“Health is capitalism’s vulnerability”

Three years of preventable COVID-19 fatalities and illness make clear what Beatrice Adler-Bolton and Artie Vierkant propose in their new book Health Communism: health is an impossible fantasy under capitalism. 

Capital defines and controls health, but according Adler-Bolton and Vierkant, health is also “capitalism’s vulnerability.” In Health Communism, they urge the left to engage with the political economies of health, illness, and disability, arguing that identifying as disabled and understanding that health is impossible under capitalism is critical for imagining a radically different future. To fight back and reclaim health from capital, Adler-Bolton and Vierkant propose a radical path forward: health communism.

I spoke to Adler-Bolton about her book, health communism in practice, and her hopes for how health communism will guide leftist movements toward global solidarity and an anti-capitalist future. Our conversation has been edited for length and clarity. 

What is health communism and how did the idea behind health communism come to be?

Health communism is a proposal for a different way for the left to think about health, and an approach to health justice that’s not contained within borders and refuses all nationalisms. It’s an alternative framework to our current system of health capitalism which insists that health will always be limited to nationalistic industry reforms.

When we say we want health communism, we mean we want everyone to receive the care they need. Under capitalism, “need” is determined by a cost-benefit analysis weighted in favour of capital, even in countries with so-called universal health care like Canada. We don’t make any policy recommendations in the book. We do, however, propose that we recognize that we are all sick under capitalism and that understanding how capitalism disables and debilitates us has revolutionary potential. 

What drew you to talking about the global conditions of the political economy of health beyond the obvious American struggles?

Nothing exists in a vacuum. When American leftists say, “We’re the richest country in the history of the world and we can’t even have the health care that Canada has,” it creates this rhetorical zero-sum landscape which frames Canadian care as a kind of perfect panacea, a gold standard compared to the U.S. But what does that do to movements in Canada fighting against the austerity of the Canadian health-care system? How does American advocacy rhetorically undermine Canadian advocacy by painting a too-rosy picture out of a desire to be persuasive? We unintentionally limit political will in Canada through these narrow framings.

Any analysis of health-care systems that’s limited to one national context is incomplete because it fails to account for the violence and resulting health outcomes of colonial and imperial border regimes. We need to start considering that in our organizing and analysis. The logics of the American health-care system are often tested out in the U.S. and then exported globally. We are seeing global trends toward increased privatization of national health systems as an answer to the strain caused by decades of austerity. There are lessons we can learn from each other if we build cross-border solidarity. 

Functionally, nation-locked health reform frameworks, which we end up engaged in for reasons of scale and practicality, limit our political imagination of what health systems could be to the narrow realm of capitalism. We wrote Health Communism to help our movements strategize on a bigger and more transformative scale, which might require thinking beyond borders.

What is the ideology of Health Communism?

Health Communism is neither a roadmap nor a plan – it’s a materialist history of health-care systems that offers a framework for understanding the logics and values embedded in health-care institutions and our understanding of health. We try to introduce a few key ideas that might be unfamiliar to readers, like the false binary between workers and the surplus population, and extractive abandonment. 

The surplus population is often understood to be all non-working people, or those whose labour isn’t profitable to the ruling class. Extractive abandonment is the process by which these populations are made profitable to capital, such as charity fundraising aiming to “repair” disabled people to become workers and policies that support and grow for-profit private nursing homes. We then trace how these ideas are socially, intellectually, and structurally reproduced throughout our global systems, law, and governance. 

The book is a call to see health for what it truly is – a marker of how profitable your labour is to capital – and to build from this new forms of solidarity to fight head to head with health capitalism. We want to emphasize not just the importance of coming together in defeating capitalism’s parasitic relationship to our health, but why it benefits the capitalist state to use health to keep us apart. 

Health communism is the other side of the coin of our current reality. Our health systems shouldn’t be taken for granted as natural phenomena – they are the result of deliberate policy choices, ideas, and values. Health communism asks what the political landscape could be by making obvious the fact that while capitalism makes us sick, it also needs our health to survive. Health communism is a challenge, a demand, and a name for something that does not yet exist – but which could if we build it. 

The Canadian government rapidly expanded access to medical assistance in dying (MAiD) during the COVID-19 pandemic, while disabled people are being subjected to austerity health cuts and record inflation. Can you tell us about the particular moment we are in under the coalescence of fascism and capitalism?

The broader understanding of MAiD is that it’s an act of mercy and a necessary part of a humane society. But in reality, we’re only offering people mercy from the austerity that we’ve deliberately designed, chosen, and subjected them to. 

At its core, MAiD is asking people to do a cost-benefit analysis: do you want to live a life of continued deprivation or do you want a way out? Many disabled and poor people report being asked by their physicians if they want to continue to be an economic burden on their families and loved ones. And so that way out for you becomes something that’s positive, even necessary, for the people in your life, as well as a way to free up resources for the state and the rest of society. 

Other times, as your podcast Invisible Institutions shows, MAiD is offered by physicians as an alternative to being put in a carceral facility like a long-term care institution or an institution for people labelled with intellectual or developmental disabilities because the state refuses to support people in their homes due to concerns about cost. That’s not mercy, that’s austerity. That’s social murder.

