Fragments of an Anarchist Public Health: Developing Visions of a Healthy Society
Tuesday, July 07, 2009
[Contribution to the Reimagining Society Project hosted by ZCommunications]
Taking note of intensifying anarchist social movements worldwide, the goal of this paper is to provide some vision through relating the objectives of these movements to discourse going on within the area of public health—specifically, taking into account these movements’ social, political, and economic goals, impact, and implications toward considering what functionally makes for a healthy society. The intention of this paper is both to work toward developing a proposal for considering the merits of radical and utopian ways of thinking and practice within the domains of health care and public health policy, and discuss a developing awareness that such currents of thought are (re)emerging worldwide and have been reconsidering and challenging hierarchical institutions and industry across the board. Development is needed in terms of envisioning functional health care and (more broadly) a healthy society by discussing where things can go from here.
This essay was adapted from a much longer paper (my graduate thesis) that had the following trajectory. It began with a series of arguments as to the definitions, aims, relevance, and scope of radical anarchist thought and praxis (grounding its early articulations in classical liberalism and blossoming into libertarian socialism). It then looked at the challenges anarchist theory brings to bear on health care and public health policy as it stands, in order to ultimately argue for a more horizontal and participatory conception of public health. These challenges were illustrated through comparisons with the widely-accepted work of Lawrence Gostin regarding his advocacy for strong public health law (more mainstream and much less radical in formulation). As I contrasted Gostin’s approach with the standards of a participatory society, Gostin came to model the framework for what I consider orthodox public health (that is, public health with a liberal but non-radical stance at best). I then challenged the non-radical, orthodox approach by discussing some of its inherent problems, namely (1) the manner in which public health tends to limit itself by narrowly gravitating toward lifestyle when enacting its interventions as opposed to focusing on more broad structural and empowering interventions; (2) how it tends to operate from a cultural disposition that has blocked much anarchist discourse from the academy in regards to discussing radical social theory, and similarly from public health dialogue; (3) how it tends to largely accept capitalist market economics as foundational for economic considerations (to be mitigated perhaps, but not fundamentally challenged); and (4) how it tends to be plagued by conflicts stemming from an overemphasis of hard sciences and an underemphasis of softer, social sciences.
In terms of moving forward and pursuing alternatives, the vision I am after advocates for incorporating more holistic radical leftist theory—a multi-issue, -focus, -tactic, growth-oriented, revolutionary perspective encompassing the principles of anarchism, the ideals of participatory society, and horizontalism—into public health discourse in order to piece together a vastly more robust and effective conception of public health and thusly work toward a more healthy society as a whole. This vision considers the feasibility of such radical leftist theory in the current context of the greater society, the unique nature of the anarchist project, and how conflict resolution (both internal to the movement and external in the greater society) is understood within such a context. It offers a few illustrative observations of prefigurative health movements that, while not necessarily vocally anarchist, largely abide by the principles and (through doing so) open up practical alternatives to orthodox health care and public health policy. It then offers a few brief considerations of what the social framework of health-focused anarchist organizations could look like, how they would operate, and how they would interact with more conventional institutions. It finally concludes with pragmatic considerations of what the movement can do today to bring this about—focusing directly and simultaneously on immediate efforts toward (re)creating social structures that promote freedom, solidarity, diversity, self-management, justice, participation, and overall healthy communities, and dismantling social structures that perpetuate alienation, disenfranchisement, disempowerment, and exploitation.
The notion of “fragments” in the title is drawn from much of David Graeber’s social, anthropological, and anarchist analysis. He offered a similarly titled work (Fragments of an Anarchist Anthropology) that ignited much of my curiosity and excitement behind writing the longer version of this essay. Much of his articulations of contemporary anarchism find resonance in this effort, so his ideas consequently offer much of this paper’s backbone.
Picking up the Pieces: Developing Radical Theory and a Vision of Healthy Society.
Vicente Navarro said that for a complete and functional national health policy to exist, public health interventions that emerge from this arrangement should be three-pronged: structural interventions that deal with the political, economic, social, and cultural determinants of good health; they should concern lifestyle determinants that focus on changes in individual behavior; and they should include socializing and empowering determinants that encourage individuals to become involved in collective efforts to improve the structural determinants of their health.[i] If we carry the importance of empowerment to its fullest logical extent in terms of health care and public health policy—that is, seeing the need to build real conditions for self-management, attacking the roots of inequalities instead of just minimizing their effects, addressing market forces and norms of competition that have invaded every facet of social life, and realizing that these conditions are systemically perpetuated through the institutions we create but not intrinsic to the societal roles these institutions need to fulfill (this will be expanded later)—we can pragmatically and rationally consider more utopist visions of how health care institutions (and institutions throughout society) can be restructured.
