Upstream - Health Communism with Beatrice Adler-Bolton

Episode Date: July 17, 2023

When we think of health under capitalism, it's easy to go straight to the fight for universal healthcare, and understandably — that battle is one of the most contentious and important in the ongoing class war between the mass of people and those who rule us, the capitalist class. But it would be a mistake to think that that’s where our battle ends, that there isn't an expanded struggle over the ways that health and sickness are even conceptualized under the capitalist ideological framework which shapes how we value ourselves and how we are either utilized or abandoned by this system.  In this episode, we’ll take a deep dive into all of the different places where health overlaps with capitalism, with Beatrice Adler-Bolton, co-host of the podcast Death Panel and co-author, along with Artie Vierkant, of Health Communism: A Surplus Manifesto. This conversation glides from Marxist economic analysis to healthcare policy to history and to some of the most foundational philosophical underpinnings of the political economy of health. Beatrice directs a striking blow against any perceived possibility of true health ever existing under capitalism, arguing that we must fight for our lives, literally, to bring forth the fall of capitalism and to build a new system that works for everyone — what she calls health communism. Thank you to Carolyn Raider for this episode’s cover art and to Fugazi for the intermission music. Upstream theme music was composed by Robert Raymond/Lanterns. Further Resources: Health Communism: A Surplus Manifesto, by Beatrice Adler-Bolton and Artie Vierkant Death Panel Podcast Death Panel Medicare For All Week Decarcerating Disability: Deinstitutionalization and Prison Abolition by Liat Ben-Moshe Mad World: The Politics of Mental Health by Micha Frazer-Carroll This episode of Upstream was made possible with support from listeners like you. Upstream is a labor of love — we couldn't keep this project going without the generosity of our listeners and fans. Please consider chipping in a one-time or recurring donation at www.upstreampodcast.org/support If your organization wants to sponsor one of our upcoming documentaries, we have a number of sponsorship packages available. Find out more at upstreampodcast.org/sponsorship For more from Upstream, visit www.upstreampodcast.org and follow us on Twitter, Instagram, Facebook, and Bluesky. You can also subscribe to us on Apple Podcasts, Spotify, or wherever you listen to your favorite podcasts.    

Before we get started, please, if you can, go to Apple Podcasts and rate, subscribe, and leave us a review there. You can also leave us a rating on Spotify now. This really helps us get in front of more eyes and into more ears. We don't have a marketing budget or anything like that for Upstream, so we really do rely on listeners like you to help grow our audience and spread the word. Also, please visit upstreampodcast.org forward slash support to support us with a reoccurring monthly or one-time donation. This helps keep this podcast free and sustainable, so please, if you can, go there to donate. Thank you. Health communism describes a political ideology, but it's also meant to name something for which there is really no real name, which is whatever a kind of ahistorical timelessness that makes it seem

like health capitalism is the only way that things could have ever been. So health communism is a kind of naming of the unnameable. And it's, as I said, an ideology about our political economy, why it is the way it is, who that serves. And our book is ultimately looking at where the vulnerabilities of our political system lie and pointing to health both as a central aspect of political power and economic control, but also as a central vulnerability of capitalism itself. There is no capital without health. It is capital's host. And capitalism's greatest trick is convincing us that it exists independent of this parasitic grasp. You're listening to Upstream. Upstream. Upstream.

Upstream. A podcast of documentaries and conversations that invites you to unlearn everything you thought you knew about economics. I'm Della Duncan. And I'm Robert Raymond. When we think of health under capitalism, it's easy to go straight to the fight for universal health care. And understandably, that battle is one of the most contentious and important in the ongoing class war between the mass of people and those who rule us, the capitalist class. But it would be a mistake to think that is where our battle ends, that there isn't an expanded struggle over the ways that health and sickness are even conceptualized under the capitalist ideological framework which shapes how we value ourselves and how we are either utilized or abandoned by this system. In this episode, we'll take a deep dive into all the different places where health overlaps with capitalism

with Beatrice Adler Bolton, co-host of Death Panel podcast and co-author, along with Artie Virkent of Health Communism, a surplus manifesto. of Health Communism, a Surplus Manifesto. This conversation glides seamlessly from Marxist economic analysis to healthcare policy to history and to some of the most foundational philosophical underpinnings of the political economy of health. Beatrice directs a striking blow against any perceived possibility of true health ever existing under capitalism, arguing that we must fight for our lives, literally, to bring forth the fall of capitalism and to build a new system that works for everyone, a system she calls health communism. And now, here's Robert in conversation with Beatrice Adler-Bolton. Hey Beatrice, it's great to have you back on Upstream.

Thank you so much for having me. It's really nice to be back. Yeah, we had you on, I think, almost maybe even two years ago now. I can't quite remember to, you know, talk about Death Panel, your podcast. And at the time, you were really sort of zoomed in on COVID and the pandemic. And so that's what we based our conversation on last time. And we may touch on that a little bit this time. But you know, have you on this time to talk about your recent book that you wrote with Artie, Health Communism. And so I'm excited to get into that in a sec. But I guess just first for folks who didn't catch our first episode with you, I'm wondering if you could maybe briefly introduce yourself and yeah, just tell us a little bit about

how you came to do the work that you're doing. Yeah, absolutely. So, you know, most people probably know me through my work as co-host of the podcast Death Panel, which you mentioned. We're a twice weekly show and we cover the political economy of health very broadly. So I host the show with my brilliant collaborators, Artie Vierkant, who is also my co-author on health communism, Phil Rocco, who is a political scientist who studies healthcare, Jules Gil-Peterson, who's a historian of medicine, and Abby Curtis, who's a social epidemiologist. And so the five of us together, you know, we explore health, I'd say, in probably the broadest sense possible.

And I came to do the work that I do on Death Panel, of which health communism is definitely both like a reflection and an extension of that work. And, you know, my broader work to studying radical patient groups and the capitalist political economy of health through my own experiences of chronic illness and disability. So I got sick at 19. And I've been sick ever since. And after a few years of being chronically ill all through college, and then leaving college and entering the workforce, I really started to realize that my relationships instantly shifted when people found out that I was sick. And it

was hard to understand at first how so much power could be tied up into your health status. And as I tried and tried to make my body, you know, do what it needed to do so that I could make enough money to pay my rent and my co-pays on my monthly medications that I needed to be able to show up to work. You know, I realized how trapped I was in this cycle of getting sicker by pretending I was less sick to be able to keep my job, to keep accessing the care that I needed to not get sicker. So it was a pretty, you know, frustrating time in my life because I also believed that

if I could just find the right job with the right health insurance, everything would be fine. But I think as many people know, you know, there really is no such thing as the perfect health insurance plan. Nobody fucking likes their private insurance. That's just the fact and the matter of it. And so I started to realize how the ways that we were talking about health care at the time, and this was during the implementation of the Affordable Care Act. And everyone was talking about, you know, guaranteeing coverage for preexisting conditions and whether we could or couldn't actually afford to do that.

And it really didn't match my experience of health care materially speaking. The ACA was a huge step forward and meant that people like me were not doomed at 19 to be uninsurable forever, which is the case of how it was like before. Because for folks who are too young or don't remember how it was here in the US before the ACA, health insurance was a lot more like how life insurance is now, where being sick once could often make you categorically ineligible for health care coverage for the rest of your life. So it was a difficult thing to reckon with the fact that people were telling on themselves

all around me, left and right, in the ACA debate when they were sharing their opinions on who they thought deserved health care and who they thought didn't. And I think I realized that a lot of folks thought that it was going to be too expensive to make a law that people like me deserved care to and that that would bring, you know, the end of civilization or the end of capitalism. And the thing is, is that it didn't. You know, the ACA was a big step forward for like health policy in the United States, but it sure as hell didn't fix anything.

