Health Communism by Beatrice Adler-Bolton and Artie Vierkant, London: Verso, 2022
Health Communism is a book dripping with urgency. and the reading public would seem to agree: off the back of the authors’ popular Death Panel podcast about the political economy of health, the book sold out its first print run on pre-orders alone.
The ‘communism’ of the book’s title speaks to its manifesto-like character, with the urgency stemming from its clear aim as a political intervention. The short text covers a dizzying amount of ground, switching from case studies to broadly sweeping socio-political analysis with vertigo-inducing speed.
Like Marx and Engels’s Communist Manifesto, it feels like the authors have decided to bring out this short text quickly, to shape ongoing struggles over health, in lieu of a later, more comprehensive tome. Importantly, the authors’ communism is one shorn of much of the baggage of the ‘old Left’ and its complicated divisions, instead seeing communism as the overcoming of capitalism and its replacement with a system oriented around human needs.
The first three chapters, ‘Surplus’, ‘Waste’ and ‘Labor’ lay out the authors’ theoretical ideas. These are followed by ‘Madness’, ‘Pharmacology’ and ‘Border’, which explore the confinement of the ‘mad’, the political economy of the pharmaceutical industry, and global health in turn. The chapters ‘Care’ and ‘Cure’ segue into a historical study of the 1970s German radical political group Sozialistiches Patientenkollektiv (SPK) – the Socialist Patients’ Collective – a sudden change in pace which initially feels slightly jarring. This is recouped well, however, in the concluding chapter ‘Host’, which integrates the SPK’s theory and practice into the book’s overall project.
The key concepts developed by the authors are those of ‘surplus’, ‘extractive abandonment’, and ‘health communism’ itself, which is contrasted to its contemporary counterpart, ‘health capitalism’.
The idea of surplus builds on the ‘surplus population’ of Karl Marx’s Capital, i.e., that section of the proletariat (the non-propertied classes) who are not engaged in wage labour, or are excluded from it. The authors use this to refer to the class of people seen in capitalist terms as non-value producing, due to the posited objective markers of health and ability.
It is important to contextualise this idea in relation to the disability justice movement of which the authors are a part: as both blind/partially-sighted and chronically ill, Adler-Bolton has been at the sharp end of oppression. An earlier subtitle of the book was A Surplus Manifesto, which gestured towards reclaiming a callous label for a group of people; indeed, the thrust of the book is a damning critique of anyone being deemed as such.
The authors’ key claim is that regimes of biocertification are arbitrary and inconsistent, reducing individuals almost entirely to their capacity to work. Following Marta Russell, they view disabled workers as ‘canaries in the coalmine’, whose treatment is a sign of what threatens others after a workplace injury or a shift in what is deemed ‘healthy’ within society.
Their idea of extractive abandonment refers to the way that these populations make the transition from surplus to waste – they are not only pushed to the margins of society and institutionally warehoused, but also monetised, where welfare systems become mechanisms for public money to pass into private companies. The authors give the example of care homes as sites of both violence and capital accumulation, epitomising the dual character of extractive abandonment. The term is also developed in dialogue with recent theories of the state abandonment of black and queer populations.
Health capitalism is a system where health is an impossibility: a state one cannot get to, but to which one must always strive. It refers to the way capitalism has intertwined itself so completely with health to make the two seemingly inseparable; its definition of health as ‘able to work’ seemingly unquestionable.
The SPK, to whom the book is dedicated, and whose ideas the authors apply and develop, saw sickness as resistance to capitalism, and health as an ideologically irredeemable ‘biological fascist fantasy’. In contrast, Adler-Bolton and Vierkant see the task of health communism as the separation of capital from health. The book is thus not just an analysis of how things are, but a blueprint for political strategy. The authors try to locate key sites of political intervention, centring the ‘surplus’ within political movements to counteract social marginalisation. The book reframes political struggles around issues like pharmaceutical patents or Medicare for all (both writers are based in the US), as ‘transitional demands’ i.e., not goals in themselves, but ongoing struggles that point to a horizon beyond capitalism.