Radical social theory is that which, as the label implies, seeks to get to the root of various social problems with the aim of eradicating their fundamental causes as opposed to just managing their effects (e.g., targeting capitalism instead of merely its negative externalities, or pursuing sound public health practice by employing the precautionary principle[ii] instead of accepting the negative externalities of capitalist industrial processes and merely managing—at best—the resulting poor health of the population). Often, because such jarring critique calls for fundamental changes in the basic ways we do so many things, the ideas that sprout forth are often those of sensationalized revolution: romanticized images of ultimate confrontation, highly-frictional social readjustment, and sectarian clashes out in the streets (as Graeber pointed out, all the elements characteristically included in both the classic misconceptions of active democracy and in the current misconceptions of the active anarchism—essentially chaos in both forms). As so much of radical theory historically talks of grand theatric revolutions, empirically however, such misconceptions of change have made change all the more difficult to pursue. Now when radical theory is brought up, the amount of baggage that must be unpacked and dealt with is often stultifying—the romanticization/bastardization (either way) of social change as cataclysmic ruptures; the incompatibilities of many leftist theories; the predominance of the stylized revolutionary image; the lack of vision beyond social confrontation—all collectively leaves many of those who would otherwise support attainable change thinking that there are no realistic and practical societal alternatives. Fortunately, learning from history, many reconstituted surges in revolutionary and leftist radical thought today take very critical stances on past leftist movements—consequently unearthing much more fruitful information and discussions around the nature of building a healthy society premised on participation.
Unifying Radical Social Theories to Affect Change.[iii] Radical theories revolving around social change have been problematic. They emerge out of constituencies enduring certain oppressive situations that are unfavorable to the extent that they are deemed not only worth talking about, but worth bringing into question and framing critical understanding around. Unsurprisingly, as they all arise out of specific experiences and as they all profess to explain the world, the narrowness of the constitutive experiences from which they grow becomes their Achilles’ heel as the theories are shaped and evangelized. This does not mean however that they are not ultimately useful, should be scrapped, or even that they are flat out wrong, and it most definitely does not mean that Margaret Thatcher was right when she said “There is no alternative.” It merely means that considerate reconciliation is necessary between them and having the flexibility and openness to consider what makes for a good theory is a good way to pick up the pieces.
A theory is a tool that explains, predicts, and/or guides situations. To the greater extent that it can do these things, the more useful it is. Unfortunately, radical social theories have historically been too confined to narrow experiences. In other words, they may serve to explain, predict, and guide actions taking place within those particular social frameworks, but fail to accurately conceptualize human action more broadly. If you look at how Marxists (to use one example) focus on class and economy, they tend to frame experiences as derivative of that understanding. While they may be well aware of gender and racial oppression (for instance), at the core of it all, the Marxist agrees the economy and class struggle are at the base of, and are accommodated/replicated in, every other social ill. In this sense, the Marxist professes that class struggles are so powerful that they permeate every other facet of life and experience, and if only the economic structure was to be changed, race and gender relations would ultimately be altered as well. A feminist may say the same thing, just replacing classism with notions of sexism: do away with sexism and gender hierarchy in the kinship sphere of social life (that deals with socialization, education, etc.) and that will subsequently dissolve the crippling patriarchy throughout the economy and political spheres and all the ills that emanate. Needless to say, the problems here in this context are easy to see. The degree of each of these theories’ usefulness depends on the relevance of the concepts upon which they are built. Concepts—being merely slices of reality drawn out for purposeful attention—are born out of experience. Good concepts will be relevant to specific priorities, concerns, and aims; however, the narrower the experience is from which they arise, the less primary and acceptable they will be to a more diverse array of people and situations. This has been a formidable source of tension in leftist organizing throughout its history.
The vision for a healthy participatory society would have to come from robust, unifying, and diverse understanding that somehow coalesces other radical social theories and consummately values everything in terms of promoting a fully participatory society. As such, the radical theory that emerges from such integration deals compellingly with that which is useful for democracy/participation (basic anarchist principles in a libertarian socialist sense), and informing this process is an empirical understanding of what is undemocratic. As a result, dealing with what is and is not useful for a democracy serves in highlighting a democratic constituency as well as extracting relevant concepts that pinpoint a democratic society’s basic features. By the nature of what it is that needs to be brought about—a truly participatory society—the radical theory that would help craft its vision would be a multi-issue, -focus, -tactic, growth-oriented, revolutionary perspective.[iv] What follows from this standpoint is fundamentally a value-based approach toward institution-building with participatory/democratic values at its core.
