge has to be renewed every two and a half years.

People in this situation are afraid to approach the NHS for medical treatment, because they know that if they owe the NHS £1000 or more (the cost of roughly one day’s hospital treatment that isn’t directly provided in the emergency room), the UKBA will refuse to consider any visa application they may make in the future. This rule was brought in when Theresa May was in charge at the Home Office. Other policies included detaining children without visas, removing the right to legal aid to assist children to regularise their status even if they have lived in the UK for most or all of their lives, the indefinite detention of people without visas and so on. It was also May who introduced the advertising vans threatening any foreigner who was living here without a visa – all part of what she meant when she called for the creation of a ‘hostile environment for illegal migrants’.

Scott Krieger
London SE3

Undocumented migrants receiving NHS treatment are not as lucky as David Lindorff was. Nowhere is this more clear than in the case of maternity care. Government regulations state that maternity care is ‘immediately necessary’ and so must not be refused or delayed because of a woman’s inability to pay for her care in advance. But the care is still chargeable, as is all ‘overseas visitor’ treatment, at 150 per cent of the tariff charged to Clinical Commissioning Groups. Full maternity care including antenatal care, labour and postnatal care can easily cost more than £5000 for an uncomplicated birth and more than double that if the pregnancy and birth are complex. Recent migrants and women who do not speak English are among the groups with the highest risk of maternal mortality and adverse pregnancy outcomes. The effect of NHS charges, and the fear of being reported to the Home Office by the hospital if they have unpaid debts over £500, is to prevent these pregnant women from seeking crucial maternity care.

Rayah Feldman
London E9

send letters to

The Editor
London Review of Books
28 Little Russell Street
London, WC1A 2HN

Please include name, address and a telephone number

Read anywhere with the London Review of Books app, available now from the App Store for Apple devices, Google Play for Android devices and Amazon for your Kindle Fire.

Sign up to our newsletter

For highlights from the latest issue, our archive and the blog, as well as news, events and exclusive promotions.