Health Communism — All Care For All People (Part 1)

Adler-Bolton and Vierkant envision a society transformed by a radical abundance of healthcare

Health Communism: A Surplus Manifesto (Verso, 2022) by Beatrice Adler-Bolton and Artie Vierkant is the most memorable book I’ve read this year. The authors are co-hosts of the “Death Panel” podcast and longtime disability justice and healthcare activists. In fact, I’ve already read the book three times, as I find myself drawn to the text again and again, and the book does lend itself to re-reading. It is written with a unique combination of alluring eloquence, ideological fervor, and penetrating insight. The book’s relationship with its reader is simultaneously welcoming and selective. If you do not find yourself in sympathy with the ideological vision it offers, the book has little to say to you and very little patience to even make an effort to convince you; but if you are willing to go along, you are rewarded with a new moral clarity and a new utopian idea of what healthcare should aspire to, even if its implementation is not foreseeable in the near future.

The book is aimed primarily at readers aligned with movements that take inspiration from socialism and seek some version of universal healthcare. It is also aimed at readers interested in critical psychiatry/antipsychiatry and mad studies. In case of the former, the book offers a new analysis of the relationship between healthcare and capitalism; in the latter case, the book highlights the problematic assumptions that have led to the political failure of antipsychiatry movements.

Adler-Bolton and Vierkant offer a sweeping vision of all care for all people. They explicitly seek to go beyond a framework in which provision of healthcare is based on determinations of need (“everyone should receive the care they need”) to a framework that offers an abundance of care for everyone. Adler-Bolton and Vierkant make the extended argument that any left political project that accepts the logic of scarcity of healthcare, and accepts the necessity of official mechanisms that separate those who are “deserving” of healthcare from those who are “undeserving” is bound to fail; it will end up re-enacting the same exploitative and eugenic logic currently manifest in capitalist systems.

“We call for a radical abundance of care that functionally casts off centuries of ideologies of austerity, subjection, and extraction.

It is therefore important to recognize that, even as we fight within the US for policies like Medicare for All, the task at hand is much greater than one program could capture. It is the total reformation of the political economy of health, and in so doing, the total reformation of the political economy.” (p 13)

“Any left political projects that rely on the logic of waste—that are structured around scarcity, lack, capital accumulation, certification, citizenship, property, or carcerality—are doomed to fail.” (p 42)

It has been difficult for me to decide what parts of the book to focus on. The text is so quotable that I am tempted to reproduce large chunks of the text itself (and in fact, I will give in to this temptation and quote liberally!). The book tackles a lot of different issues, and I won’t be able to touch on all of them. In particular, the book contains a rich historical discussions of the ACT UP movement of AIDS activists and the Socialist Patients' Collective (Sozialistisches Patientenkollektiv aka SPK) that I am not going to address in any detail.

In order to make my discussion accessible, I strongly recommend reading this book review by Evan Sedgwick-Jell for Asylum magazine and this Q&A of Beatrice Adler-Bolton and Artie Vierkant by the New Republic.

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Health Communism starts with a quote from SPK, to whom the book is also dedicated. It’s a quote that I’ve come back to again and again.

“Illness—you point out—is the only possible form of life in capitalism. In fact, the psychiatrist, who is wage dependent, is a sick person like each of us. The ruling classes merely give him the power to “cure” or to hospitalize. Cure—this is self-evident—can’t be understood in our system to mean the elimination of illness: it serves exclusively as the maintenance of the ability to go to work where one stays sick.”

(Turn Illness into a Weapon: A Polemic Call to Action by the Socialist Patients’ Collective of the University of Heidelberg, 1972)

This captures several major themes of the book, namely, the impossibility of health under capitalism; the potential of solidarity between physicians and patients, despite the power dynamics that otherwise separate them; and the need to turn illness into a weapon to dismantle capitalism itself.

Adler-Bolton and Vierkant write,

“Health under capitalism is an impossibility. Under capitalism, to attain health you must work, you must be productive and normative, and only then are you entitled to the health you can buy. This fantasy of individual health under the political-economic conditions of capitalism only ever exists as a state one cannot be, to which one must always strive.