Understandably, reshaping society in such a way sounds daunting—just trying to demarcate a sizeable constituency that all share the same values—but this theory is not dogmatic. All values do not need to mesh, but there are a few overarching values that are endemic to a functional democratic society and as such should be non-controversial if democracy is the gem we are after. Among these fundamental values are solidarity, diversity, self-management, liberty, justice, participation, and tolerance.
· Relationships in a democratic society should be based on solidarity and cooperation as—all other things aside—cooperation would be preferable to anti-social personal relationships infected with abstract market values and based on competition.
· We value diversity in choice, resources, as well as ideas.
· We value self-management in that people should have a say in decisions to the extent that they are affected.
· We value justice in terms of fair and equal treatment.
· We value participation in that people be involved in decision making without distortion or coercion (see self-management), but in ways that accommodate for different levels of people’s political stamina.
· We value tolerance in that we accept that there are other ways or doing things and accommodate when possible.[v]
These are the fundamental principles that receive general acceptance in that most people agree having them in a society preferable to not having them. More than preference however, these are not values that merely sound good, but rather they serve functional and necessary societal purposes. For a properly democratic society, where people would be without rulers, logic implies that there will have to be certain mechanisms constituting the democratic situation that must be in place for it to function as a society. That is, these are the principles endemic to a properly democratic manner of existence that must be in place (that is, inculcated into all the spheres of life: the economy, kinship, polity, community, etc.) for such a situation to continue as social organization.
So what kind of robust radical theory could all of this boil down to? First, unlike other theories that take the laborer, the woman, or the ethnic identity to be at the core, this theory broadly places the person at the center. Refusing to account for people only as functions of economic class status or their biological sex, this personalizes the theory much more dynamically as it takes those factors into account yet also makes room for personal needs, aspirations, capacities, knowledge, energy, etc. as all important slices of reality. Next, surrounding the person in the theory are various social spheres. These include the economy, kinship, community, and polity, but may very well include others. These specific spheres fulfill societal functions like other facets of society, but are distinguished and included here by necessity due to the fact that they exist in some form in every society, and their functions are unique to institutions in that they could not be accomplished merely person to person.
This is made more obvious if you consider their basic functions. Economy deals with production, consumption, and allocation of things; kinship concerns the nurturing, socializing, reproductive, etc. aspects of life; polity deals with laws, execution, and adjudication; and community deals with cultural identity. As such, stripped down to their basic functions, we can begin to conceive of redrawn images of these in ways that still complete their basic functions, but do so along the lines of participatory social values. This approach is ultimately important not in just understanding the world, but changing it from the point of view of bettering the worst off and making the entire situation qualitatively better for all involved. These are the targets in terms of social change.
With this understanding, the goal is now to conceive of an economy that deals with production, consumption, and allocation; kinship that concerns nurturing, socializing, reproduction, etc.; polity that deals with laws, execution, and adjudication; and community that deals with cultural identity in ways that uphold the values of solidarity, diversity, self-management, liberty, justice, participation, and tolerance. Looking at past movements toward social change, if you set your focus on one overarching sphere to target all your energy upon (like Marxism upon economy, feminism upon gender, classic anarchism upon polity, or nationalism upon community), you will see that each sphere (carried out to each theory’s full logical extent), is the basis for everything else. Looking at feminism and Marxism for instance, you will see that classism accommodates and reinforces sexism, just as sexism accommodates and reinforces classism, so which do you target? Conceptually, the answer is both, hence the robust multi-issue, -focus, -tactic, growth-oriented, revolutionary perspective (as Michael Albert has pointed out, sociology is much harder than physics in that it lacks the luxury of formulaic preciseness).
Considering the Feasibility of Radical Theory. All of this is made on the basis that it is understood what injustice is (or at least that understanding injustice is a key element of the overall pursuit). It should be a relatively basic understanding, but has been up against a pervading sentiment that there is no alternative, so it has had limited manifestations. This is why developing vision is crucial—reinvigorating thoughts of alternatives to ignite momentum. In looking at the feasibility of manifesting such a vision—of a value-based reconstruction of all the relevant institutions of our society along properly democratic principles—it begins to seem daunting again, even if you step away from common misconceptions of feasibility (the misconceptions that cater to wealth and are confined to the slanted mechanics of Washingtonian politics, coordinator class managerialism/paternalism, and habituated and socialized submission to hierarchy and authority).