And the fight over the ACA and coming into being a worker as a young disabled person in denial about being disabled were what really put me on the path of health justice organizing many years ago now. And I've been doing that for, you know, over a decade. I've been writing about it since 2017. And we started Death Panel in 2018, really just because we wanted to have a place to have conversations about health care from a left perspective that we felt like just weren't happening. You know, it was very frustrating to see the conversation around Medicare for All during the 2020 election, during the 2016 election. They were dominated by the question of how do you pay for it? So, I mean, I guess this is all to say

that like, when I get up in the morning, I hope that I can be like the worst enemy of the health insurance companies in the United States. And death panel is really a project that's seeking to support and cultivate a sick left in the US, which is not something that we've had for a long time. Thank you so much for that. Really describing your experience, becoming aware and sort of, I guess, in a way entering what you call the surplus population in the book, which we will get into all of the sort of the details and the terms that you introduced me to. And I'm sure a lot of our listeners will also be introduced to a lot of this stuff for the first time. But maybe just to orient people a little bit and, you know, zoom out to start. I'm wondering if we can just start with the title of the book, which is Health Communism. And yeah, so what is health communism?

And also, I think importantly, the flip side of that question is what is it in opposition to? Great question. So health communism is lowercase c communism, meaning that it describes a political ideology, but it's also meant to name something for which there is really no real name, which is whatever the opposite of the political economy of health that we have right now would be. So, you know, part of what we wanted to challenge with the title is the way that health capitalism goes unnamed. And in doing so, it projects a kind of a historical timelessness that makes it seem like health capitalism is the only way

that things could have ever been. So health communism is a kind of naming of the unnameable. And it's, as I said, an ideology about our political economy, why it is the way it is, who that serves. And our book is ultimately looking at where the vulnerabilities of our political system lie and pointing to health both as a central aspect of political power and economic control, but also as a central vulnerability of capitalism itself. Basically meaning that while under capitalism, you're only entitled to the survival that you can buy and the price for ill health or not maintaining your health as a worker is really high. Capitalism still needs all of our bodies. And even those of us who have left or have

been pushed out of the position of worker into the surplus class, we also have bodies that are necessary to the reproduction of capital. So this is really why we open the book by saying health is capitalism's vulnerability. There is no capital without health. It is capital's host. And capitalism's greatest trick is convincing us that it exists independent of this parasitic grasp that is indifferent. Because honestly, the truth is there's no endless supply of healthy workers waiting in the wings to replace the bodies that become surplus. Capitalism needs workers. Workers don't need capitalism. And capitalism ultimately is bad for our health. So what health communism is, is a proposal for a different way for the left to think about health, an approach to health justice that's not contained within the borders of any one country and that refuses nationalistic kind of frameworks

of health justice. It's an alternative framework to the present one that also insists that health is always going to be limited to health finance reforms and simply changing out the payer. Ultimately, when we say we want health communism, we mean that we want everyone to receive the care that they need, all of the care that they need. And one of the things that Artie and I were working on before the pandemic was already developing this lens through Death Panel of looking at sort of how health policy manifests in people's lives, how we economically feel the impact and materially feel the impact of the ways that our life is valued relative to our

capacity to work. And when the pandemic happened, basically, as soon as it happened, you know, it was immediately obvious that the things that we had already been talking about on death panel, it just was sort of exploding into a broader, more prominent position within the sort of general political economy. And so, you know, I think folks may read the book and be expecting it to be a COVID book because maybe they know our work on Death Panel or they know us because of COVID. And in many ways, like the book is a COVID book because you can understand exactly why the pandemic happened the way it happened, but not because the book details

what happened during the pandemic, but because we lay out the dynamics and the values that are embedded within the different institutions of our political economy, the ways we talk about care and choice that have actually dictated the pandemic response. And the pandemic response or lack of response, the organized abandonment of the pandemic response, you know, unfortunately is actually in keeping with our political economy of health. Yeah, I think the only time that you actually mentioned COVID or the pandemic was near the top of the book where you said that this is not a book about COVID or the pandemic was near the top of the book where you said that this is not a book about COVID or the pandemic. But again, like you said, it certainly is just, you know,

it's not like a deconstruction of the pandemic or COVID in that kind of explicit way. It's also not like, you know, simply a call for like Medicare for all or anything like that. It's really like reading it, I realized you're really calling for like these really deep, deep ideological shifts and structural shifts. And it's almost like there's just so much almost like philosophical content in the book. And yeah, it was really just such a good read and really like expanded the horizons on which I think about health in general in capitalism. And yeah, just a quick quote that I want to read from the intro. You write, we propose our own lens by which health is reclaimed, not just for workers, but also for those marked as surplus for all people, health communism. And so you brought up a few terms in your last response

that I think that we're going to spend some of the time today unpacking some of these terms. And one of them is a surplus population. And so I'm wondering if you can sort of unpack what that term means. And then also, if you could talk specifically about like disability and surplus, and, you know, I was particularly fascinated by how you describe how the state determines these things, like in terms of SSDI eligibility, like bio certification regimes, and, and so on. So yeah, I'm wondering if you can just kind of unpack that all for us. Yeah, absolutely. And I so also appreciate the high praise of the book. I'm so glad that it made those connections for you.

And part of the reason why we mentioned COVID the way we did in the introduction is because we wanted it to kind of haunt the reader as they went through the rest of the text. Because if you're familiar with the COVID response, if you've been paying attention to COVID, you're going to see parallels page after page that are going to remind you of things that you've been through the last three years.

And I hope that for people that helps to contextualize them beyond this immediate moment and locate it within a much broader political dynamic that is oppressing all of us and that goes actually way beyond just the singular instance of COVID and touches on all aspects of the state of our identities and of how our health itself is even conceptualized. And so one of the ideas that's so important to the book and to understanding why we're pointing people to this analysis is the idea of the surplus population. So the surplus population is historically talked about as non-working and therefore non-important. And we really push back on this framing and expand it.

But most people understand the surplus population as a kind of human waste, not part of the working class or not part of political movements. And this was initially defined in economic terms in writings by Engels and Marx, which was sort of in response to the very moralizing panics induced by some of the early philosophers of capitalism. We're thinking about people like Adam Smith or Thomas Malthus, you know, who were making arguments that overpopulation and dysgenic traits posed a huge threat to the economic order, to capitalism. And of course, what they really meant is that there were too many poor people, more than was necessary or needed to support and provision the needs of the ruling and the owning class. So this is part of why Engels and Marx, in referring to the surplus class, talks about it as capital's general reserve army.

And they make clear that their formulation has to do in part with like this being a population of unemployed people who are thought about as people who could otherwise be a part of the labor force who were tapped and used when there were conflicts over wages or working conditions as a kind of ready-made scab army. So obviously, that's a kind of definition of surplus and the surplus populations that is kind of the older formulation. So what we do is we're trying to take that and bring it, you know, up into a contemporary understanding, but also, you know, have it reflect the history of disability and illness that has happened since Marx and Engels were writing. Because that's one of the things that I think people often don't consider is you'll hear, oh, well, there's not a lot of consideration of health and disability in Marx and Engels. But you could actually look at a lot of their work and say, well, this is also foundational research for conceptualizing what public health even means and how economic relations dictate our health. So what we do in the book is we try and, you know,

convey a contemporary understanding of what it is to be surplus, which is much more expansive. So the surplus populations can be defined as a collective of people who fall outside of normative principles for which state policies are designed, people who are excluded from the entitlements of capital. It's a kind of certifiable population that is fluid, and we attempt to ascribe definitions as to who counts and who deserves to be a part of this population. But the most important understanding is that culturally, the surplus person exists in opposition to the worker, and they're seen as sort of mutually exclusive. And so it's important to understand the methods that the state employs to try and certify the boundaries between surplus populations and

workers. And that's a place that we really try and examine. And so, you know, just understanding sort of who's in the surplus population, right? That contains people who are disabled. It contains people who are not disabled. It contains people who are precarious workers, who, for whatever reason, fall outside of the bounds of the ways that we design policy. So whether that's someone who has a job that doesn't provide them with employer-sponsored health insurance, or it's someone like me who can't work due to disability, we're both in the surplus class. We're both outside of the realm of the dominant policy model. And so it's also sort of more important to

understand the surplus population relative to a kind of enforced precarity than it is to what that person's actual designation is that made them become a part of the surplus. And can you talk a little bit too about waste and like this idea specifically of like the conjoined eugenic and debt framework? Yeah, absolutely. So in Waste, which is the second chapter of our book, we looked at how, you know, once someone is certified as surplus, marked as surplus, how does the surplus population sort of function within capitalism? And often, it's kind of used as a political constituency to which concessions are made as a way to stave off broad reforms. So what we're talking about here is something like, for example, Medicare and Medicaid, which are really important policy innovations, huge changes in American political economy.