[SPK] called this cultural imaginary of health a “biological, fascist fantasy” because it obscures the true and violent architecture of economic systems of extraction underneath the shadow of a capitalist-realist depiction of the perfect worker.” (pp. 10-11)

The book is full of such aphoristic statements and slogans whose force is felt even when their meaning is not immediately obvious. While I was captivated by this, for some readers this style will no doubt be too annoying (or perhaps too “woke,”) and the book unfortunately doesn’t make it easy for such readers to appreciate the arguments.

Let’s look at a few central ideas.

Surplus

The notion of surplus in Marxist literature refers to the section of the population that is not engaged in wage labor or is excluded from it. Adler-Bolton and Vierkant expand this concept and use it to refer to those in the population who fall “outside of the normative principles for which state policies are designed.” That is, surplus populations consist of individuals who are not able to participate in the usual mechanisms of value production that exist in capitalist societies. Due to this lack of participation, they are also excluded from the rewards that accompany such participation. The surplus then come to be seen as “waste” and a burden, and they are targeted for exploitation. Individuals can become surplus due to a variety of states of illness and impairment, but there is nothing intrinsic about these states that marks the individuals experiencing them as surplus. The surplus category is instead created by socioeconomic arrangements, and precisely who is excluded will be different in different arrangements.

“While the surplus population does contain those who are disabled, impaired, sick, mad, or chronically ill, the characteristic vulnerability of the surplus is not inherent to their existence—that is, it is not any illness, disability, or pathologized characteristic that itself makes the surplus vulnerable. Their vulnerability is instead constructed by the operations of the capitalist state.” (p 23)

Worker-Surplus Binary

Workers in a capitalist economy are always confronted with the possibility of losing their ability to participate in mechanisms of value production and becoming surplus. While this ought to bring solidarity between workers and the surplus, capitalism pits the two against each other by presenting the surplus as a drain and a burden on the workers.

“… the worker is not a part of the surplus populations, yet faces constant threat of becoming certified as surplus, is one of the central social constructions wielded in support of capitalist hegemony.” (p22)

“A pivotal factor in the rendering of whole segments of society as “waste” was the construction of the worker/surplus binary. This binary is at the foundation of the eugenic and debt burden framework, a principle that rationalizes political notions that not all people are in fact equal in deserving assistance or support.” (p 62)

Extractive Abandonment

The surplus population is then subjected to what Adler-Bolton and Vierkant call “extractive abandonment,” the process by which populations deemed surplus are made profitable to capital. Since these individuals cannot participate in mechanisms of value production themselves, systems are created to extract value from them.

“Those who are deemed to be surplus are rendered excess by the systems of capitalist production and have been consequently framed as a drain or a burden on society. But the surplus population has become an essential component of capitalist society, with many industries built on the maintenance, supervision, surveillance, policing, data extraction, confinement, study, cure, measurement, treatment, extermination, housing, transportation, and care of the surplus. In this way, those discarded as non-valuable life are maintained as a source of extraction and profit for capital. This rather hypocritical stance—the surplus are at once nothing and everything to capitalism—is an essential contradiction.” (pp 23-24)

Adler-Bolton explains this in the New Republic interview:

“And for people like me, who are sick, who can’t work, we’re sort of seen as having negative assets, on the other side of that. It’s this idea of, well, if there are too many disabled people, we’ll sort of be overwhelmed by all of these burdens.

But in actuality, a sick person like me—I create jobs, technically. There are a lot of people whose jobs it is to take care of people like me. I have nine doctors! I have an infusion nurse who comes once a month, there’s an infusion company who coordinates my infusion, there’s someone who has to do the insurance billing, [who] gets paid to fight the insurance company, someone in the insurance company gets paid to fight my doctor, to try and deny me care. And I’m not even someone who lives in a nursing facility. And that’s just one part of the economy that my care creates around me.”

Biocertification

Societies rely on “biocertification” to determine who among the surplus is eligible to receive any kind of care, benefit, or aid. The process of certification is presented as objective and scientific but is often arbitrary and laden with problematic assumptions about who deserves what sort of care. The certifications take the form of medical diagnoses or physician judgments of disability. Biocertification operates with a logic of scarcity of resources and a distrust of self-identification.

“These benefits are gatekept by abstract bureaucratic systems of eligibility predicated on the verifiability of someone’s biological state and identity… Biocertification is assumed to be a necessary gatekeeping mechanism or checkpoint to prevent the “wasting” of resources on fakers, cheats, imposters, and malingerers: “invoking both a model of scarcity, in which resources must be reserved for those who truly deserve them, and a distrust of self-identification, in which statements of identity are automatically suspect unless and until validated by an outside authority.” [Ellen Samuels]” (p 25)

Adler-Bolton and Vierkant clarify that rejecting biocertification doesn’t translate into a rejection of diagnosis or medical assessment; it is a rejection of the use of medical assessments by the state to determine who is eligible to receive care or benefits.

