Adler-Bolton, Beatrice, and Artie Vierkant. Health Communism. Verso, 2022.
“We set the productive forces free and control the destructive ones. We exterminate what is inferior and increase what is useful….anyone who makes the slightest effort can see what’s waiting in the future. It’s like a serpent’s egg. Through the thin membranes you can clearly discern the already perfect reptile.”
–Hans Vergerus in Ingmar Bergman’s “The Serpent’s Egg.”
The proto-Nazi villain of Bergman’s film provides a window on how capitalist logic separates “useful” individuals or communities from superfluous ones. People are either useful to the “productive forces” or not. The latter can be dealt with so as to maximize efficiency.
In Health Communism, Beatrice Adler-Bolton and Artie Vierkant first identify and provide an overview of the methods and ideology that have solidified into modern Health Capitalism.
We articulate how health is wielded by capital to cleave apart populations, separating the deserving from the undeserving, the redeemable from the irredeemable, those who would consider themselves “workers” from the vast, spoiled “surplus” classes. We assert that only through shattering these deeply sociologically ingrained binaries is the abolition of capitalism possible. The contours of capitalism have formed around health, to the point that they have come to appear inextricable from each other (xii).
Against that logic of separation, the authors propose that “to win health communism, our political projects must center the populations capital has marked as ‘surplus’: unwanted, discarded bodies viewed as waste that nevertheless have become the subject of capital accumulation” (xvi).
They provide a couple of case studies of radical resistance to Health Capitalism, The AIDS Coalition To Unleash Power (ACT UP) in the US which formed in 1987, and the West German Sozialistisches Patientenkollektiv (Socialist Patient’s Collective or SPK), founded in 1970. They see both groups as exemplary if not perfect, and propose learning from their strengths and weaknesses to build an anti-capitalist movement to establish “all care for all people” (xii). I include a brief look at their description of the SPK below since that group is less written about in the historical record of left activism.
Health Communism traces the above mentioned taxonomy of “useful and inferior,” or as the authors put it, the “worker /surplus binary,” to pre-capitalist responses to health crises, especially plagues. In the aftermath of the Black Death in England, in which roughly a third of the lower class perished, Parliament saw that the labor shortages created by mass death gave workers leverage to demand higher wages and other concessions. So in 1349 they passed the first “Statute of Laborers” pulling the reigns on the remaining laborers. This and other new laws required workers to drop demands and practices of worker-control and instead surrender total labor control to the state and ruling class. Work became compulsory and those who refused it became criminals (45). Legal categories were constructed to separate the idle and vagrants from those unemployed who were willing to work but had none.
Vagrants, cripples, paupers, and beggars were pathologized as morally and biologically spoiled, lacking the will to fulfill their potential as upstanding citizens. Illness, impairment, and disability had already been framed under Christian religious dogma as a personal lack; in many cases even considered to be a kind of phenomenological punishment for sin or bad deeds (46).
As capitalism developed, the emerging bourgeoisie formulated new laws to separate the “deserving” from the “undeserving” poor so as to minimize the costs of aid, support, and care that might destabilize capitalism (xvii). The surplus population is identified as “waste” under capitalism, as a burden. They can be a “eugenic burden,” meaning a threat to the demographic, genetic/”racial,” makeup of a people or to their systems of law and order. Alternatively they can be a “burden of public debt.” The latter implies that protecting the health of the vulnerable will only take away from the productive and healthy (21-22). Both definitions of burden in capitalist logic adhere to a Malthusian view of surplus populations, sustaining a worthy core group while leaving the rest to chance, “nature,” the market, etc. And yet, there is nothing random or unplanned in the fate of neglected surplus populations.
It was the “worker/surplus” model that served as a prototype for Elizabethan (1558-1603) Poor Laws, which in turn form the outline of modern capitalist welfare (48). In 1572, the position of “Overseer of the Poor” was established. Overseers would collect taxes from the local property owners to pay for poor relief. This tied aid and survival to the whims of the overseer and propertied classes, based on how much they believed the poor and ill were “worth” and whether or not they were “worthy” of aid (48). Eliminating “waste” in such programs meant cutting costs. I’m not sure exactly what the authors’ take on the Labor Theory of Value is, but my first thought when the rich complain about paying too many taxes is that their wealth largely came from the labor of the working classes they employ, or those surplus populations they are able to extract value from in other ways.