But also Medicare and Medicaid emerge out of a health justice movement and a very robust and coordinated demand for single payer. And it arose as another option that we could do instead to stave off the need and the demand for a single payer health insurance for a kind of program like Medicare for All. And so part of sort of what we interrogate is what are the ideas that are used to try and sell people on the fact that, for example, these kinds of reforms that will meet the need of just the most neediest population, that then we'll put means testing in, we'll put bio-certification in, we'll make sure only the people who absolutely need the help,

the most desperate people are getting this, right? It's kind of like, what are the ideas that actually tell us that that's the only way to do policy? And part of the idea that supports that is this kind of idea that people who are not working do not contribute to the economy. And while people who don't work may not have surplus labor value that can be extracted, there is still surplus value that's extracted from our physical bodies, from the surveillance of our bodies, from upon the framework of proving if someone's healthy or not, proving if they're disabled or not, treating them, rehabilitating them, diagnostics, transportation, pharmaceuticals, pharmacies, right? It just grows and grows and

grows. And so it's actually really difficult to see the surplus population as, quote unquote, human waste. when you start to understand all of the different ways that we contribute to the economy, quote unquote, through literal extraction from our bodies, from our lives, from our ability to survive. And this also acts as a kind of form of labor discipline, because if people who are not working are subjected to forced poverty on programs like SSDI, where the average recipient makes no more than $12,000 a year and still has to pay for out-of-pocket costs as a result of Medicare's not actually being free at the point of service, it's one of those frameworks that it's impossible to begin to see the truth

of the surplus population being waste. When you look at things like the nursing home industry, the billions of dollars that flow through Medicaid that can, for example, go into the construction of enormous high-tech academic medical centers that might raise the profile of the particular state that's using that Medicaid money that should be going to the care and treatment of poor people or people in the surplus class, but then instead goes towards building a giant brand new medical center. And this is something that happens all the time. This is a recent example I'm referencing from a Supreme

Court case. It was actually decided only a couple couple weeks ago, which was about, you know, whether or not people had a right to sue the nursing home that they were in if their care is paid for by Medicaid or if, you know, the state paying for your care basically means that you can't sue over the conditions in the nursing home that you live in, because, you know, that's not sort of considered to be something that people in the surplus population really have the same kind of rights in terms of enforceability. And ultimately, the thing to remember is that the idea of human waste or of non-working people being non-valuable, it serves a purpose. It serves a purpose both in limiting the political horizon, in limiting all sorts of demands, but in also dividing and undermining attempts to build solidarity between the surplus and the working class. Yeah, absolutely. That was one of the most interesting aspects of the book, I think, was, yeah, I mean, you talk about how the disabled and the sick are abandoned in many ways under capitalism. And absolutely, that's true. And they're also extracted from,

right? And they're like, hyper exploited in certain ways, I guess you could say. And it's really interesting to you just mentioning that it serves as just another aspect of division. And one of the things that we know about capitalism is that it really relies on division in order to be able to exploit different groups of people, even more so than non-sick or non-disabled people, for example, in this case. And, you know, another thing that I thought was really interesting too, is when you kind of went into the history and, and sort of examined historically how we got to some of these, uh, bio-certification regimes, for example, can you talk a little bit about like the, the history of the poor laws and, and they sort of, you know, created this, what you call like a taxonomy of poverty and shaped contemporary capitalism's welfare programs with like, you know, what we know now

through like means testing and work requirements and such. Yeah, absolutely. This is one of my favorite parts of the book, to be honest. This is in the chapter called Labor, which really sort of is looking at an idea that we call the worker surplus binary that we can get into in a little bit. But really sort of most importantly, where this comes from, in many ways, is actually a kind of similar scenario to the circumstances in COVID, which is part of why we talk about this early on in the book. So the categorization and certification of surplus, again, has become this sort of focal struggle in the history of capitalism. It's foundational to the development of capitalism itself.

People who are marked as surplus, they're rendered excess by the systems of capitalist production. And we've been talking about how the framing is that people who are surplus are a drain on the economy. And I think a lot of people take that to be self-evident and they say, oh, well, this idea has existed historically for decades and decades. Like it must be truth, right? It must be nature that, you know, just people who are non-normative, they just have too many needs and society just can't handle it. is an idea that appears over and over and over, but really has a lot of foundation in the poor laws, which come into being in the United Kingdom after some of the worst years of death from the plague. So it might come as no surprise that some of the first definitions of who is worthy as a non-worker or who is a kind of idle louse layabout sucking on

the taxpayer like a tick or a flea, right? If you go back into the archive and you study the stuff the way that we do, you'll see all of the most ridiculous kind of ways of framing the poor, leeches on capital, right? So you have this whole framework of sort of dealing with idleness that emerges through the English poor laws. of growing leverage commanded by workers who were demanding better wages in their post-plague labor market where you had all of these people who had died. And so the people who remained were able to demand higher wages, and it sort of started a moral panic. And obviously, I think a lot of people that are listening or who read the book might look at some of these stories about, in particular, the poor laws or malingerers and see so many parallels to, for example, the way that we're seeing, you know, as people still continue to get sick and die with COVID, as COVID continues to be

a problem and the state tries to make it invisible, we're seeing all this rhetoric about how work from home is really going to ruin people. It's going to make people ugly as they age. Only ugly people still wear masks. And it's because they're anxious, like, oh, people are staying inside because they don't want to work. They don't want to go to the office, right? And so you could really see how this works as labor discipline. But ultimately, what happens during the poor laws is that after years of plague, you know, up to a third of the lower class in the UK had died. And this is really a crisis of labor power that had arisen. And Parliament passes laws that essentially require workers to cede total control of their labor conditions to the ruling class and to state representatives. the ruling class and to state representatives. And it essentially compels all able-bodied people below the age of 60 to work and criminalized all who refused. Now, ultimately, you know,

the statute really explicitly states what we would basically call now a work requirement. Like if you look at things like Medicaid work requirements, you know, you can see the architecture of the poor laws in contemporary laws like that. So anyways, during the years following this highest concentration of deaths from the plague, idleness is made out to be this kind of looming social threat. It's a corrupting contagion. It poses an existential crisis, you know, not just a social threat, but it's it's really, you know, a threat to the entire survival of the way of life for the ruling class. And the poor law statute, you know, there are many of these statutes that kind of iterate. But deservingness and deviancy. Legitimate idleness was very narrowly defined as people who deserve to be included from compulsory work. It was a very specific set of groups of people, people who are considered to be legitimately, quote unquote, crippled through no fault of their own,

of course, people over the age of 60, people who owned land, right? And so the point was not just to regulate the non-working poor, but to also establish this categorical distinction between the idle or the vagrant poor and unemployed workers, so that you could sort of sort and essentially compel those unemployed workers to take jobs, regardless of the wage. And so ultimately, what you see is, you know, the stakes for disobeying this work order keep getting raised. The resulting punishment to people who are deemed idle poor, who are, you know, people who are just unemployed workers, maybe they're holding out for a better wage, you know, they're forced into taking

a job. They are barred from quitting. You know, you're sent to work camps, right? There's a whole sort of framework where this entire labor sort of milieu that was much more informal, that sort of worked through different modes, begins to be bureaucratized through the taxonomy of who's a deserving non-worker and who's an undeserving non-worker that needs to be reclaimed. And this is really kind of taking place pre-capital as capital is developing. Again, statute of laborers first passes in the 1300s, right? So, you know, the point is that we get into this in much greater detail in the book, but the point is that like this is just one of many

examples of how labor relations really shape our perceptions of human value, of human worth, and ultimately also shape the idea of disability or idleness itself and what we as individuals and a society are entitled to. And ultimately, the kind of resulting shape of this worker surplus binary, as we've been talking about, you can find it today all over, you know, eligibility requirements for various welfare programs, for pensions. You can find it in your health insurance benefits package. You can find it pretty much anywhere there's a policy that is supposed to be targeted or only reach poor people or only reach certain people who are deserving. targeted or only reach poor people or only reach certain people who are deserving. I mean, I think that the student loan cancellation example is such a great connection as well,