“Resisting biocertification does not mean resisting “diagnosis” or identification. It means resisting the leveraging of these certifications by capital and the state.” (p. 28)

Money Model of Disability and Organized Abandonment

Adler-Bolton and Vierkant’s notion of extractive abandonment build on Marta Russell’s money model of disability and Wilson Gilmore’s notion of organized abandonment.

“Marta Russell’s money model of disability theorizes that while the disabled—the surplus population—are widely regarded as a “drain” on the economy, in truth over time capital and the state have constructed systems to reclaim this lost population as a source of financial production.” (p. 32)

“Rather than pay benefits directly to recipients to help them live or age safely at home, Medicaid has a preference-by-design for institutional care, which steers many into congregant facilities and nursing homes… Russell argued that funding mechanisms like these demonstrate that social policies are designed not toward the anticipated benefit to the targeted population, but instead to create pathways, or capacities, to generate market value through the investment of public funds.” (p. 35)

“Rather than support disabled people directly in their homes and their communities, welfare systems have been designed as mechanisms for public money to pass into private companies seeking to apply economies of scale and generate revenue from mass market care.” (p. 36)

“Wilson Gilmore identifies these as the state’s process of “organized abandonment.” Organized abandonment describes how the state constructs itself through its capacity to sort and separate the surplus populations, marking some for reclamation and others for slow death.” (p. 37)

“Profit lives in the interstitial spaces between bodies, in the counting of bodies, in the measuring of bodies, in the creation and destruction of bodies, in every locus where capitalism touches illness, disease, disability, and death… Public money guarantees a fixed amount per body, leaving public and private entities (long-term care and nursing home corporations, prisons, jails) to find or create the opportunity for growth and revenue.”

Adler-Bolton and Vierkant, Health Communism (pp. 38-39)

Eugenic Burden and Debt Burden

Surplus are regarded as “waste” and are seen as a burden on the society in two ways, the eugenic burden and the debt burden.

Eugenic burden: The surplus populations are viewed as a “demographic threat, threat of disruption to the social order, reproductive threat, bloodline threat, “three generations of imbeciles,” etc.”

Burden of public debt: The belief “that protecting the health of the most vulnerable few will lead to the immiseration of the many, a demographic threat managed by the appeal that we can and should only “take care of our own,” which itself constructs the “we.””

As noted previously, Adler-Bolton and Vierkant make the case that all genuinely liberatory political projects have to overcome the logic of scarcity and waste.

“… capitalism will only be defeated through a movement that centers the surplus populations and resists the eugenic and debt ideologies perpetuated by capital to function. Health is so policed by capital because health is so necessary to each of capital’s functions.” (p. 18)

“The only way to spur genuine liberation is to assure care even for the most vulnerable, those at the most extreme margins. To borrow from Black feminist thought, we mean to bring the margins to the middle.” (p 42)

“We contend that a socialized medicine that fully rejects the eugenic ideology of “deservingness” for treatment and rejects the public debt ideology of care as economic burden must be understood as fundamentally threatening to the existence of capitalism. We write to say what few others have claimed: the panicking industrialists of the early twentieth century were correct in their hysterics. The severing of health from capital will mark the end of capitalism.” (p 42)

The chapter Waste ends with the apt slogan: “Malingerers of the world unite.” (p. 61)

“Malingerers of the world unite.”

Adler-Bolton and Vierkant, Health Communism (p. 61)

Health Under Capitalism

“Capital has been allowed to define the meanings, terms, and consequences of “health” for long enough. In these pages we propose a radical reevaluation of our political economy that seeks to undo capitalism’s definitions of health by laying bare the violent and eugenic assumptions at its foundations. 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.” (p11)

“The provisioning of medical care and the social determinants of health have been based on a system of triage that attempts to devote maximum care resources to those most able to contribute productively to the economy.” (p 63)

“Capitalism has defined “health” itself as a capacity to submit oneself to labor.” (p 65)

“We’ve been told that work will heal us. We’ve been tricked into trying the work cure. We are told that work is in our best interest, when the truth is that it only serves the needs of capital and the ruling class at the expense of our health. Breaking the mirage of worker versus surplus provides a revolutionary opportunity to unite the surplus and worker classes in recognition of a better truth: safety, survival, and care are best ensured outside of capitalism. This revolutionary potential has been divided, discouraged, and criminalized.” (p 78)

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In the next post (part 2), I will go over the themes in the second half of the book, which relate more directly to psychiatry, madness, and psychiatric institutions.