Instead of focusing all attention at the finish line right away, consider how movements emerge—any movement, especially during the emerging feminist, civil rights, Vietnam eras. Movements emerge for all kinds of reasons. The difference here is that this movement for a participatory society is unified around a vision and not just anger. Many leftists criticize “the system” out of anger, but produce little in the way of visions for alternatives. In terms of bringing about such a vision, the democratic principles that we value must be injected into our organizations and institutions now. Many movements have collapsed in the past due to the fact that their internal structure did not reflect their external declarations and professed concerns (e.g. anti-Jim Crow organizations trying to build movements while keeping internal racist structures intact).
The essence of being prefigurative is that organizations should begin structuring themselves now according to the desires of the participatory society they intend to create. As many people are already convinced there is no alternative, for an organization extolling otherwise yet not acting accordingly will ultimately reinforce such crippling sentiment. In terms of labor and the basic economy, prefigurative work would appear as workers councils being built and balanced job complexes being instituted in the present (and not just because this seems more fair, but because without such a structure, all major decisions will eventually be made by those in empowered positions while everyone else will be too tired and disenfranchised from the grunt work). Self-management should be fought for now, but whether it is or not within the complex of public health led by public health professionals, growing antisystemic conditions will continue to work the notion of real participation much more centrally into the public health dialogue.
Addressing Inevitable Conflict in the Anarchist Project.
“Every minute of every day almost is a constant negotiation between what you want, what you want to get, and the community, the collective, the other person.”[vi] Gostin spent some time on this—highlighting it as seeking balance between the common welfare on the one hand and the personal burdens and economic interests of individuals and businesses on the other as negotiated by public health law and government. Cindy Milstein, an anarchist organizer, writer, and book publisher, steps away from the political mythologies and usefully centers such jockeying within anarchist praxis: “It’s a constant balance in negotiation between yourself and society—between difference—but also sharing a value together. In a way, anarchism is just being honest that this is how we act in the world, it is full of contradictions, and in a way, anarchism tries to say ‘let’s just make them all transparent and try our damnedest to make the best possible balancing act between the two’ knowing its going to be a constant negotiation.” This is in stark contrast to other political philosophies that say it is either all about the individual or all about the community and brush aside those contradictions. Such philosophies impose a binary that does not actually exist in the real world instead of trying to see and work through the complexities of life. In this sense, anarchism is constantly dynamic, evolving, changing and open—making it free and flexible, but also often difficult to understand.[vii]
Anarchism presents a fundamentally different sort of project than what Gostin proposes as it is not about having the right answers and the correct formulations, but rather it is about engaging the complexity of the world in such a way that achieves the results the anarchist is after and upholds the values the anarchist holds dear. Milstein offers some central characteristics of anarchism that shed some light on how this engagement is pursued.
The first characteristic of an anarchist is that they are anti-capitalist as well as anti-statist. These are fundamental values, but their manifestations take many shapes and look very different from one another as they are both two very different operations. The anarchist works from a generalized critique of domination and hierarchy. This is not only a critique, but a desire to abolish both. As such, one of the natural inclinations with the anarchist project is that it is always looking to find new forms of domination in things as it is an intrinsically growth-oriented perspective. This can be nagging in the extreme, but also (more commonly) amazingly fruitful. The anarchist orientation is obviously not just a focus on economics, but a multi-dimensional focus on political, social, cultural understandings about freedom and unfreedom (though this is not unique to anarchism). Additionally, Milstein points out that the anarchist project is always grappling with how to be ethical (or approximately ethical in the context of this problematic society). In this sense, the central questions become “Is that domination? Am I doing the right thing? Is this a good quality of life? Am I really listening to other people? Am I talking too much?” The nature of anarchist praxis is such that the project tries to have an operational framework where it asks “Is that something that is wrong, and what would be right?” before asking “Is that possible? Is that pragmatic? Is that strategic?”[viii] Granted anarchists within the project are all shrouded in elaborate personal constructions and gradations of human shortcomings (no one is perfect after all), the fundamental orientation and moral sentiment still tends to gravitate toward “Is that domination?” as opposed to “How can that be dominated?”, which (even in all its imperfections and taken as a part of the whole of the anarchist project) can still amount to qualitatively better societal outcomes.