which is that one of the reasons why student loan cancellation is like probably not happening is because the Biden administration tried to target it. They tried to means test it. Rather than doing a universal program, they wanted to means test it. And that's actually the grounds on which the Supreme Court struck it down recently. So it's fascinating to sort of see how, you know, ultimately, means testing itself is not something that our political economy thinks is a good thing that it wants to do, right? Means testing is a necessary thing that it wants to do, right? Means testing is a necessary dynamic that capital requires. It's part of how our economy works. And when, you know, it suits capital, it's employed in the cases of Medicaid, right? When it doesn't suit capital, you know,

when it could lead to the cancellation of student debt, to the siphoning of a very valuable industry of debt, well, then, you know, it's unacceptable, right, to target a program like that. And so you really, you know, I hope that the people who read the book can sort of not only redefine the way that they're thinking of their own health or their own labor power, but also begin to see that there are just ways that our policy and our political economy basically guarantee these kinds of results through the different preferences and values that sometimes are ancient, but which we still see embedded in the institution systems, laws, and governance that controls our lives.

Yeah, no, absolutely. And it was just so interesting reading that history sort of the rise of capitalism as, you know, totalizing political economy and social order in terms of health and productivity. We recently did a documentary exploring freedom under capitalism. So our listeners who are familiar with that one will be able to really make that connection in terms of, you know, health, and the sort of the scientifically meticulous categorizing of groups of people around productivity, make that connection with the book to in terms of yeah, that how that from the angle of health, and I think really importantly to the punishments associated with nonproductive individuals. Or I love that, idle louses. I'm going to read a fairly lengthy quote from the book here.

Not too lengthy, but yeah, I think it just really encapsulates a lot of the discussion so far. So you write, worker-surplus binary solidifies the idea that our lives under capitalism revolve around work. Ourselves, our worthiness, our entire being, and right to live revolve around making our labor power available to the ruling class. The political economy demands that we maintain our health to make our labor power available, lest we be marked and doomed as surplus. The surplus is then turned into raw fuel to extract profits through rehabilitation, medicalization, and financialization of health. This has not only justified organized state abandonment and enforced the property of the poor, sick, elderly, working class, and disabled, it has tied the fundamental idea of the safety

and survival of humanity to exploitation. So just a really, really powerful quote, really nice, succinct encapsulation of what we've been talking about. And I think I want to move next to this question of like mental illness and, know what has been called madness and another quote a short one this time you write in the book madness is depicted as antithetical to the needs of society under capitalism a hindrance to productivity the burr on the otherwise smooth surface of forward progress and so thank you for letting me read your own quotes at you. But I think, yeah, it really helps to sort of, yeah, they're just like so many good quotes in the book. I have a Google Doc filled with them, and I'm only touching on some of them. But just wanted to

read some of that and then maybe ask you if you can talk about how psychiatric institutions are emblematic of the sort of contemporary political economy of health. Absolutely. Really great question. So in the fourth chapter of the book, which is called Madness, we talk about the asylum system, quote unquote, lunatic asylum system or a psychiatric inpatient facility. You know, there are so many names for essentially what is ultimately always an economy of scale style warehousing approach to involuntary treatment often. So there's a very long history of asylums, of institutions for intellectually developmentally disabled people, for physically disabled people, for chronically ill people, for people just,

you know, accused of desertion by husband, whatever, essentially, sort of very early on, actually, you know, is part of the long history of sort of what to do with that idle population, once you've sorted and identified them, if that population gets too big, right, the kind of issue becomes sort of how do you take care of people as cheap as possible and with the sort of best economy of scale that you can engineer? And the answer to that for a long time was very large institutions. And historians and scholars of disability and carcerality will usually call this model the total institution model. But the fact of the matter is,

if you are alive today and you're chronically ill or disabled, or you have mental illness symptoms or a mental illness diagnosis, it's possible that if you were born in the 30s, 40s, 50s, 60s, 70s, sometimes 80s, 90s, it depends on what your diagnosis is, but there's a likelihood that you could end up institutionalized and people still are institutionalized. And it's a kind of ongoing process of trying to close institutions and trying to provide people the promise of in-home care. you know, discourses on surplus populations, especially for people who would be categorized as what we would now call mentally ill, has really had this very long history that is really intertwined with capitalism itself. And so you see, you know, various names over long periods of time, you know, sometimes called distracted persons, natural fools, schizos, criminally insane,

crazy people, etc. Right. Like you sort of have all of these different ways of naming this population, which, you know, for a long time is characterized by the way that it's been identified, sorted and targeted. And ultimately, the idea is sort of just that madness presents a threat to the normal functioning of society. And so the best thing to do for quote unquote normal people was to round mad people up and put them in institutions, remove them from the community and allow sort of them to, you know, live within these institutions often for their entire lives. So we talk about how this is really often then a kind of arbitrary distinction, how a lot of people who end up in these institutions

are sometimes in there for reasons that have to just do with structural racism, where they were maybe in a white restaurant, they were a black person, they complained about the circumstances of their service in the restaurant, the police were called. They were upset. They were arrested. They went to an institution and they did not get out again. And they were there for another fucking 40 years where they died. Right. Like this is how life used to be for disabled people. This is how life used to be for people with mental illnesses. It's only recent, only starting in the 1950s. It's taken years. It's still happening, as I said. Only recently was it really acceptable for disabled people, for mentally ill people to

receive treatment in the community, to live at home, right? This is the way that people in the surplus population were dealt with for hundreds of years. If we sort of look at the reasons why that was happening to you, why could not the model have been that, you know, for example, if you are someone with a mental illness diagnosis, or you're someone who's disabled, let's say even in the 13th, 14th century, right? Like whenever you get this stipend, and the people who you live with get money to care for you in your home, right? Like saves the government from having to build up these carceral institutions and hire

doctors. But the problem would be then those families that had the non-working people in them would be getting more than the working class, than the people who have people, you know, every family member sent to work. And so it posed a problem of, you know, a political problem, ultimately, that no one really wanted to address head on, which was, well, if we put sort of the structural, social and economic investment required to, you know, really provide people with the care that they need, with the supports that they need, with the means of survival to thrive, to live in the community, then that somehow takes away from what we're able to withhold from the working class too,

right? So if we were to give the kind of bottom of the barrel this leg up, what would it mean that we would have to do to the people above them in the social and the economic order? And so ultimately, you know, for folks who are coming from a contemporary perspective and might hear the word madness and be like, what, what, what is that? You know, it's, it's the word that the bad rights movement sort of prefers to use to self-describe. But most importantly, you know, this is kind of like a word that's been appropriated, like within the disability community, the word cripple has also been reappropriated. People use the word crip. So I wouldn't go to your friend to be like, you know, you're not mentally ill, you're bad. But if your friend identifies as mad,

or if you identify as mad, or you identify as mentally ill, and you sort of want a more political way of approaching that identity, you know, there's a long tradition of patient organizing, of self-advocacy, of institutional sabotage, revolt, and protest that is how people were freed and how these institutions closed. And it's actually the largest example of abolition, of institutional abolition in the United States. I'd highly recommend the book Decarcerating Disability by Liat Ben-Moshe. She writes about this. It's fantastic. But, you know, what she says also is that this is a really good case study and object lesson in also how police and prison abolition is absolutely possible within our lifetimes. And if folks want to sort of read more and get into like a kind of,

I don't know, if they want a text that maybe is less about sort of how madness is located within political economy and more about sort of understanding madness and mad people as a political category, I'd also really recommend the book Mad World, which just came out by Misha Fraser Carroll from Pluto Press, which is a really good and especially good starting point for anyone that's new to the subject and wants to learn more or anyone who's just like fucking sick to death of like capitalist wellness, mental health, self-care, you know, talk. You're listening to an upstream conversation with Beatrice Adler Bolton,

co-host of Death Panel Podcast and co-author, along with Artie Virkin, of Health Communism, a Surplus Manifesto. We'll be right back. I never thought too hard on dying before I never sucked on the diet I never licked the side of dying before And now I'm feeling the tire You got your hands over your ears You got your mouth running on You got your eyes looking for something

That can never be found Like a reason Good God, I don't need a reason I never thought too hard on dying before I never thought on the dying I never held a hand at dying before And now I'm feeling the dying And you got to, and you got the diet And you got to

And you got to And you got to Give me the shots Give me the pills Give me the cure Now won't you talk to my world I never thought too hard on dying before I never thought on the diet I never walked aside and died before

And now I feel like I'm And now I feel like I'm And now I feel like I'm Under your skin I can't hold my eyes I'm at the tip of your fingers It's pain, it's pain, it's pain Don't need reason Give me the shots

Give me the pill Give me the fear Give me the cure You throw through my walls Coming around Coming around Coming down Give me the shot Give me the pill

Give me the cure Now won't you come to my world Give me the shot Now come on, give me the pill Give me the cure Now I'm just dancing my world Give me the shot That was Give Me the Cure by Fugazi.