I am drawn to the idea of “a radical abundance of care” and “all care for all people” but it also strikes me as quite utopian. While it is true that healthcare resources need not be as scarce as they have been made out to be in current societies, and that current scarcity is a policy choice, I also find it hard to imagine what a radical abundance of care could look like in practice. Physicians take for granted that resources are limited – we have a finite number of MRI machines, or a finite number of physicians who have the skill to perform a certain procedure, or a limited supply of medications, etc. People working in healthcare also appreciate that patients often want things for all sorts of reason — they may have a mistaken idea of what it’ll do for them and cannot be convinced otherwise, or they want it just because they think they are entitled to it. There is the bureaucratic dimension of mechanisms set in place to determine “need” and eligibility, and Health Communism does an excellent job highlighting the problematic nature of such mechanisms. But such mechanisms are different from clinical and scientific judgments of the benefits and harms of clinical interventions and what appropriate use of these interventions looks like. The clinical and the bureaucratic are often enmeshed and intertwined in our world, but they are not the same. It is not clear to me that Adler-Bolton and Vierkant’s critique extends to the clinic in that sense, that patients can ask for whatever procedure or medication or intervention they want regardless of whether it is likely to be helpful or even if it is likely to harm. At the same time, I can see that any mechanism to determine clinical need/necessity would rapidly get coopted by the logic of waste, scarcity, and debt. Maybe as a clinician I am of so immersed in ideologies of austerity, subjection, and extraction that I cannot even visualize a different arrangement in practical terms, but I suspect that there are genuine gaps here that need to be worked out. Perhaps we should see all care for all people as an aspirational goal, one we may not necessarily achieve in practice, but one that drives us towards ever greater abundance of care.

All care for all people… but what is care to begin with? We want all sorts of things — enhancement, distraction, pleasure — but we are not entitled to them as forms of care. Adler-Bolton and Vierkant believe that our access to healthcare should not be limited to the care we can buy, but what constitutes healthcare is not some fixed fact of nature. How can how all care for all people exist in a world where the boundaries of healthcare are actively constructed and negotiated, and scarcity exists outside the boundaries? A radical abundance of healthcare can perhaps only exist in a world that has radical abundance of everything we may desire.

The idea of extractive abandonment resonates with me strongly. It fits with my own experience working as a psychiatrist in the mental healthcare system, especially in the public sector. I had never quite thought of it this way, but now that I am familiar with the concept of extractive abandonment, I see it everywhere around me. Aspects of the healthcare system that previously seemed bizarre, Kafkaesque, and maddeningly inefficient to me, I can now see as engines of extractive abandonment.

I am bothered somewhat by the tendency to anthropomorphize “capitalism,” as if the economic system had intentions and was an agent capable of deception and scheming. No one here literally believes this (I think), but it’s easy to get lost in the metaphors and lose sight of the fact that large numbers of unsuspecting, even well-intentioned individuals, often with no conscious understanding of these larger social dynamics, are interacting with each other in ways that create and sustain these processes. How does this happen? Overthrowing capitalism, so to speak, requires changing the behaviors of large number of individuals to create something new, and the individual vices at play — greed, resentment, discord, sloth, etc. — do not make any of this easy, barring a total reformation of human nature in addition to a total reformation of the political economy of health.

It also seems to me that the logics of surplus, austerity, extractive abandonment, eugenic burden, debt burden, etc., are not simply features of “capitalism,” narrowly understood, but features of (nearly?) every human economic system that has existed. When Adler-Bolton and Vierkant attribute these features to capitalism, the relevant contrast here is not some alternative economic system that already exists or has existed, but one that, at present, can only be imagined. Like all visionaries, the brilliance of Adler-Bolton and Vierkant lies in being able to see through the mist of possible worlds to make out the image of a society transformed by a radical abundance of care, but the vision is far enough and blurry enough that we don’t know the shape and form it can take, or what it would take for us to get there.

[To be continued in Part 2]

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