One method of extracting value from surplus populations is putting them to work. The “rehabilitation movement” swept America in the nineteenth century with the goal of making impaired workers “normal,” meaning productive to the capitalist class. The authors note this made the medical profession “a kind of industrial maintenance” arm of the ruling class (50).
What about those who could not be rehabilitated? Not to worry! Capitalist alchemy could still transmute that surplus population into gold via “extractive abandonment” (xvi). As Marta Russell has shown, “capital and the state have constructed systems to reclaim this lost population as a source of financial production.”
One way to separate out the surplus for extractive abandonment is simply to warehouse them. Think of prisons, poor houses, senior care homes, etc. In these institutions while you can extract value from the patients or inmates’ labor, their mere presence can also make them commodities. Care institutions can gain government subsidies and run on a for profit model, as seen with public/private ventures. These institutions can also profit by attracting investors who will demand cost cutting efficiency to protect their dividends. Care can also be just another part of the service sector. Employee’s care-work is the source of value extraction via the system of waged labor (16).
The authors reference the research of Marta Russell, who has analyzed a “money model of disability.” They note that merely having state funding is not a guarantee of eliminating the cold logic of the market and cost cutting as “this market-driven money model of disability and elder care was only made possible through the mechanism of federal financing” (16). Care recipients do not get direct funding that would allow them to receive it at home. Instead Medicare focuses on institutional care, and many of those institutions are for profit care homes. Further explaining Russel’s model, the authors note that “nursing home residents are counted as assets in Wall Street evaluations of nursing home corporations, which are assigned a valuation in anticipated annual revenue per person” (15-16).
Social Determinants of Health
Adler-Bolton and Vierkant are clear that there can be no place for such cost-cutting, profit maximizing capitalist logic in a truly socialized healthcare system, but well intentioned left and social democratic efforts to help underserved often groups fall victim to the logic of scarcity. Otto Von Bismark’s welfare state was understood to be a way of outflanking the socialists of his day, undermining their more radical demands to preserve capitalist state control over social safety nets. And yet, the authors point out, many reformers believe such programs are the path to socialism, missing how such appeasement is designed specifically to prevent radical revolt (25).
We are obviously living in a time when defending basic welfare state care programs is vital to our survival, but we also know they are not enough. To go beyond mere welfare schemes as found under capitalism, the authors want to deepen the meaning of what is called “the social determinants of health.” As defined by activists, the idea that health is socially determined means that housing, clean air, food, clean water, public sanitation, social supports, etc. are all forms of healthcare. Capitalist welfare systems contain the kernel of revolutionary care if “we can imagine the reformation of the political economy around the social determinants of health.” To do that will require centering the surplus populations with the goal of meeting “the social needs of all” (22-23).
As I read them, this is not the call to build the new society in the shell of the old, or the call to seize and use the mechanisms of the state as they are but for the working class. They are talking about first understanding the ways capitalist production will turn every seemingly decent aspect of care back into the project of surplus value extraction. This first needs to be understood, then dismantled. The focus on health care has to do with the way every aspect of production is enmeshed in the process of care (housing, food, environmental impact, borders, etc.). The bottom line is that capitalism has to go, and the systems of production have to be overthrown and totally redesigned.
The difference between a liberal and a communist view of social determinants of health is similar to the difference between a bourgeois and a social revolution. The former ushers in a new more progressive ruling class, while the latter abolishes class divisions, private property, and waged labor entirely redesigning the social relations of production. The capitalists’ half analyses pathologize the poor to then designate them as surplus for extractive abandonment while the health communist analysis places the surplus at the center of the revolution.
Health is the War of the State
“Why should we spend money for a fool, for a hopeless ill person, if I can do with the same money so much good for a poor peasant’s kid…”
–SS officer Reinhard Spitzy recounting Hitler’s justification for the T-4 Euthanasia program.
Of course, there are worse things than the state damping down the revolutionary elan of the working class with half-measure concessions. The ruling class usually openly crusades against socialized medicine. Health Communism presents the case of Frederick Ludwig Hoffman as a chilling embodiment of the ruling class ideological and legal war on socialized care.