Now back to our conversation with Beatrice Adler-Bolton. So before the break, you'd mentioned a couple of books that I just wanted to let people know that we've thrown the links into the show notes for those, Decarcerating Disability and Mad World. So just in case you didn't have a chance to jot those down, they're in there now. And yeah, I also wanted to just say,

I appreciate you talking about how language is being reclaimed and, you know, like the word mad, for example. So that was interesting and important, I think, to, to take note of. And I think now I'd like to move the conversation to, um, pharmaceutical companies. Um, I think that, yeah, I guess maybe I'll start with another quote, um, just to sort of set the table a little bit, and then I'll ask you to maybe, um set the table a little bit and then I'll ask you to maybe unpack it a little bit and talk a little bit more about it. So yeah, you write pharmaceutical companies are among the most visible examples of the threats posed to global public health by the international spread of health capitalism. So you're going to say they

operate as extra state international actors and actively participate in both're thinking of how nations and I'm actually reading Decolonial Marxism by Walter Rodney and, you know, talking about- Great book. Yeah, absolutely. And yeah, framing it as, you know, there are specific entire nations that are actively underdeveloped, right? And so, yeah, I'm wondering if you can talk a little bit about the colonial nature of pharmacology, the weaponization of patents, and why true health communism must be an international struggle. Absolutely. This is one of my favorite chapters of the book. In pharmacology, which is the fifth chapter, we talk about

the rise of the global pharmaceutical industry, which is really know, is really kind of, I would say the period that we focused on is kind of the second half of the 20th century. And also how the pharmaceutical industry as an industry, as part of its growth, had such a direct role in crafting imperialist international trade policy. You know, the kind of global NGO health capitalism model that we know now could not have existed without the professionalization of the pharmaceutical industry, without the kind of influence that they had on policy, on trade, and on the ability to influence which nations are marked as surplus. Because it's not just people who are marked as surplus, but it's neighborhoods, it's whole countries, right? It's whole continents. And, you know, the United States and other wealthy

capitalist countries, I think they're best understood as having served as the kind of hosts to this growth of a kind of predatory health capitalist relationship where pharmaceutical companies and the products that pharmaceutical companies make become tools of barter or points of negotiation in all sorts of other agreements. So one of the things that we talk about is, for example, you know, when certain countries were offered membership to the World Trade Organization, that offer of membership came with a contingent request that said if you're going to join the WTO, which of course, like the countries that, you know, are essentially being offered this to join the WTO, like they kind of have to, right? Like they're not in a position to refuse. And one of the conditions of joining is that you have to set

up private health insurance companies. And who's going to be there to help you do that? But like American companies who run the private insurance companies there. And oh, and you have to respect global trade and patents. Right. And and so we get into some of the history of how, for example, like, you know, the TRIPS agreement is something that was talked about a lot during COVID. You know, a lot of people talked about it relative to vaccine apartheid and the ways that vaccines were unevenly being shared. The control over even something as simple as whether or not a country had the license to buy the bottle to put the vaccine and let alone the formula for the vaccine itself was, you know, something that there was no reason to not share that stuff during COVID, right? Like, the advantage that capital would have had by sharing the vaccine widely and freely globally is a really interesting example to look at. And because in sort of treating these things like all other pharmaceutical products, right,

we get to actually see that pharmaceuticals aren't made for all countries. Pharmaceuticals are made for the countries that have patients in them with good insurance plans who will pay for it, right? And there have been instances, there's a really good example that we talk about that's from the Obama administration, where Merck basically goads the Obama administration into threatening India with sanctions because India has decided that they want to, under the absolutely legal doctorate, like under the rules of the TRIPS agreement, they were going to issue a compulsory license to produce a cancer drug that was way too expensive to import domestically. Now, Merck said, the CEO, there's a great quote in the book that's from the CEO. I think it was like a Financial Times, you know, industry panel of some kind. And he's basically like, you know, these drugs weren't made for people in India. These drugs were made for white people in the United States and Europeans. Like, why does India think that they deserve this cancer drug for their people? Because that's not what we design products for. And so,

you know, it's important to also recognize that throughout the 20th century, U.S. imperialist practices were wielded in no small part through private pharmaceutical companies themselves with the explicit goal of also furthering a U.S. and Eurocentric capitalist hegemony. And, you know, we've seen throughout, especially the kind of era of, you know, globalization from the 1980s forward, where we've seen, you know, the importance of internationalism kind of lose out to some of the scales of global capital. So when we're talking about health communism needing to be an approach that refuses all nationalisms, that ignores borders, and that recognizes that health is a kind of phenomenon that supersedes the state or any one state itself, part of that is because pharmaceutical

companies operate at this scale. Health capital operates at this scale. And so we also have to conceptualize our movements, our resistance, our political theory at the scale that our enemies are operating at. You know, the importance of internationalism is not simply to just wrest profits from massive global enterprise to benefit only patients in the United States, right? Like capital control of international pharmaceutical research hurts everyone. And ultimately, you know, the left really, I think, loses out in focusing only on,

you know, health reforms that exist in only one country. And also, on top of that, just focusing on health finance reforms alone, just simply, you know, the who will pay for it question, I think is also a narrow focus at our own peril. If we don't think about healthcare reform in terms of not simply eliminating private insurance companies, but also eliminating the ability of pharmaceutical companies to own medicine, to really say, this country doesn't deserve this cancer drug. This drug wasn't made for you. You haven't earned it. You're not entitled to it. It's not just who pays for our care. It's, is the drug privately owned? Is the clinic a private company? What about the pharmacy? What about the distributor?

What about, these are all the questions of, is the problem public-private? Is the problem political refusal to engage in policies like Medicare for All? No, this is how the state has built itself. This is how the state has built its wealth. Pharmaceutical companies, healthcare, this is part of how our global power is actually sort of constructed and perceived as these sort of biomedical giants who have access to all of the wonder drugs, right? And in that sort of refusal to make drugs available to everyone, to give all care to all people, it is one of the most powerful forms of ensuring that the capitalist political economy is the one that remains dominant. And again, yeah, I just want to say I really appreciate how you and Artie really helped me shape my understanding of, you know, how health is so central to all of these questions, and that, you know, it's not accidental. And I just got to say, too, I fucking hate the

how will we pay for it question. I'm so sick of that question. Even when it's reheated and reused these days, it was old in 2016 when it was more dominant. And I can't believe that it's still part of the discussion. It was old in 1971. Yeah. Yeah. It was old in 1930.

Yeah. Yeah. No, we have a great episode of a series we've done called Medicare for All Week with two economists, Nathan Tankus and Marshall Steinbaum. And they're coming from like completely different like left economic perspectives. Right. And the theme of that episode is that it doesn't fucking matter how much it costs and it doesn't matter how we're going to pay for it.

