Health Communism starts and ends with the same contention: “Health is capitalism’s vulnerability.” Because the conditions of health are bought and worked for, illness is its logical effect. On the other hand, many left critiques of capitalism recognize no state of health beyond the eugenic fantasy of wellness, a state of being that ever eludes the worker. The authors Beatrice Adler-Bolton and Artie Vierkant, co-hosts of the biweekly podcast Death Panel, disagree. They seek to reclaim the category of health not only for workers but for the non-working “surplus” adult population precluded from health in the capitalist system. Hence the book’s title.
The distinction between deserving workers and irredeemable surplus is sociological. The authors argue that surpassing it—effectively achieving socialized medicine, in which class, money, race, ability, and gender cease to preclude distribution of care—is a condition of surpassing capitalism. Arguments for socialized American medicine have scarcely changed in the last century. However, the dependence of health upon capital has altered, and with it, the determination of debt and need.
To determine a citizen’s debt and need is to delimit the productive from the surplus population, the latter of which is made profitable by their warehousing and policing (usually by reason of their “burden” upon society). Interestingly, the authors identify the modern source of this distinction as the English Poor Laws. The first legally defined worker/surplus binary was the earlier Statute of Laborers (1349), passed in response to labor shortages caused by the Black Plague, which increased worker negotiating power. This law criminalized all unworking able-bodied people under 60.
It is telling enough that the metric of eligibility for state social welfare programs today is not the severity of illness or impairment but the effect of these upon the applicant’s relation to work. This conflates health with labor power. The authors argue that the social construction of madness was integral to the certification of ability. The legitimation of psychiatry at the dawn of the 20th century depended upon its separation of the curably ill from the incurably disabled.
Asylums are a paradigm of this intersection of care and carcerality. As institutions grew, they harnessed the labor-power of patients, from launderers to farmers to research subjects (this is the most harrowingly researched part of the book). Deinstitutionalization did not end these profit mechanisms but distributed them to the present American network of consumer-driven, “publically private” long-term care homes.
This growth was mirrored and fed by pharmaceutical monopolies. State subsidization of pharmaceutical rights instituted the present role of capital “as defender of a global intellectual property regime”, enforcing the trade dependence of developing countries. The authors provide a densely-researched history of the pathologization of illicit drug use as a foreign social contagion and the privatization of licit drug production from the Cold War to the present day. They make a forceful case that resistance to this internationalist privatization requires an internationalist platform. “…[I]nternationalism must be an essential part of health communism if we are to achieve the end of capitalism,” the write.
Capital accumulation structures precarity and pathologizes unproductivity. While the surplus may be disabled, mad, or chronically ill, it is not their condition that renders them precarious but their dependence upon the medical-industrial complex. These “burdens” upon the state are essential to its profit. After all, disabled patients bear more GDP in a hospital bed than they do at home. The authors define this capital accumulation from surplus bodies as an “extractive abandonment” process.
As the fight for policies like Medicare for All grows more urgent in America, so does the need to reform the political economy which would provide these policies. Even quasi-forms of socialized medicine in Canada and the UK result from repressive austerity and bureaucratic risk management engines; the authors remind that the UK promoted its campaign to leave the European Union based on NHS debt burdens. Otto von Bismarck presented the first modern health-insurance program as a concession to German workers in the interest of socialist repression.
Health Communism ends with a random account of the Sozialistisches Patientenkollektiv (Socialist Patients’ Collective, SPK) in West Germany and a brisk but confounding exposition of the existentialist origins of the mid-century anti-psychiatry movement. The relation to the authors’ argument becomes airtight as they explain each failure: the anti-psychiatry movement “died as its founders died” because they did not center their patients, the surplus. The SPK (which Sartre deemed “the only possible radicalization of the anti-psychiatry movement”) and subsequent European patient groups were censored and libeled by the state and press and beaten and disbanded by police because they regarded the illness of this surplus not as an individual cause but a social effect of the capitalist political economy.
Thus far, the authors are clear as to what must be resisted—the social symptoms which maintain the dependence of the disabled—but vague as to what this resistance entails (particularly in cases where illness, even if socially produced or worsened, is irreversible). Here, their discussion of SPK’s goals illumines theirs: to center the self-directed care of the marginalized is to turn an “unconscious unhappiness” of their dependence into an “unhappy consciousness” of the mechanisms of this dependence. To sever one’s status as a patient from one’s status as a commodity is to sever health from capital.
The current pandemic, during which Health Communism was written, is wholly and deliberately excluded. None of the Covid pandemic’s “lessons” were unknown, and none of its effects (save for the most menial) were unforeseen. They have only affirmed the authors’ socially determined view of health: housing is healthcare, working conditions are healthcare, food is healthcare, and clean air is healthcare. To attain it is to center on our demands of the current system and the surplus population that it creates and extracts.
In short, this seamless book fills an urgent void in leftist theories of illness: a conception of health that is possible to work toward within the capitalist system but which is mutually exclusive with this system’s model of health (along a spectrum of capacity to work and, barring this, to be an institutional subject of extractive abandonment). Health Communism is a slim book, and its argument is tight. However, it is so tight between mutually informing threads of class analysis, early modern categorizations of disability, the decline and fall of asylum systems, and international pharmaceutical policy that the achievement of such a concise yet cogent framework (aided by the fact that the past years have only confirmed its conclusion) is a marvel.
There is a sense in which we are all sick in the current system. But this does not relegate all imaginable states of health to some eugenic fantasy simply because this is the logical outcome of current healthcare management. It is more accurate to hold, with the authors, that none of us are well, so far as we fail to center the margins.