Other characteristics of anarchist action according to Milstein involve looking for both the liberation from constraints and the freedom to explore new avenues of interest. It is concerned with substantive equality: an understanding that we are not all equal in every way, but we should be “equal in our differences.” In this sense, we should be able to acknowledge our common values in respect of our common differences, and out of it all, be able to form organic (as opposed to mechanical) relationships with one another. This is a different take on justice movements that call for an equal share of the pie for everyone—substantive equality would allow people to share and receive different sizes of pie according to their needs and desires since we are not all the same. Accordingly, anarchists share an understanding that people need things as well as desire things. Marx said “To each according to their need,” but for the anarchist, “To each according to their desire” also stands. Needs and desires are part of the project to be figured out, which can only happen through trial and error. The anarchist also values spontaneity, playfulness, joy, and happiness, and voluntary association. For the anarchist, voluntary association must be in conjunction with mutual aid in the sense that it is not just about doing whatever you want whenever you want, but accepting a sense of commitment and solidarity. The anarchist project is such that it tends to look for decentralism and interdependence simultaneously, local and simultaneously global, self and simultaneously society. To this, the anarchist project says that it is never “one or the other”, but instead “how do we do both together?” In this sense, anarchists are often utopian and visionary. This is significant in that (as opposed to other philosophies and radical theories) anarchism is not just a constant critique (not just anger, as mentioned earlier). It is a project constantly about the present and trying to shape the world according to such utopian ideals—the very essence of prefigurative action.[ix]
The central political moment for the anarchist is negotiation for something acceptable for all with a deep respect for diversity. The Okanagan concept of en’owkin fits perfectly here that says: “I challenge you to give me your most opposite perspective to mine—in that way I will know how to change my thinking so I can accommodate your concerns and problems.”[x]
This is a direct contrast with politics as usual which have, as Audre Lorde put it, never been able to functionally exist with difference. Whenever something different is introduced, it is treated either indifferently and ignored, dominated if possible, or otherwise assimilated with. In contrast, the anarchist project does not seek to convert other mindsets to its points of views. Instead, it values diversity and discussions focus on concrete questions of action, and “coming up with a plan that everyone can live with and no one feels is in fundamental violation of their principles.”[xi]
[In group settings, most anarchists] operate by a consensus process which has been developed, in many ways, to be the exact opposite of the high-handed, divisive, sectarian style so popular amongst other radical groups. Applied to theory, this would mean accepting the need for a diversity of high theoretical perspectives, united only by certain shared commitments and understandings. In consensus process, everyone agrees from the start on certain broad principles of unity and purposes for being for the group; but beyond that they also accept as a matter of course that no one is ever going to convert another person completely to their point of view, and probably shouldn’t try.[xii]
It is important to understand that in addressing conflict within anarchist praxis, there are no blanket answers and there is no blanket policy. Less radical sentiments may look at the project and conclude that its utopianism far exceeds its feasibility and in turn suggest a more attainable middle ground to seek (this has largely been the stance of natural capitalism that has been promoted by Paul Hawken and others). The problem with this however is twofold. First, Marx long ago pointed out the truism that you cannot negotiate with capital for a new form of social organization;[xiii] you must dismantle it. Marx saw capitalism as a system of social organization fundamentally premised on exploitation, so you cannot have a “nicer” capitalism, or a “smaller” capitalism, or a “little bit of” capitalism, because at its core, it is intimately about a form of social organization based on domination and exploitation.[xiv] Secondly, this notion of compromise is premised on a fundamental misunderstanding of the anarchist project. The challenge here is explicitly not about winning a specific vision to which people have to convert. That would be impossible and go against nearly everything for which anarchism stands. Instead, the goal is prefigurative. This is a completely different project entirely built around process and seeing change as an ongoing experiment, as opposed to being predicated on classical mysticisms of a great and sudden revolutionary cataclysm. It is about a multi-issue, -focus, -tactic, growth-oriented, revolutionary perspective that says that the project focuses on that which works, and focuses without coercion.
Graeber offered this schematic theatrical interplay between a skeptic and an anarchist that I think is telling as to the type of project that we are after and to the type of ideological barriers confronting it.
Skeptic: Well, I might take this whole anarchism idea more seriously if you could give me some reason to think it would work. Can you name me a single viable example of a society which has existed without a government?
Anarchist: Sure. There have been thousands. I could name a dozen just off the top of my head: the Bororo, the Baining, the Onondaga, the Wintu, the Ema, the Tallensi, the Vezo...
Skeptic: But those are all a bunch of primitives! I’m talking about anarchism in a modern, technological society.
Anarchist: Okay, then. There have been all sorts of successful experiments: experiments with worker’s self-management, like Mondragon; economic projects based on the idea of the gift economy, like Linux; all sorts of political organizations based on consensus and direct democracy...
Skeptic: Sure, sure, but these are small, isolated examples. I’m talking about whole societies.
Anarchist: Well, it’s not like people haven’t tried. Look at the Paris Commune, the revolution in Republican Spain...
Skeptic: Yeah, and look what happened to those guys! They all got killed!