He was an anti-socialist race-scientist and a representative of the Prudential Insurance Company at the turn of the twentieth century, very much an “industry stakeholder.” His approach to healthcare focussed on defending the capitalist system.
Hoffman’s 1896 book, Race Traits and Tendencies of the American Negro is a white supremacist tome. His general outlook and expertise in statistical analysis led to his work for Prudential where he rose to the rank of vice president. In his 1928 book Some Problems of Longevity he wrote about Black people, saying they were in denial about negative health outcomes stemming from their “racial disposition.” Hoffman saw it as a sign of the incredible benevolence of white society that they would include Black people in health coverage at all (29).
Hoffman lobbied extensively against socialized medicine, dedicating himself to employing his professional credentials as a statistician in developing an economic and moral argument to prove its danger to the higher classes. Among these were surveys of early European welfare systems, conducted to prove that their implementation collectively increased poverty and immiseration. While Germany’s early health insurance program may have been intended by Bismarck to stymie socialist revolt, Hoffman asserted that in its purported failure it had accomplished the opposite (29).
The authors respond to Hoffman’s complaint with a sick burn: “In this area alone, we agree with Hoffmann: socialized medicine has a profound capacity to change what individuals demand from the state and whom it ultimately serves” (30). It goes to the heart of their thesis, that “[t]he severing of health from capital will mark the end of capitalism” (23).
Hoffman was an early professional voice against socialized healthcare, but that resistance became entrenched in one of the most powerful medical institutions in the US, the American Medical Association (AMA). Wikipedia currently lists the AMA as having “one of the largest political lobbying budgets of any organization in the United States.” The AMA led the efforts to defend the capitalist mode of healthcare in class solidarity with other industry groups (33). They lobbied strongly against President Truman’s 1948 health insurance plans. Various physicians groups set about associating socialized medicine with communism, the Civil Rights Movement, and the Soviet Union as scare tactics to discredit any reforms that would threaten their professional hegemony in running a privatized, for profit healthcare system. That coalition of private organizations wanted to guide the state to carry out their own interests (34).
By the 1950s, organized labor also mostly dropped their attempts to attain national health insurance. In the strong McCarthyite atmosphere of the day, such programs were seen as too communistic. The AMA attacked labor attempts to gain disability benefits as a threat to capitalist organized healthcare. One former member of the Social Security Board said that the AMA opposed those benefits because “the next thing you’d have a broader disability program and the next thing you’ll be giving medical care to the disabled” (36). Horrors!
The position of the AMA, of the organized labor movement, and increasingly in the post-war era, of the American public, carries a lot of the eugenicist and Malthusian assumptions that the authors establish as key to capitalist health care. This is not to say most people are against socialized medicine, only that the assumptions of what that could be have been constricted by now dominant views of what is possible.
American politicians and pharmaceutical companies set out to prove the inherent inferiority of healthcare in the nations they deemed communist. Spreading capitalist healthcare to the world was framed as a humanitarian mission, but also used the language of cost effectiveness and maintaining efficiency in production. In 1957, Senator Hubert Humphrey told the Pharmaceutical Advertising Clubs that the reason they had to spread capitalist health care globally was because “there is a growing awareness of the fact that disease-ridden populations are unproductive and therefore a drain upon national economies and upon the world economy. This in turn becomes a drain on our own economy” (38).
Delegates of pharmaceutical companies visiting the Soviet Union found they had more physicians and medical staff than was expected and that in fact they were exporting their medical workers to less developed countries (39). Some suggested the US engage in a medical arms race against the Soviets as a form of colonial strategy. The authors rightly point to the fact that socialized medicine usually produces better outcomes than capitalist ones. I had slight reservations on some of their descriptions of Bolshevik Russia as “communist” but in the context of the book, this is perhaps a minor quibble, and I have no idea of what critiques of Bolshevism or Leninism they might have.
At any rate, the authors explain that drug companies capitalized on national sentiments during the Cold War to tell “the drug story” in which only capitalist economies could advance pharmaceutical science, while “communist” economies could not (39). Given the sad state of US healthcare, the massive inefficiency and cost redundancies, the stranglehold of private insurance companies able to crush political attempts at socialized medicine, these Cold War statements that only capitalism brings medical advancement are absurd.