We need Medicare for All now. And it's just the floor, not the ceiling. Absolutely. Well, speaking of, you know, everybody's favorite thing, health insurance companies, I'm wondering if, yeah, maybe we can talk a little bit more about on this same thread of how healthcare is distributed through capitalism. I'm wondering if you can talk a bit about, I believe you call like the debt eugenic burden frame or model of health insurance and how this current model, yeah, came to dominate how we distribute healthcare. Yeah, absolutely. So this debt eugenic burden framework, you know, in a lot of ways,

this is the thing that we've been talking about the whole time, which is really the idea of like, thing that we've been talking about the whole time, which is really the idea of like, what does the surplus pose as a threat to the survival and thriving of a capitalist nation? And how does that work to constitute essentially a theory of power and deservingness? And health communism, you know, really attempts to kind of give shape to this broader political philosophy beyond, you know, how to understand health, beyond how to understand disability. We hope that this can guide left movements who are demanding universal health care. But also, you know, this is, I think, really helpful for anyone who's interested in any kind of dramatic expansion of social welfare supports, whether that's

something related to environmental justice, clean air, clean water, housing justice, police and prison abolition. And ultimately, you know, part of sort of what we are obviously centrally focusing on is how health insurance and the health insurance market and how these kind of figures of the threat, the waste, the surplus threat really kind of begin to be actualized and made material through different actuarial products and systems, right? So, you know, health insurance is one of those things that in its risk assessment, in the ways that it categorizes us and categorizes our needs and our healthcare and how we should pay for, and who's responsible, that in and of itself does constitute this kind of total ideology that says that medicine in and of itself is something that is always scarce, and something that we will never have enough of, and something that will always have to be rationed, not necessarily according to need, but according to social and

economic value, ultimately. But the fact of the matter is, is that, you know, socialized medicine, and one of the things we argue in the book is that there isn't actually like a form of true socialized medicine that exists. You know, the NHS people call socialized medicine, but it fundamentally is not. It's a system that, you know, I think is definitely on the spectrum that's much closer to, I think, what we would call true socialized medicine. But the NHS still has a lot of work to do, and they've been fighting really ongoing, aggressive attempts to privatize the NHS for decades now. And ultimately, the idea of a kind of debt and eugenic burden is really an excuse to say why certain classes of people are not entitled to the same kind of support.

And it really comes from some of the early arguments for and against socialized medicine. And you see it, again, brought up every single time health reform is mentioned in this country. I mean, I mentioned the ACA right at the beginning and how something that was really difficult for me early on in being sick was people saying, you know, talking about the ACA, not knowing that I was sick and saying, well, you know, fuck people with pre-existing conditions, they're going to raise my premiums, right? But that dynamic of someone with a pre-existing condition or someone with more healthcare needs, raising your premiums is not a law of nature, right? Like that's a specific economic dynamic

that we've decided in terms of trying to generalize risk, in terms of turning risk into profit. And instead of recognizing it as an attempt to commodify risk, we see it as a natural reflection of nature, right? Of human worth, of the way things are. And part of that has to do, you know, with the ways that the eugenic movement still exists in our society and the ways that eugenic ideology kind of never disappeared, but just really kind of fell out of fashion or were rebranded within the academy. But ultimately, you know, there's a kind of capitalist logic at play here also, which says that anyone who has needs that are too great, by some narrow definition of too great, they pose a risk for everybody else. And that to stop and make sure that everyone has the care that they need is not fundamentally compatible with capitalism, with American capitalism in particular. And so that's why I think, you know, we're really trying to say, like, one of the things that's important to understand about whether it's things

like proposals for national health insurance in the United States, where you have some of the earliest proposals for national health insurance in the United States are not proposals that are coming really necessarily towards building a socialist state or building a communist state. They're coming as these kind of immediate stopgap measures. So when we're sort of talking about how do we remove some of these value judgments that harm people, that enable industries to extract from them, that enables the slow death and the organized abandonment of all sorts of populations that forces workers and non-workers alike into substandard living and working conditions. How do we actually tackle that? Well, it's way beyond health finance, and it has to involve a radical

redefinition of what worth and value are that involves a rejection of the idea that any one person's needs take away from the whole. So we've done a really, I think, a pretty thorough examination of health capitalism up to this point, you know, exploring the creating of, you know, surplus populations we've talked about, exploring organized abandonment and extraction of the surplus. We've talked about the sort of bifurcation of deserving and undeserving surplus populations and how pharmaceutical and health companies work as sort of a bureaucratic layer of sort of state capitalist hegemony and global domination.

And I think we've provided some, you know, I think pretty concrete examples that can help sort of concretize these somewhat abstract ideas. And I hope it's making sense to some of you out there, you know, why things are as fucked up as they are. Rotten roots bear rotten fruits. And it's not your fault. And it's not your fault. You didn't make the wrong choices. No. And that's another thing to, yeah, definitely the sort of individualizing of all of our problems so that we think about them as personal problems, personal failures, instead of thinking of them as structural issues. And I think that's one of the biggest barriers to, you know, beginning to create a mass class consciousness and starting

to think about these things in terms of systems. And, you know, I think that's something that the book does a really amazing job at. And we try to do that with upstream as well all the time. And yeah, so I think at this point, I'd love to focus on the last two chapters or the last few chapters of the book, which actually were my favorite part of the book was when you talk about SPK. And so I'm wondering if you can sort of, yeah, just tell us about SPK and why you see them as an ideological precursor to health communism. Absolutely. I'm so glad that you liked those chapters. There are two chapters that are very special to Artie and I, and they're a little bit different in some of the other parts of the book. It's a history of the group SPK, which is a patient group that formed in Heidelberg, West Germany in 1970.

SPK stands for the Socialist Patients Collective. And the reason why this history is in health communism is really because there's not another place that we could point you to where you can read this story. There's not an account of SPK like the one that we've put together, which is trying to contextualize SPK within a couple historical movements, one of which is something called anti-psychiatry or sort of the moment where biopsychiatry and anti-psychiatry are vying for dominance. In kind of like the late 60s through the late 70s, you have this real moment of upheaval within psychiatric practice that sort of comes as a result of the introduction of a lot of novel pharmaceuticals starting in the late 40s and 50s. Things like Thorazine that were sort of shifting the role of a psychiatrist within the medical system. And the Socialist Patients Collective was a group of mad people. It was a group of patients that formed an organizing collective within Heidelberg Hospital.

And they argued in their manifesto, which is often translated in English as either turn illness into a weapon or to make an army out of illness. They said that patients, you know, they deserve care. They deserve a role in their treatment. They deserve a role in the research and the knowledge production that centers around who they are. And they deserve a role in understanding and defining what treatment and therapy are, and really sort of rejecting the idea of patients as passive receptacles. They're to receive therapy, but as real actors who are a central, not just object within the care encounter, but are a driver and in control. Because that's one of the things that I think people, you know, maybe until you're sort of spending a lot of time dealing with the healthcare system, Maybe until you're spending a lot of time dealing with the healthcare system, I think it's hard to totally understand the ways that your own autonomy and your sense of self become true story of SPK because a lot of the accounts of SPK that you

might read, you know, if you read those two chapters, you go and read those two chapters after you listen to this and you're like, oh, SPK is so cool. I want to read more about them. Oh my goodness. So much of it, so much of it is like these crazy left-wing terrorists who you know just are absolutely wild and have all these ridiculous ideas you know part of it is that spk and the work that they did was criminalized and so they kind of exist in the historical record with a very biased um framing and account so we try and and correct that and we try and show how, you know, they were organizing around the principle of patients as actors in the scientific process, not just fodder for, you know, growing a doctor's career, not just like the raw material for medical innovation,

innovation, but people with real lives, not objects, right? And so, you know, this critique was really a huge challenge to the budding biopsychiatry movement that was trying to deal with, you know, as I was saying, this is a moment of professional upheaval, psychiatry is really changing. And this is also a moment where patient organizing was sort of ascendant. And there were a lot of groups of people who were organizing within asylums, which in the 70s, which again, was much more broadly the way that people with mental illness lived was institutionalized. So you had folks organizing together in asylums and, you know, sort of asserting their value and critiquing the relationship that they've been sort of forced into both in terms of treatment, whether that's coerced or forced treatment, whether that's restraint, chemical incarceration,