The dice are loaded. You can’t win. Because when the skeptic says “society,” what he really means is “state,” even “nation-state.” Since no one is going to produce an example of an anarchist state—that would be a contradiction in terms—what we’re really being asked for is an example of a modern nation-state with the government somehow plucked away: a situation in which the government of Canada, to take a random example, has been overthrown, or for some reason abolished itself, and no new one has taken its place but instead all former Canadian citizens begin to organize themselves into libertarian collectives. Obviously this would never be allowed to happen.
There is a way out, which is to accept that anarchist forms of organization would not look anything like a state. That they would involve an endless variety of communities, associations, networks, projects, on every conceivable scale, overlapping and intersecting in any way we could imagine, and possibly many that we can’t. Some would be quite local, others global. Perhaps all they would have in common is that none would involve anyone showing up with weapons and telling everyone else to shut up and do what they were told.
In this light, it makes much more sense to focus on linking projects together in federations to be mutually reinforcing rather than trying to expand them as all-encompassing bubbles—so the few examples I will offer now I would argue are appropriately on track, rather than too small-scale, too local, or too grassroots.
Imagining a Healthy Society: Observing Alternatives.
One of the premises of this work has been that antisystemic, anti-neoliberal, radical, anarchist movements have been growing worldwide and have been searching prefiguratively to build alternatives to the dominating, non-participatory, and hierarchical institutions throughout society. In terms of health care and public health policy, movements continue to flourish that challenge the currents of for-profit and industry-run health care, both in the US and abroad. While not necessarily vocally anarchist, they still largely abide by the principles, and in doing so, have been opening up alternatives to business-run health care and public health policy. Between Cuban health care, indigenous health care maintained by the Zapatistas in Chiapas, Mexico, Paul Glover’s Health Democracy movement, and Patch Adams’ Gesundheit! Institute, these are just a few brief observations I would like to offer.
Cuba offers a national example of a remarkably functional national, yet community-based, non-capitalist health care system with health indicators comparable to those of the US. Life expectancy in Cuba is 77.5 years; in the U.S. it is 78. Cuba’s infant mortality rate is 5.3 deaths among 1000 live births in the first year, whereas in the U.S. it is 6.9 [according to 2003 figures]. In Mississippi infant mortality is 11.4 and as high as 17 among Blacks, and rising. In our nation’s capital, infant mortality is 14.4 among African Americans. In Cuba on the other hand, only 5.3 infants die out of 1000 births in the first year of life, and basically the same low rate is found in every region and sector of the population, and continues to decline year after year.[xv]
The variation in the range from best to worst rates of infant mortality and general health disparities within given populations are telling as to the quality of the society as a whole. Richard Levins—in looking at broad societal health—looked at these variations within the U.S. Comparing numbers state-to-state within the U.S. revealed little information on variability, but increasing the magnification and looking across counties in Kansas, the variation was alarming. Being aware of smaller-scaled variation such as this is incredibly significant to know whenever health statistics are generalized across larger populations.
Levins: “We observed average rates [of infant mortality] as well as the disparity; we divided the variation, the difference between best and worst, by the average. For Kansas the range divided by the average is .85, but in Cuba it was .34. We saw that the cancer rates in Kansas and in Cuba are comparable, but the variability is higher in Kansas than in Cuba.”[xvi] In the World Bank’s 2001 edition of 'World Development Indicators' (WDI), Cuba was shown outpacing virtually all other poor countries in health and education statistics. Interestingly, immediately after Hurricane Katrina hit New Orleans in 2005, Cuba offered to send well over a thousand doctors to help its victims. In one of the many ways government can interpret its role regarding public health, the Bush administration ignored the offer.[xvii]
This obviously raises the question as to how this possible given Cuba’s situation. How is a poor country that lacks the sophisticated medical technology we have and has difficulty getting basic equipment and medicines due to the U.S. blockade been able to take such good care of the health of its population? One answer is doctors. Cuba has 5.3 doctors per 1,000 people–the highest ratio in the world and nearly twice that of the U.S. The 60,000 dedicated physicians and other health professionals work within a system based on the principle that “health care is a right rather than a commodity for sale.”[xviii]
As far as the work that went into this and building prefigurative infrastructure, Cuba’s medical situation was not at all by coincidence. After its revolution in 1959, half of the nation’s doctors followed their affluent patients to Miami. So right from the beginning the government had to make great efforts to educate new doctors. Today, there is a major medical school in every province. The country now graduates 3,500 doctors a year, far more than required for it population of 13 million.[xix]
Speaking prefiguratively, Cuba’s health infrastructure has been incredibly forward-looking. It has more doctors serving abroad than the World Health Organization. Since 1963 100,000 doctors have served in 101 countries. It is also training 20,000 healthcare professionals from 26 countries and carrying out special initiatives such as Operation Miracle. It created the Latin American School of Medicine (ELAM) that offers young people from the poorest regions of Latin America and Africa the chance to become doctors. The unwritten commitment of each and every student is to return to their country and practice their skills for a period of ten years in the poorest and neediest of their communities, thereby replacing the Cuban doctors. From the time when Cliff DuRand wrote this article, ELAM had students from 29 different nations and 67 different ethnic and cultural groups to become doctors, medical technicians and other health care specialists (around 10,200 current students). Among them are 91 low income students from the U.S. The six-year course provides everything: lodging, clothing, food, books and a small amount of spending money.