Even so, the pharmaceutical industry had a big hand in shaping US colonialism via the creation of capitalist global trade regimes and laws that ensured corporate control over who could produce and profit from vital medicines as well as ensuring scarcity as needed to guarantee higher profits for pharmaceutical companies. Today this regime, known as Trade Related Intellectual Property Rights (TRIPS), means that “in effect, twelve corporations made public law for the world” (90). Those countries not willing to play by the rules of TRIPS may be excluded from trade in and access to life saving drugs and treatments. This “global rationing regime” marks “entire nations as surplus” (78).
The Surplus Fights Back
“For too long, socialized medicine has been billed as a humane concession to be made by the capitalist state, while those in power have recognized it as the threat it is” (26).
In their chapter “Madness,” we see the expansion of institutionalization in the nineteenth and twentieth centuries of surplus populations diagnosed as mad. An ideology the authors identify as “Sanism” drives the capitalist approaches to warehousing those deemed insane: “Sanism is based on the fundamentally flawed notion that the mere existence of madness threatens the safety and order of society.” The resulting institutions and industries that arise around Sanism are punitive, carceral, and designed to facilitate the smooth functioning of capitalist production and value extraction while lowering the costs to the state of caring for these surplus people (61).
Health Communism contains “the most comprehensive account in the English language of the Sozialistisches Patientenkollektiv (Socialist Patients’ Collective, or SPK)” (128). This group arose in part out of a broader resistance to mainstream psychiatry that began in the 1960s. SPK created a model of patient and doctor solidarity with the goal of providing care for all and breaking down a commodified capitalist health care system based on scarcity.
In this way they went beyond most of the contemporary anti-psychiatry movement that tended to be reformist, with left and right wing political iterations. On the right, US libertarian Thomas Szasz promoted the idea that psychotherapy was mostly fake, but that it’s value was subjective and should be determined by the free market, meaning those who could not afford it were not a major concern to him (134).
There was a big influence from existentialist philosopher Jean-Paul Sartre who believed patients should be free to derive meaning from suffering and symptoms of mental illness and then develop away from those symptoms to realize a higher purpose in their lives (132). Generally, the anti-psychiatry movement believed that “madness was not an individual’s biological destiny but a socially determined phenomenon at the population level…” and that “madness was always political…” (131).
Under capitalism, doctors tend to defend their own class interests (as with the AMA) and to see patients in terms dictated by the capitalist state, as either workers or surplus. SPK sought to unite the ill, sick, queer, trans, and those with all manner of disabilities in a way that was more inclusive than only focussing on organizing “the working class” (129-130). From the descriptions in the book , it seems this was not a retreat from class or an abandonment of class struggle. Rather it was a broadening of the concept of the class struggle to include all who fall in the category of “surplus” into the war against capital.
Dr. Wolfgang Huber organized the SPK at Heidelberg University in West Germany in the 1970s. The political backdrop was turmoil, including student rebellions that had emerged in the early sixties and the upsurge in the global anti-capitalist movements of 1968, as well as organized armed struggle groups like the Red Army Faction (Baader-Meinhof). Given the Cold War context, and the fact that West Germany hosted important NATO and US military bases, government officials, business, and civil society representatives were discouraged from critiquing capitalism given that the post-war global capitalist system was considered crucial to their nation’s survival (172).
Huber was critical of the American model of psychiatry, especially the way it failed the lower classes. He saw capitalism itself as a hurdle to patient care, with the class system dividing patients and doctors, but also precluding access for those who could not afford it. The model of treatment he developed with his patients was called “therapeutic political education” a blend of anti-psychiatry and anti-capitalist politics (140).
The SPK view was that “health is a biological, fascist fantasy, whose function … is the concealment of the social conditions and social functions of illness” (152). For Huber, there wasn’t much difference between the standard psychiatry of the 1970s and the Nazi eugenic model of a few decades earlier in Germany. Patients were not only still categorized as surplus based on disability, but they were ranked as undeserving of care based on economic status, often pathologized due to homosexuality, using (illicit) drugs, and even based on having done political organizing (140-141).
The SPK’s activity eventually brought a backlash from the Heidelberg University administration, the West German state, and other nation state’s security forces, as they were designated a terrorist group. They got lumped in with the RAF and other global armed struggle movements. As Huber and his group resisted, they carried out protests and occupations which were met with extreme police brutality. Huber and his wife, Ursula, were both jailed for four years, with one year of solitary confinement each (172).