The perceived need for MAiD is informed by the idea that society’s survival depends on preventing the people deemed “burdens” from overwhelming the “healthy” population, which is an old idea but was formalized into a policy logic by eugenicist thinkers. Eugenic logic proposes that to fix what ails society from within, people who are burdens must be identified through systems of testing, marked and sorted by regimes of medical and scientific authority, and then managed at a population level by the state. This is all toward a more efficient state and a more productive or ‘fit’ labour force. 

As sociologist Donald MacKenzie wrote in his 1981 book on the social construction of scientific knowledge, eugenicists naturalized their inherited class power into a policy ideology and that became their enduring legacy. Eugenicists were committed to change within the framework of capitalism through “a cautious commitment to modernisation and efficiency, to the gradual reform of existing institutions, to ‘insider politics.’ [...E]ugenicists were not (in general) ‘cranks.’” We can find this line of thinking still embedded in policies across North America, from immigration quotas to border control policies, to the institutionalization of disabled people, to conservatorships, to limited access to transition-related care for trans people, to the COVID pandemic response. 

The eugenics movement never went away – it rebranded. I’ve joked many times in the past on my podcast Death Panel that eugenics is the love-language of capitalism. But I’m not really joking. Eugenics is not a “loaded charge” – it’s a way to describe our systems of health and a system of thought that transforms everything from a collective responsibility into the faults of individuals.

One of the main focuses of the book is surplus populations. Can you explain who the surplus population is and why centring the surplus is vital for our movements? 

Surplus populations are commonly understood to be non-working people. And if you’re working, it’s assumed that you’re not sick, ill, disabled, or otherwise. We push back on this false binary and assert that the surplus builds upon the working class. If health is the carrot (something workers are told they should aspire to), then the surplus class is the stick (something workers are threatened with becoming). 

We are all surplus, even workers. While the surplus population does contain disabled, impaired, sick, Mad, and chronically ill people, it is not any illness, disability, or state of health that makes the surplus vulnerable. Our vulnerability is constructed by the capitalist state.

The false worker/surplus binary is the fundamental underlying dynamic of labour discipline. The imposed poverty of the surplus is always there as a looming threat leveraged against all worker demands. We are only entitled to the survival we can buy with our surplus labour. 

Surplus populations are always assumed to be elsewhere, never assumed to be a worker or an organizer. Our movements need to stop thinking of the sick, the ill, the Mad, and the vulnerable as being elsewhere. We’re passing up a huge opportunity by devaluing the perspectives of those who live the day to day of the surplus population and their unique political thought that is lost when we say, “Oh, we’ll circle back and include those vulnerable people later.” Nothing good is going to come from fighting for only part of the working class.

Now entering our fourth year of the COVID-19 pandemic, many unions have abandoned the fight for clean air and the right to not get sick at work, and many leftists are hosting unmasked, indoor movement meetings. What does leftist organizing that practises health communism look like? And what are some projects implementing these principles that are giving you hope? 

The more projects that I see trying to force their way through the cracks in capitalism’s shield, the more hopeful I am. Our organizing and political analysis will likely shift and change many times throughout our lives. It’s our responsibility to see that it grows toward liberation and not revanchism.

People can get caught up in trying to find or build the “Perfect Movement”(™) that will save us all with one perfect protest or policy. But it doesn’t work like that. There are thousands of imperfect movements happening right now and that is beautiful and impactful. There is not one great movement, but a lot of great people doing great work under difficult circumstances. We need to do what we can with the time that we have. And a lot of people, I’m sure, want to do better and can do better. Health Communism proposes that it’s a great first step to listen to and centre the surplus, and it gives me a lot of hope to see how quickly so many have adopted its lessons as points of praxis. 

So many people are collaborating, listening to each other, learning together. I’m especially seeing connections between trans liberation, abolitionist movements, and disability justice movements, which have been coming together and building off each other’s work to expand how we understand ideas like carcerality and criminality. Podcasts like Invisible Institutions, Work Stoppage, and When A Guy Has A Really F***ed Gender, which take on the task of political education that considers the political economy of health and offers that crucial toehold from which emancipation, co-operation, solidarity, and political identity can be derived. I would love to see labour organizers fight for more COVID-19 protections, but I’m actually really hopeful that it’s still possible, especially because of projects like these. The left’s organizing potential on COVID-19 is huge – and the mainstream left is sleeping on a missed opportunity.

Engaging in this practice, thinking about the surplus, and trying to centre the surplus is how we build unity, collectivity, and political analysis to last. There’s something really wonderful and valuable about being surplus, and what can come politically from that experience (though it doesn’t come automatically) will help bolster the left. Solidarity and organizing is not just for the young, free, and “healthy.”

Part of why we wrote Health Communism is because we want the left to change the way that it thinks about health and disability. Not just because it’s morally right and important, but because the left has a lot to gain from this analysis. There’s a lot of power and momentum that we can build toward making all of our lives a little less brutal, cruel, and short. Capitalism needs our health, but we don’t need capitalism.