Care for All

Health Communism BY Artie Vierkant and Beatrice Adler-Bolton. Brooklyn, NY: Verso. 240 pages. $25.

For low-vision viewers, bright colors, which reflect light, are easiest to see. The cover of Beatrice Adler-Bolton and Artie Vierkant’s new book Health Communism is thus bright blue––what Adler-Bolton calls “true blue,” and what the Pantone color guide calls #2736 C. The coauthors’ names aren’t on the cover. Instead, they’re listed inside, on one of the opening pages. 

Adler-Bolton and Vierkant are perhaps best known as two of the hosts of Death Panel, a health justice podcast which takes its name from Sarah Palin’s 2009 claim that federal universal health-care would lead to state-sanctioned austerity and murder (which, as Vierkant has argued, is what capitalism does already). The show stands out not only for its extensive pandemic coverage but also for its analysis of how concepts like “health” and “value” are socially reproduced, that is, how public policy shapes whose lives are supported and whose are forfeited.

While canonical accounts of political economy begin with the “worker,” Adler-Bolton and Vierkant begin with the “surplus class.” In Health Communism, they show how members of the “unproductive” surplus class are cast as burdens even as health capitalism sets up entire cottage industries (e.g. for-profit nursing homes, prisons) to extract value from this very population. Society, Adler-Bolton and Vierkant show, “does immense work to forestall these two groups—the workers and the surplus population—from imagining themselves in solidarity.” In September, we discussed (per the show’s catchphrase) how to be in solidarity forever, and how to stay alive another week. 

CHARLIE MARKBREITER: Some readers of Health Communism might be familiar with the ideas you discuss on the podcast Death Panel, which you cohost together. How would you describe that project? 

ARTIE VIERKANT: I’d say Death Panel is a political project that most commonly manifests as a podcast, currently with Beatrice, myself, and our collaborator Phil Rocco, who is a political scientist at Marquette University. And more recently, also Abby Cartus, a perinatal epidemiologist, and Jules Gill-Peterson, a historian of trans history and medicine. The core of Death Panel is similar to what we explore in Health Communism, that is, political analysis that takes into account what we could call “the political economy of health.” On the show, sometimes that means taking an hour or two to walk through big ideas, like what “the social determinants of health” means as a concept, and how we should interpret them in light of the fact that a lot of contemporary discourse about that term stops at incredibly vague platitudes like, “We should pursue equity in public health policy.” Other times, Death Panel is about picking apart policy documents from the state, and trying to identify how certain populations will be excluded from or immiserated by these policies by their very design. Other times still, we’ll walk listeners through some extremely depraved opinion column or other news piece and point out how fundamentally eugenic a lot of their assumptions are. Which has been, I think, an especially prevalent mode for us during the pandemic, considering that social murder has been the name of the game. 

Did the show change significantly when the pandemic began? 

BEATRICE ADLER-BOLTON: One of the things that we were working on before the pandemic was developing a lens of looking at how policy affects people’s lives in material ways. How do we economically and materially feel the impact of laws that dictate what care is and how care is supposed to be paid for? What are we entitled to in terms of housing or clean air or clean water? As soon as COVID began, it was obvious that these kinds of questions were indicative of the direction the pandemic was going to take. You didn’t need to be clairvoyant to see how bad this was going to be. 

Some people may be surprised to find that, in Health Communism, there’s not a gigantic chapter on COVID-19. But that omission is really intentional: we’re trying to make a hard point. A lot of people like to say that we’ve learned some very tough lessons with COVID, but that’s absolutely not the case. These are not new lessons. These are not new horrors. We’re looking at an acceleration of an existing political economic phenomenon that was already marking people for a slow death. What we’ve seen is the pandemic applying additional pressure to a system that was already unsustainable and in no way conducive to “good health.” 

I’m grateful for the way you resist exceptionalizing COVID. And I think the show is key for looking at how pandemic discourse is produced and to what ends, and how this fits into a longer history of health capitalism. In Health Communism, you write that “health functions as capitalism’s host body.” Could you elaborate? What is “health”? 

AV: In the introduction to the book, we write, “Health is a vulgar phenomenon.” What we mean is that health has become inextricably linked to capital and capitalism. Furthermore, the definitions and metrics by which we judge health are fundamentally seen through a capitalist, political economic lens. For example, ill health is the threat that disciplines the labor force. When you think of the term “health” as something abstracted—as physical and cognitive capacity—it can be and is used to define who is and isn’t allowed to identify as part of society. Health in this sense can disqualify people from participating in civic and political life. It’s similar to how a term like “citizen” constitutes the boundaries of who is able to engage in social and political life, and the degree to which people are able to exercise autonomy over their own lives. 