Cuba also began the Sandino Commitment with Venezuela that aims to train 200,000 Latin American doctors over this decade. Like the students in ELAM, more than being trained in medicine, these doctors will be prepared with a high sense of social commitment—motivating them to care for the peoples of the region wherever they are needed, says Hugo Chavez.
Understanding how basic aspects of personal and community empowerment are also essential aspects of an effective public health outlook, Cuba developed a new pedagogy for teaching literacy called Yo Si Puedo (Yes, I Can). In 2006 UNESCO again awarded Cuba its literacy prize for this new method. It is currently being used in 16 countries to teach over 580,000 people how to read and write in just 7 weeks.[xx]
The Zapatistas offer a grassroots example of prefigurative action. Health care in the indigenous communities of Chiapas has long been neglected by the Mexican government. During a session on health, the participating councils of Good Government (“Juntas de Buen Gobierno”) discussed issues regarding a shortage of medical supplies and transportation, the loss of traditional medical knowledge, barriers to sexual education, and the hazards of dependence on foreign aid. After the discussion, the Zapatista communities organized their own health care network and called in help and resources from other organizations in solidarity throughout Mexico and the world. Resources from abroad boosted autonomous health projects. The Zapatista hospital (the hospital of Guadalupe in Oventic, Chiapas, Mexico built in 1991 by local Zapatista communities) runs with aid from foreign donors without any government support, and seeks to provide service to those suffering discrimination in state-run institutions.
The Zapatista health care system has been widely recognized both nationally and internationally as having brought treatment and medicine to more rural indigenous men, women, children, and elders than either the government or private sector ever did. By training local “health promoters” from the ranks of the communities the effort has excelled in preventative medicine, health education, and the preservation of herbal and other traditional forms of medicine. International solidarity has allowed the communities to construct clinics and purchase equipment and ambulances.
As a more targeted focus on health was adopted however, the dependence on foreign aid became an increasingly pressing issue. The lack of follow-up by some solidarity organizations stalled or suspended important projects after they were begun. Consequently, traditional medical knowledge has been promoted more heavily as a means for indigenous communities to recover control of their health care.
In terms of women’s issues, Zapatista Women’s Law was made public in 1994 with a declaration of women’s rights. This arose out of a growing concern for the need to focus on empowerment issues of the Zapatista women, with a particular focus on women’s health and its tie to community health as a whole. The session on health during the Juntas de Buen Gobierno presented a progressive health platform, but despite the focus, it was clear that “some of the main hurtles to women’s health remain set by a system of patriarchy left as inheritance by a Spanish conquest.” [xxi] Consequently, “many conferees agreed that the education and participation of women in this matter are essential to the overall health of the community.”[xxii]
Such sentiment around the need for empowerment finally grew into the first Encuentro for women that occurred on January 1, 2008. It gave women space to deal on their own terms with issues of self-determination, liberty, democracy, health, and justice within their own communities. While pointedly casting off patriarchal relationships (the men during the meeting were responsible for cooking, childcare, cleaning the latrines, and hauling firewood), the Zapatista women made it known that this was not a splintering into a separate women’s movement which has been something distinctly different from most women’s liberation movements. Instead, the Zapatista women emphasized that their movement still included “their, brothers, husband, children, elders, everyone in the community.”[xxiii] In terms of spreading the Zapatista model, when asked what non-Zapatista communities could do to support their work, the Zapatista women replied, “Organize yourselves.”[xxiv]
The ethos of the Zapatista health movement was captured by one 8-year-old girl during the Encuentro’s plenaries. She said, “Without the organization, I would not be alive. I would have died of a curable disease.”[xxv]
Paul Glover’s Health Democracy movement—the Ithaca Health Alliance (IHA) based in Ithaca, New York—is a cooperative health care model built on mutual aid and was developed with the idea to create a sustainable model of community-oriented, community-driven solutions to the ongoing national health care crisis. According to the organization’s main website, the Ithaca Health Alliance was created as a cooperative model that has been continuously shaped and sustained by members in the alliance. The idea is that through the power of community-building, IHA members help each other with health expenses—financially through the organization and through the services they make possible, and directly through member-to-member benefits, like discounts on health care which Provider Members offer to other members.[xxvi] The IHA functions on three main levels: the Ithaca Health Fund, the Ithaca Free Clinic, and general education.