sedation, or denial of care, denial of certain types of treatment, or, you know, treatment that only comes in carceral forms, right? So you sort of have this moment where the authority of psychiatry is changing. The authority of psychiatry is being questioned. And there's a lot of money at stake also in the rehabilitation of West Germany during this point. You know, this is during the Marshall Plan. This is in the post-war sort of imperial mode where the United States is sort of acting as this capitalist imperialist to parts of Europe, really trying to shape the narrative post-World War II. And so I think one of the most important things that readers can

take from SPK's work is really their kind of interrogation of why the doctor-patient relationship is the way it is, which is, you know, the way that most of us really still experience medical encounters, which is a kind of relationship of direct control. And fundamentally, this relationship rests on what they call a fascist fantasy of health. You know, the idea that there is a perfectly healthy person somewhere and that the doctor, as the kind of therapeutic authority, needs to always be in that position of the healthy person who has kind of dominion over the sick person, you know, and the patient on the other end of that spectrum never has that kind of power and is not seen as a kind of participant in their own care. And SPK's critique tried to really kind of wake people up to

the fascist nature of this dynamic. They saw a lot of their work, you know, as a kind of therapeutic political praxis. They would come together, they would talk about the things that they're experiencing. You know, they would, a lot of the techniques that they actually pioneered are very similar to what you might see in like a contemporary group therapy practice or, you know, a kind of a grief group or a support group. We have a lot of peer-to-peer, self-led, self-directed support oriented around thinking about yourself and your symptoms, not just as personal, but also as a kind of social and political axis on which to locate yourself and understand the world. So they said it was trying to sort of turn, I love this quote, happy unconsciousness into unhappy consciousness. And, you know, that there was a really important

political transition that could happen to any person who has sort of health needs or a body, I guess. the political identity, but that it was not de facto what granted you the political identity, and that you really sort of weren't automatically, you know, brought in from being sick to being sick under a kind of revolutionary praxis, right? Like, but that you could actually deliberately undertake a process of radicalization in which you start to try to look at your identity, look at your symptoms, look at the way that your disease and your treatment and your relationships around your care are located within political economy, and try to understand how that structure is influenced by such a wide range of social, political, and normative assumptions and expectations that don't really have a lot to do with you, but have everything to do with labor, discipline, and capitalism. And really what SPK

said mattered about therapy for the medical industrial complex is being able to repair the body for work. You know, they said we want treatment, we want care, but we don't want care that's given to us only because it makes us better workers. We deserve and demand care that's for us. Care for its own sake. Right. And, you know, if we want to abandon eugenics and abandon the legacy of the Nazis with regard to, you know, how the Nazis impacted Germany, how the Nazis sort of shaped health and this kind of eugenic project, how the Nazis sort of shaped health and this kind of eugenic project, where better to kind of levy this critique than in the heart of Heidelberg Hospital, which is one of the places where some of the earliest pathologies begin to be cemented. This is an institution that is known for the work of a guy named Kraepelin, who is called the grandfather of the DSM. And his big innovation is sort of taking what was

thought to be one disease, taking sort of a totalizing version of madness and breaking it into these two distinct categories, kind of a manic depression framework and what he called dementia praecox, which then became schizophrenia. And so, you know, it's really one of the origin points of what becomes the kind of enormous taxonomy of mental illness pathologies that we understand today. Actually, you know, the tradition of this kind of study and categorization and the work that goes into demonstrating its value begins in Heidelberg Hospital. So it's almost like a kind of poetic thing that SPK started there. And ultimately, you know, it's a really important symbolic institution, also in the history of biopsychiatry, which is emerging at the time. And there was a lot of, there was a high stakes to the critiques that SPK was making. So, you know, they really felt like, okay, here we have an opportunity to kind of create this

revolutionary practice to turn illness into a weapon. And ultimately, you know, they were doing things that we would right now recognize as pretty average mutual aid, right? Like support group work, peer support, peer led work. They were doing things like interrupting arrests, providing protection for people who were fleeing domestic abuse or abuse at home. They were creating a space where people who were unhoused were able to get care and treatment. They were receiving and providing essentially no-strings-attached support. And this was a

very experimental model that they were just getting started on when they were criminalized, arrested, and kind of put on the show trial. And then that criminalization is then used in academic literature that examines terrorism and looks at the European quote-unquote terrorist movements of the 1970s, the anti-capitalist terrorist movements, and takes the pathologization of SPK and tries to create like a pathology to understand all left movements through their fucking biased interpretation of SPK as this group of sort of crazy, unhinged, deranged, anti-capitalist, quote unquote, lunatics, right? And so we talk about not just sort of what SPK did, but what purpose silencing them served in the moment and why

their critiques were so challenging to the political economy of the 1970s, such that, you know, the record of their work is really, you know, only exists in their own words. And many of the accounts that talk about their work, you know, unquestioningly reproduce the idea that, you know, this was a group of sort of bad actors who were there to essentially take advantage of people with mental illness and use them as pawns in some sort of revolutionary chess game, which is ridiculous, but, you know, was treated as a totally serious accusation at the time. I think it's really remarkable, like, yeah, that whole story, and you've only just sort of touched

on it here. So for folks who really want to dive deep and really understand like what happened to them, the full boot of the state and multiple states, I mean, you know, it's all part of like Cold War anti-communist ideology, which I think certainly played a role in the US itself. Like for folks that want to get deeper into it, check out the book. It's really fascinating history. Yeah, it's like 20,000 words, just this two chapters, I think. And SPK's approach to healthcare also actually reminds me a little bit of Paulo Freire's ideas in like Pedagogy of the Oppressed and, you know, the more dialectical relationship between teachers and students, but apply to like healthcare providers, or, you know, those receiving healthcare and blurring those lines a bit and exploring it as a two way process, which I thought was really fascinating. I know so many of us have had such terrible experiences with doctors and, you know, the whole process is just, it's made to make you feel little, made to make you feel like you don't know what your own problems are and like erasing your lived experience oftentimes. And so I thought that was just a

really beautiful example of, you know, how it could be done. And it is really tragic that they were just, like I said, the entire boot of the state was just trampled down on them because they tried to rethink things. And another thing too, that I'm very appreciative of you for introducing me to the term sick proletariat. And so there's a quote here that I'll read. It's very short. The idea of the sick proletariat identifies that capitalism owns even our bodies. And only once we apply class analysis or perspective to this fact of collective illness can we create a truly revolutionary struggle? And so I just have a couple of more questions. And this one might feel a little bit like a tangent. I thought it was

really interesting because a few months ago, we got like a listener commented on one of one of the posts on Instagram that I had used a screenshot of a tweet or a meme or something that that used the term working class. And there was a bit of a pushback. And it really get it at first. And in reading your book, I'm starting to really think of, you know, that the term working class, like, you know, working, right? Like it almost in a way reinforces a lot of these ideas that we've been talking about. And, you know, I don't know, maybe it's time to like break the dam around some of these conversations and outdated terms, you know, Marxist terminology specifically, you know, yeah, this term working class. And, you know, I'm always inspired by, you know,

Fanon talks about stretching Marxism, right? And so we're always rethinking Marxism. And so I also don't want to get like too into this fear of like language policing or anything like that. But I guess I don't have a specific question aside from just like, I'm wondering what your thoughts are on that. I so appreciate hearing that the book really kind of helped you understand why someone might hear, you know, working class, which for a lot of folks on the left, I think we just default to, right? It's part of the norms of the left, how we talk about politics, what we share as common language. And ultimately, you know, as we've been talking about ableism, you know, racism, these are all sort of values and ideas that conceptually, you know, we understand

as kind of abstract concepts, but they also materially are a part of all sorts of parts of our lives, right? And these ideas through language, through law, through policy, through norms become not just a kind of symbolic utterance, but they're reproduced socially and structurally, like in so many aspects of our lives. And so when it comes to like not saying words like crazy, or when we use the conceptualization of the working class to try and think about how can we stretch that to also include non-working people.