Most importantly, as we emphasize in Health Communism, the term “health” demarcates the “productive” member of society from what mainstream discourse very openly refers to as the “burdens” of the sick, the unhealthy, the disabled. When this political economy of health interacts with the threats of ill health or loss of benefits, health as a socially and politically constructed designation is very literally used to limit the labor force. In other words, it draws the distinction between the productive worker and the unproductive surplus as these socially imagined categories. One of the theses of Health Communism is that this process does immense work to forestall these two groups—the workers and the surplus population—from imagining themselves in solidarity. We argue that it’s very important to understand all these roles as codetermined, and these struggles as shared. We should encourage collectivity between these populations, even though capitalism and our political economy would prefer for us to see them as completely segmented and separate.

BAB: Absolutely. People are basically trained to think of health as an individual consumer good, as a kind of aspirational, positive quality that each of us needs to work hard to achieve, in order to be valued by society. But we’re arguing that health actually is a very violent architecture: an economic system—not a personal trait—in which your body is commodified based on how it interacts with the things that it needs to survive. Housing is not a good that we can choose to go without, and our health care is not a good that we can choose to go without. These realities are obscured by myths about personal responsibility, by the idea that everybody can work hard enough and grind hard enough and girlboss their way to being healthy. But in reality, the system is designed to force people into poor health while maximizing profit. 

You introduce a term that I found extremely helpful, called “extractive abandonment.” What is the intellectual genealogy of this idea? 

BAB: It’s a riff on Ruth Wilson Gilmore’s theory of “organized abandonment,” which is a concept she talks about in Golden Gulag (2007), her book about the growth of prisons in California. The example she uses to support this idea of organized abandonment is an in-depth analysis of how the state of California grew itself, not through positive investments in public goods, but through the expansion of carceral practices. When the state allocates funding—in order to create jobs, in order to create the kinds of positive social determinants of health, like infrastructure, that can support some people in an area that is experiencing poverty because of disinvestment—these investments are not made directly. They come at the cost of mass incarceration, and this is a discrete decision made at the structural level. These investments could be funded directly, but instead the state funds them through the carceral system. Organized abandonment is often naturalized as a “choice” in the neoliberal sense of the word—meaning that individuals should just choose to remove themselves from circumstances where organized abandonment occurs, but this is not a choice people usually have. It’s like telling people in a flood zone to “just move.”

Our concept of “extractive abandonment” builds off both this idea and the “money model of disability,” another framework that we think is incredibly important, which was developed by a relatively little-known Marxist disability theorist named Marta Russell. The money model of disability argues that another way the state indirectly invests in itself is through the commodification of survival, by which people who are non-workers are marked as surplus and made available to the economic order as a site of creating surplus labor power through other means than labor alone. For example, a disabled person who’s a non-worker becomes more valuable as a bed than as a person because they occupy a room in a nursing home, and that nursing home is guaranteed a certain amount of federal funding every month. Then it’s up to the company that manages that public-private partnership to find a way to make a surplus profit out of the maintenance of the life in that bed. Scholar and abolitionist Liat Ben-Moshe likens this process to a kind of alchemy, in which surplus populations are “spun into gold.”

With the term “extractive abandonment,” we’re trying to give people a way of naming how health is constructed through logics that are carceral and extractive, not towards making your quality of life better or relieving your pain or curing you. Rather, there is simply an agreement that this economic relationship is going to pass through you, which is the result of discrete decisions at the structural level—not your personal choices. We’re arguing for a new theory of health and class that pushes beyond this disciplinary relationship in which the subjection of people who are not workers acts as a way of enforcing terrible labor conditions: so-called “health” is actually the primary form of labor discipline. 

You argue that surplus populations are used to stave off broad reforms that would otherwise be destabilizing to capitalism. Usually, however, “common sense” argues that that the surplus population constitutes a twofold burden to society—that is, a eugenic burden and a debt burden. Historically, how has this rhetoric shaped arguments for and against socialized medicine in the US? 

AV: Health-care discourse in the US—and to an extent globally—often relates so much more to the costs of care than to anything you might think was the real priority. For instance, we don’t often talk about someone’s experience of the health-care system or of getting the treatment they need without also discussing going into extreme debt, or, in the case of trans health-care, for example, of having to endure judgment that your care is somehow unnecessary or unworthy. Liberals often like to stop at demands for access; they want “access to affordable care” or “access” to universal healthcare. But this largely ignores the pressing issues with the political economy of health under capitalism, like the fact that for the most part, the process of “accessing” that care will bankrupt you. 

This is all to address the way that we privilege costs in these conversations, which I think about in relation to two specific things. One is the work of people like Atul Gawande and the overutilization argument that was popular in the Obama White House while the Affordable Care Act was being crafted. This idea was that high cost is the root problem of the US health-care system, and that this high cost is caused by people using too much health care. You saw this in the debates around Medicare for All in the leadup to the 2020 presidential election. People, including liberals, would say, “Oh, Medicare for All would cost too much,” as though people suddenly getting care that they’ve been systematically denied for most of their lives would be a burden rather than cause for celebration. You almost imagine this alarmist notion that if care were free to everyone and the state organized its resources so that people could get the care that they need, that somehow people would start doing, like, recreational chemotherapy or something. 