One of the strengths of the book is its development of a properly dialectical analysis of health. In other words, it emphasises the contradictions of health under capitalism, recognising the violence carried out in its name, in addition to the necessity of healthcare provision and its revolutionary potential, if it is freed from capitalist dominance. This takes a different tack than much other radical work on healthcare institutions like psychiatry which – perhaps understandably from the perspective of survivors – primarily focuses on the power they have and their ultimate abolition.
The authors claim that they offer one of the most comprehensive accounts of the SPK in the English language. Indeed, their historical account of the SPK, and their revival of the group’s relevance and political concepts, is one of the book’s greatest strengths. Though the SPK originated as a collective of psychiatric patients and doctor collaborators, the authors emphasise their unitary theory of health, making no differentiation between the physical and mental, rather seeing all illness as the result of social and political determinants.
Mental health is an area consistently contested by a capitalist work ethic through harmful tropes of ‘malingering’ and ‘it’s all in your head’ on the one hand and attempts at biocertification through drug trials and neuroscience on the other. It is an area where the politics of health are most visible, making it a key site from which the assault against health capitalism has always been mounted. Seeing health as a unified concept need not be hopelessly abstract. It can rather flow into grassroots activism in calls for action on the social determinants of health, such as poverty, housing and racism, and in the fight for provision that is user-controlled and no longer gate-kept, which sees the individual in their social context.
In the aftermath of the SPK, there has been ideological repression of radical critiques of capitalist society and concrete state repression of militant activism. Yet the contemporary moment sees more and more mainstream re-linking of mental health and politics, and the spectre of the unfinished business of the SPK still haunts us. The authors follow the core logic of the SPK, suggesting that illness under capitalism might be reappropriated and turned against the system itself, making illness a weapon against capital.
However, even while centering those deemed surplus, health communism is ultimately a broad-based political project: ‘It is not necessarily the case that we are all sick. But none of us is well’. Radical critique and action never went away – Asylum magazine is testament to that – but in the current climate of ever-worsening inequality amid the ruins of neoliberalism, it feels as though we’re in a moment in which a radical politics of mental health is becoming a more visible part of the broader movement against capitalism.
The politics of health is especially important in a society in which the crisis of the NHS is proclaimed daily, where it can feel like little territory remains for the Left, other than the rearguard action of a dogged defense of ‘our’ health service. Adler-Bolton and Vierkant present not just a utopian alternative, but they offer a concrete politics that moves beyond the mere reduction of waiting lists and creation of more beds. Particularly welcome is the advocacy of patient control of and participation in care, a central demand of the SPK, representing a radical alternative to contemporary tokenistic notions of inclusion and consultation.
The final chapter ‘Host’ suggests that health capitalism can only be overcome by severing the relationship between health and capitalism. The key to this is a radical politics of solidarity, where the struggles of the mad, disabled and other people deemed ‘surplus’, are not seen as merely narrow issues of minority groups, but are centred as a means of transforming society itself. The politics of health communism involves recognising that ‘surplus’ is not a specific group, but rather an operation of capitalism, a means of reproducing itself by destroying us and our bodies.
The core project of health communism is thus to ensure that nobody is ever deemed surplus, a situation that ultimately requires dismantling capitalism. This would see the convergence of patient-controlled healthcare and the equal distribution of health’s social determinants such as food, housing and education.
The beauty of this book is that it doesn’t just advocate an all-encompassing revolution as a social panacea, but instead outlines numerous historic and ongoing struggles around health as part of the greater struggle. They also emphasise the constant danger of such struggles being incorporated into the system – for example, the reforming yet ultimately normative impulse of social psychiatry, and radical HIV/AIDS activists’ divisions over collusion with the pharmaceutical industry.
The book is an excellent read, though the shift from specific case studies to broader political analysis is not always easy to follow. Although well explained, the prose is dense with concepts and theories, so while relatively short, it is certainly not light reading. Ultimately, it is an exciting re-invigoration of radical approaches to health, which is ideal at a time of mounting discontent, and will hopefully inspire health activists and those oppressed by capitalist notions of health and normality who, as we know, are often one and the same.
Evan Sedgwick-Jell is a researcher and activist. They see politics and theory as inherently intertwined, wishing to reinvigorate Marxist approaches to mental distress.
This is a Sample Article from the Spring 2023 issue of Asylum (30:1). Subscribe to Asylum Magazine.