rs21 member Shiraz Hussain reviews Health Communism (Verso, 2022), a new book written by longtime disability justice and healthcare activists Beatrice Adler-Bolton and Artie Vierkant.

Health Communism. Photo of strike march from St Thomas’ Hospital, London 1 May 2023, by Steve Eason.

Beatrice Adler-Bolton and Artie Vierkand, Health Communism. Verso Books, 2022. 240 pp, £16.99.


This book will be of great interest to any socialist, and in particular to those of us in Britain who want to understand the private interests which are threatening our NHS.

The book’s central argument is that true socialised health care, defined here as ‘all care for all people’, cannot be achieved under capitalism. The difficulty comes from capital’s view of ordinary people. Unlike members of the ruling class, who are ends in themselves and do not have to justify their existence, ordinary people are seen as instruments whose function is to generate a profit for their employer. This leads to a definition of health as the capacity to perform work at the level required by the employer. A person who is, on average, unwell for one day in the working week is not generally considered fit for employment although they are able to work 80% of the time.

This definition of health has determined how the ruling class sees its subjects. The Elizabethan Poor Law of 1560 introduced a threefold classification – fit for employment, temporarily unfit and permanently unfit. The temporarily unfit were to be made fit for employment as soon as possible. Where this could not be achieved they were transferred to the category of the permanently unfit, who were allowed only the cold comfort of charity. The system was threatened by a folk demon – the workshy rogue who preferred thieving, begging, scrounging or malingering to honest toil for the benefit of the ruling class. This made it necessary for potential recipients of charity to be treated with the greatest suspicion.

The capitalist welfare state (introduced by Bismark who understood the importance of healthy bodies for the battlefield as well as the workplace) adopted this same classification along with the looming spectre of the scrounger/skiver/malingerer forever threatening the honest worker and taxpayer.

A recurring motif in the book is ‘extractive abandonment’. People who cannot work are abandoned by the state, classed as a debt or a ‘eugenic burden’, but they are still a source of profit for the private companies who contract to provide testing, care or medical services. The ‘eugenic burden’ in this context would be the prospect that people with congenital illness or disability might propagate their so-called ‘faulty’ genes. The care sector in particular (which falls outside the NHS in Britain) generates very large profits for its shareholders by managing costs. Rather than being cared for in their own homes patients are typically housed in small rooms in multi-occupant facilities and looked after by workers on minimum wage.

Medical care in the hands of big capital has played an essential role in the export of Western models of private health to countries in the Global South – a continuation of the colonial project by other means in which the entire population of a country can be marked for profit extraction.

Through their relationship with the World Bank and the World Trade Organization, health insurance companies seek the privatisation of health and welfare programs in developing countries in order to gain access to their markets. The drive for profit in this area generates an ideology which defines ‘health as a private responsibility and health care as a private good’, a definition which equates an inability to pay for health care with personal inadequacy.

Through the insertion of intellectual property rights into international law, developing countries can be prevented from developing their own cheap generic versions of essential drugs and instead accepting the expensive patented versions developed by western pharmaceutical companies which people in these countries can ill afford. An example given is the case of the Mexican company Syntex, which, having developed a method of synthesising steroids more cheaply than its American rivals, was only allowed entry to international markets after being bought by an American holding company.

Another side of pharmacology is seen in the ‘war on drugs’, which originated in the Cold War accusation that China was flooding the West with heroin in order to weaken its population – an accusation that was hypocritical as well as baseless, given that it was Britain and France that had fought two wars against China in the 19th century to uphold their right to sell opium to the Chinese population, and that it was the USA that had become the main supplier of narcotics such as cocaine following the second World War.

The ‘war on drugs’, with its objective of extending the power of America’s ruling class both domestically, through punitive legislation, and internationally, through pressure on other countries to fall into line, was thus framed as a patriotic endeavour and woe betide anyone, in the USA or elsewhere who expressed any doubt or disagreement. The accompanying narrative, which views consumers or sellers of illicit drugs as morally inadequate people who pose a threat to society and are to be dealt with through a regulatory/carceral approach, continues to inform state policy in most countries to the present day. And needless to say, these problematic people are a rich source of profit for the private companies who provide services to the carceral sector.

This links to the remaining category of problematic person discussed in this book – the ‘mentally ill’ person. While the book does not claim that mental illness is a myth, it correctly draws attention to the historical fluidity of the concept – homosexuality was classified as a mental illness until the 1970s. Historically it has been easy for people considered troublesome and unruly to be committed, particularly, as examples in this book show, if they are female or members of ethnic minorities. The chapter on madness sketches the sorry history of ‘care’ for these people, from the barbaric practice of lobotomy, through electro-convulsive ‘therapy’ to the non-consensual administration of drugs, for example Thorazine. Thorazine was first used in the psychiatric context to bring about behaviour modification in a labourer admitted for ‘making improvised political speeches in cafes, becoming involved in fights with strangers, and walking around the streets with a pot of flowers on his head, preaching his love of liberty’.

The seventh and eighth chapters provide a comprehensive account of a challenge to carceral sanism (the view that mentally ill people are dangerous and should be locked up) mounted by the Socialist Patients Collective in Germany in the 1970s. This group arose in the context of the anti-psychiatry movement, refused the distinction between physical and mental illness, and grounded its patient-centred practice, in which the course of treatment was agreed with the patient, in radical political philosophy. What strikes the reader in the account of how this group was accused of links to terrorism, prosecuted, silenced and largely erased from history, is the response of a ‘liberal democratic’ government to a challenge to capitalism and the structures of authority that underpin it.

The book closes with the assertion that capitalism will only be defeated by a movement that centres these ‘surplus people’ and refuses the narrative that classifies them as a burden to be marginalised and abandoned. In the context of Covid and other illnesses that may at any time transfer any one of us from the category ‘worker’ to the category ‘long term sick’, this is surely a timely and sound argument.


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