In some ways, some people, you know, take that and they're like, ah, that's just political correctness. But it's actually about building solidarity. It's about finding new ways to find common norms on the left and allowing our norms to evolve and expand to meet our needs. And I think one of the things that we really tried to do, you know, starting many years ago with Death Panel and with all the work that we've done, myself and all my collaborators, is that there just aren't norms

around how to think about disabled people and Marxism. As I mentioned at the top, you know, the Marxist conceptualization of surplus population was about people who were unemployed. People who were like me, who were outside the workforce, were not even in the register of that initial conceptualization. And part of that is because of how disability theory has evolved over the last hundred years and what it was like when Marx and Engels were writing was completely different, right? Like our understanding of disability that's contemporary is very new. People in our lifetimes are going to be

institutionalized for their entire lives. And it's our job as leftists to free them all, people in prison, people in jail, and people in psychiatric and intellectually and developmentally disabled inpatient facilities, right? Like we have a kind of left agenda that has grown and grown to accommodate the different ways that the left movement has changed. And I think one of the things that the left has not had for a very long time is norms around illness and disability and how to consider these things politically, not just as contingencies, but as strengths, as tools, as weapons, as ways of building solidarity, and as a kind of common ground that is something that,

frankly, is kind of underexplored on the left. I mean, one of the things that we talk about in the book is how, I'm trying to think of a nice way to put this. So, you know, there's a kind of trope, of calling health justice organizing like baby leftism or on-ramp leftism or kind of, you know, it's, I think a lot of people talk about Medicare for all is like, oh, well, people came to the Bernie Sanders campaign for Medicare for all, and then they didn't get it. Right. But I think that the thing that we have to realize is that health is actually the central axis around which the identity of the worker is created. And so when we talk about the working

class, we're also talking about people who are non-workers. And as leftists, the only way we can improve conditions for the working class is to improve conditions for the surplus class and the working class. These are two classes which for centuries have been denied the possibility of solidarity. And the norms are not there. And the left has a lot of work to do, self-searching, learning. I mean, it's going to be a process. And I understand that it might seem like, you know, one more issue that the left can't take on. But ultimately,

what we hope that people can understand is that the conceptualization of the working class that doesn't include disabled people or people who are non-workers, whether they're retired, whether they're forced out of work, you know, that's an incomplete vision of the true working class. And if we want to actually understand the class relationships that define what oppresses the working class, we need to understand what oppresses the surplus class. I mean, we've gotten some pushback. People have been like, I don't know if you fully justified the surplus population as a class. I disagree. I think if we're going to really, really kind of classic Marxism here, and we're talking about a class as being about someone's relationship to

the means of production defined by how their life is mediated by their relationship to that production, then the surplus population is a class. It's a class that we have refused to acknowledge and work with in so many ways, but which is so ripe for left analysis and ready to be a part of left norms. And there have been people, you know, for years where this has sort of become, you know, ascendant and resurgent. You have moments in the 1970s, you have groups like SPK, you have people like Marta Russell. And ultimately, you know, it's important to remember that disability culture as we know it is really new. And the norms for sort of how to understand these things from the dominant left just aren't there. And it's a project that I think, you know, leftists right now need to embrace. We are living in an era of unprecedented biopolitical control of our labor power, of our labor relations, and of our ability to work without being exposed to sickness and illness and the debt that comes with it. This is a debt scheme.

is a debt scheme. And to fight back, we have to begin to understand the full spectrum of the working class's relationship to capital, which again, needs to incorporate an understanding of the class below the working class, of the surplus, of those who fall through the cracks, who fall out of the working class, who are denied access to the working class ever and never have the opportunity to become a part of it, right? Like there are so many ways that labor exists beyond the traditional relationship of employee-employer. It's important for us to sort of continue to keep pushing and expanding these frameworks. And it's not about being nice or doing it for, you know, making sure to not hurt people's feelings, because that's also important in terms of building solidarity. But we're talking

about mere important structural reasons why a Marxist analysis is actually incomplete without an analysis, not just of the working class, but of the surplus class too, and what the relationship is between the sick proletariat, the proletariat, and both of them, and the bourgeoisie, not just the working class alone. Yeah, beautifully put. And I couldn't agree more. And I think your response to that feels like it could definitely serve as your final thoughts and reflections. But I didn't specifically ask you what your final thoughts and reflections are and if there are any final things that you want to convey to our listeners. So I'm just going to read a couple of very short quotes from the book and then ask you if there is anything that you'd like to add in closing, or we can also leave it there.

So yeah, you write that illness is the only possible form of life in capitalism, which I thought was just such a powerful and resonant statement. And then, and this is echoed in your previous response, but you write deviance, the surplus and the sick form the central class that can bring about the fall of capitalism, which I also thought was super powerful. So yeah, I'm wondering to close out if you did have any final reflections or thoughts that you would leave with our listeners or yeah, and we can also just leave it there too. Well, first of all, thank you so much for reading with the book and deeply engaging with it. It's been such a wonderful conversation. And I think the last thing I'd like to leave folks with is just

don't ever forget that everything about your life is political and that politics, all politics, involves conflicts over meaning. And even when there is agreement about the observable events, the things that we all see, there are conflicting assumptions about the causes, the motives, There are conflicting assumptions about the causes, the motives, the consequences. In politics, the health and looking at the ways that we can destabilize capitalism by severing that relationship in all of the different iterations and ways that it has become sort of developed and colonized and entrenched and systemized and institutionalized and financialized over, you know, hundreds of years. And that's a big task. But political action and support aren't shaped by what can be seen, but by what must be constructed, what must be imposed if we're to

survive, if we're to live better, less brutal lives, what must we do? And ultimately, you know, there is no way to establish the validity of certain political positions to people who have a material and a moral reason to hold a different view than you. And it's okay to say, you know, I want Medicare for all, and I want something way more than that, even if everyone in your life says that that is impossible and never going to happen. Because ultimately, you know, most people think that the world happens to them and that language is static and we have no control, but language is a powerful tool and it shapes the world that we experience. And by saying something is impossible, like saying Medicare for all will never happen or it costs too much. This is a self-fulfilling prophecy. So also, you know,

if we want to build a left that can actually tackle with the things that make us sick, that consign us to maiming and slow death and a brutal,, and more cruel life than is necessary, then we have to begin to sort of expand our understanding of the political economy of health to really reflect how it actually is and how it's become, especially under all of these years of neoliberalism, where no alternative has existed on the political horizon, and nothing has seemed as unmovable and unchanging as the power of private insurance and the financialization of health. But ultimately, if we want to work towards the fall of capitalism, we have to find these shared meanings. We have to make sure that our demands align. The demand is all care for all

people. Just to put it simply, we determine what health is, what care is, who deserves it, and who pays for it. There's no natural order of health. It's not destiny, austerity, slow death, social murder. These are not laws of nature. These are choices, and they reflect the values embedded in our political economy. And those are values that should embarrass us. It's time to leave that behind for something better that recognizes our independence as a strength, not a weakness. You know, we have to take the words of SPK seriously. You know, we have to take the words of SPK seriously. We have to turn illness into the weapon that pierces capital's shield and, you know, build solidarity between the surplus and we've been fighting for in left health justice movements for over a century.

You know, the systems and the capacities of health and capital that we talk about in the book, they're only going to get worse, more extractive, more violent. And as we say in the book, like, there is nothing to wait for. There is no better time. It's time for the left to begin to think about health differently and to recognize the role that it plays in all of our oppression, subjection, and in the continuance of the capitalist political economy. you've been listening to an upstream conversation with beatrice adler bolton co-host of death panel podcast and co-author along with arty virkin of health communism a surplus manifesto please check the show notes for links to any of the resources mentioned in this episode. Thank you to Carolyn Rader for this episode's cover art and to Fugazi for the intermission music.

Upstream theme music was composed by Robert. Upstream is a labor of love. We distribute all of our content for free and couldn't keep things going without the support of you, our listeners and fans. Please visit upstreampodcast.org forward slash support to donate. And because we're fiscally sponsored by the nonprofit Independent Arts and Media, any donations you make from the U.S. are tax exempt. Upstream is also made possible with support from the incredible folks at Resist Foundation. For more from us, please visit upstreampodcast.org and follow us on Twitter and Instagram for updates and post-capitalist memes at Upstream Podcast. You can also subscribe to us on Apple Podcasts, spotify or wherever you listen to your favorite

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