The second thing I tend to think about regarding cost and care is a document we talk about in the chapter of the book called “Border.” In 1993, the World Bank published a report subtitled “Investing in Health,” which ended up being very useful for the colonial expansion of the privatized US–style health finance system to other countries. There’s a section where they talk about the social role of health insurance—not health care, but health insurance, that is, who pays for health care. In discussing the moral hazard that is taken on with health insurance versus other types of insurance, they point out that if you burn down your house or abandon your car, you’re on the hook for it, and they very heavily imply that it’s unfortunate that health insurance is any different. You know, essentially asking: If you consume too much health care, why is that not too a crime? There’s an absurd quote where they say the only thing preventing us from treating health insurance like any other insurance product is that “there is no market value for the human body and no possibility of abandoning one that is worn out and acquiring a new one.” 

Health Communism is dedicated to the Socialist Patients’ Collective (SPK). For readers who maybe aren’t familiar with the group, what was SPK what is their legacy? How does your book draw from their work? 

BAB: SPK was a patient liberation organization that formed in 1970s West Germany in a hospital in Heidelberg and only existed for a very short period of time. There are people still using the name SPK today, but we are talking about their original historical formation. Two of the final chapters in the book, called “Care” and “Cure” are, to our knowledge, the most comprehensive English language account of the activities of this group, perhaps outside of their own manifesto. Their work marked an important moment, not only for disability history or patient liberation, but also in left political thought. We wanted to make sure to tell their story for what it is: a story of the pathologization of political dissent. Their manifesto came out in 1972 and is still not widely known, but many of their ideas are common in leftist thought today. They were talking about what we would now call the social determinants of health. They were saying, we have mental-health diagnoses, don’t put us in congregate facilities, we need supportive housing. We want to study ourselves and do self-directed therapy. 

For a group of patients to dare say, We deserve care and deserve a say in what our care is like, we deserve support, we deserve to be free—they were essentially marked as terrorists by the state. Their radical experiments scared the hospital that they were institutionalized in, and through various crackdowns and attempts to take away their care—essentially as punishment for their political beliefs—the German state inadvertently created this incredible moment of resistance, of international solidarity between patients and doctors that refused the binary of the worker and the surplus. It was a beautiful, budding movement of very angry patients who felt that capitalism was the thing that was making them sick, and that short of the end of capitalism, there was nothing that could be done to better society. SPK wanted to unite the sick and the healthy together in struggle toward a future where “health” is not a commodity form, but a means of understanding our interdependence, and they recognized that we need to take care of each other in order to survive. We take great inspiration from them.

AV: That’s a great explanation. I would add that I think the reason we dedicate the book to the Socialist Patients’ Collective—and the reason that the book concludes with this long and very emotional, difficult story about what happened to this group—is because we find them and their work to be incredibly important to both the movement and the intellectual lineage that we’re trying to extend and force forward into the next century. One of their fundamental ideas was that illness is the only possible form of life under capitalism, and that as a result we could recognize ourselves as, together, a sick proletariat, or a “proletariat in illness.” I think this is one of the closest intellectual or movement goals to one of the ideas that we’ve put forward, which is that we should all recognize ourselves as surplus, or at the very least of being always capable of or threatened to become surplus, because this can motivate new forms of collectivity. 

Death Panel has an amazing aesthetic, from the show images to the merch to the ending music. These component parts are great in and of themselves, but they really come together to create a very coherent, intentional, and effective aesthetic. Before we go: How was this aesthetic developed, and how would you describe it? 

AV: I love Helvetica and Helvetica loves me. 

BAB: I’m a firm believer in the idea that all learning is social. And I’ve been incredibly influenced by one of my professors and mentors from Cooper Union, the artist and political activist Marlene McCarty, who was a member of a group called Gran Fury, most well-known as “the propaganda arm” of ACT UP. They were artists, people who worked in advertising, graphic designers, curators, and they decided to collaborate toward a specific political goal during the early years of the HIV/AIDS crisis. They were behind a lot of the iconic images, like the “Kissing Doesn’t Kill” campaign, stuff like that. I think, in the best moments, Death Panel, and by extension our book, can function in a similar way: it’s not just about the recording, but also our visual materials, the community of thinkers that we’ve built around the show, the people that we collaborate with. It’s all part of a very deliberate attempt to construct the kind of world that we want to live in. 

Charlie Markbreiter is the New Inquiry’s managing editor; his first book, Gossip Girl Fanfic Novella, is out from Kenning Editions on November 1st.