The SPK produced a manifesto “To Make an Army out of Illness” along with other writings. Their critique of psychiatry was pro-illness. They saw capitalist production as destroying life. It is made up of destructive industry that creates ill health, and rehabilitative industry that then cures ill health. This is “not a collective regime of population health, but instead systems of wealth transfer generating surplus profit from the system of care.” The SPK model of inclusion meant embracing the “spoiled identity” (as a member of a surplus population). Rather than trying to “fix” the symptoms brought on by capitalism, the goal was abolishing it to undercut the causes of those symptoms (149-150).
The SPK pamphlet “To Make an Army out of Illness”
Beatrice Adler-Bolton and Artie Vierkant are the main hosts for a podcast called “Death Panel” which is part of the same political project that created their book. In the March 30th, 2023 show, they discuss the Biden administration’s “winding down” of the Covid pandemic Medicaid expansion. Despite the fact that the pandemic is ongoing, upwards of 20 million people will lose health care coverage. They’ll be thrown back into scrambling to afford care through complex health markets. Many will end up going without care for a period until they are able to figure out the byzantine paper work to get back into a Medicaid program, or not.
The emergency pandemic expansion eliminated the need for the constant and endless “recertification” steps to maintain membership and coverage. The hosts note this was hugely successful and massively increased the efficiency and reach of the program.
Though Medicaid is not the “all care for all people” the authors believe we should collectively envision and bring about, they nonetheless see it as a vital protection for millions of people, who, without it, would either suffer a decline in health, or death. They note the hypocrisy of the Biden administration for scolding Republicans for wanting to attack social security and Medicare, while the Democrats themselves are overseeing this current massive attack on Medicaid.
Artie Vierkant points out that “this could have been the new normal for medicaid or the beginning of something much bigger or better…” While he sees the necessity of fighting against these massive cuts, he reminds the listeners that “Just like everything else with Covid, this is a signal for the importance of a movement to totally sever health from capital.”
The never ending capitalist pandemic
As I read their book, so much of what they analyze comes back to the underlying assumptions that nothing can get done unless someone or some group is there to profit off of it. Years ago, when I participated in a fare strike against rider fare hikes, many people pointed to the way the mass transit system was “losing money” followed by “who will pay for all the services you want?” Over more than a decade of teaching at a community college I’ve noticed a similar set of assumptions against the possibility of worker and community based organizing against austerity, which has only accelerated during the ongoing pandemic and resulted in entire departments disappearing. Best to leave the defense of workers to our “professional assembly” which operates as a boss/administrator/state/employee collaboration rather than an organization dedicated to challenging capitalist bosses and representatives. The workers and sectors of education that are marked as surplus are those that the state and business community see as unworthy due to the fact that they will not produce the needed work force from which to extract value.
The pandemic has brought the levels of ideological reliance on such models, even on the radical and progressive left, into focus. The ways in which people on the left finally gave into the common sense that no one need wear masks anymore, in organizing meetings, classrooms, events, etc. has everything to do acceptance that eugenic and Malthusian capitalist logic is “just how it is.” Now, people who still practice Covid precautions often seem to be regarded with a polite form of pity. Worse, a huge chunk of the left will label them either delusional or “elites” who have the alleged privilege of working from home, as if the pandemic hasn’t eroded all workers’ ability to survive or fight back against capital. People circulating the idea that college professors are “PMC elites” who secretly love the pandemic would be funny if it hadn’t caught on as serious analysis in huge swaths of the modern left. But given that 75% of college professors do not have tenure and are adjuncts treated as temps, it’s one of the more ridiculous theories to gain a foothold.
Health Communism and other recent abolitionist writings show the massively negative impact of capitalist and eugenic ideology and methodology on our ability to have nice things. The ubiquitous caving to the assumption that there is simply not enough for everyone still mars efforts to defend education, health care, etc. The idea that providing more to all will only hurt the deserving and worthy core of society is always just a defense of the capitalist class’ presumed right to maximum extraction of value and profits from every aspect of society.
Adler-Bolton and Vierkant also provide accounts of the “surplus” fighting back as a call from the recent past to keep pushing against capitalist health care, and capitalist everything else for all the same reasons. Their book and podcast are beacons of radical compassion.
April 5th, 2023