The Ithaca Health Fund was established to provide financial assistance for the costs of health care. Through the fund, IHA provides grants to IHA members to help with specific categories of preventive and emergency healthcare expenses. The Fund also offers members interest-free loans for dental procedures, eye care, or for improvement of professional health services (health care provider members only). Through the IHA Community Grants program, small grants are offered to other groups doing health-related work...The Health Alliance opened a free health Clinic in downtown Ithaca on January 23, 2006. The Ithaca Free Clinic (IFC) provides 100% free healthcare services to the un- and under-insured residents of Tompkins County and the surrounding region. IFC is a medically integrated facility where volunteer health professionals provide both conventional and holistic medicine services to clinic visitors, as well as health insurance counseling and other services… The Alliance offers educational programming to our members and the general public. Informal classes, lectures, and guest speakers are offered throughout the year; other events are scheduled as they arise. We offer resources in the waiting area of our offices and Free Clinic, which everyone is welcome to browse through. We network with experts in all fields of health in order to help our neighbors learn about the wealth of health options available. Our quarterly newsletter provides information about different health subjects, and other educational resources, in addition to news of the organization. [xxvii]
The final observation I would like to offer here is the Gesundheit! Institute—the longtime brainchild of Patch Adams. The premise of the project has been a completely prefigurative attempt at what the Institute refers to as “whole system design.” The approach taken by Gesundheit!, in other words, has been to redesign the whole system of health care, not just how it is accessed:
We want to wrest neglected aspects of health care delivery out of the control of market capital, into designs of pockets of care. These local pockets of variety would run parallel to mainstream market care and be loosely linked with one another to act as perturbations to the system.[xxviii]
This theory conceptualizes the system as it stands as a Goliath to their David: it recognizes that the system is (1) controlled by people/institutions who have certain power over the population; (2) “the system as is—unchanged—benefits them enormously;” and (3) these people/institutions have no intention of allowing that system to change—no matter how reasonable and ethical the arguments, how compelling the evidence of human suffering and human waste, or how many compromises activists are willing to make.[xxix] As unyielding as this framing seems however, the window of opportunity that Gesundheit! strategizes around comes from the understanding that “the health care system in the US is so big, so complicated, so bureaucratic, with parts unable to connect to other parts, so insensitive to the mood of its environment, so unable to see its consequences—that falling by means of its own weight is a possibility.”[xxx] Consequently, it frames its actions around the notion of perturbation—aiming to disturb these weak points within the system. Specific targets come about through the concept of whole-system design which sets out to demarcate what aspects of health care can be changed by mere decision and policy design, therefore targeting problematic aspects that are not intrinsic to health care’s overall presence or function.
There are numerous aspects of contemporary health care that the Institutetargets for change and redesign. It notes that hierarchical relationships in health care interactions are inherited from a culture of hierarchy, rank abuse, and posing. Consequently, people, in shaping their health care facility along the lines they want, have the option to support, oppose, change, or alter such manners of relating. Many studies show that a person has better health outcomes if she feels her wellbeing integrated within a larger group. Along these lines, Gesundheit! believes that healers/designers can come up with a language—frames and metaphors—that oppose isolationist and consumerist tendencies (particularly of health and sickness being identified as individual properties), and instead situate the health of the individual within the health of a group. Following this logic, Gesundheit! makes note that the health of its staff is just as much a priority as the health of the patient: just as the patient needs to feel her well-being is nested within the well-being of a larger group, so does the staff.
In terms of making health care a much more participatory experience, Gesundheit! recognizes that the current commercial culture of health care designates the patient as consumer and the doctor/nurse as provider in such a way that health care interactions are largely experienced as a form of shopping—complete with significant information imbalances, profit motives, socioeconomic disparities amongst consumers in bargaining/buying power, constrained and often non-participatory choices, etc. Designers on the other hand can oppose this mode of interaction and devise elements in their facility (by means of language, imagery, structure) that enable popular participation in all aspects of health, health care, and building a health care system. While national health care is currently nested in bureaucratic and private financial institutions, it is actually within larger beneficial social groups that healing interactions need to be nested and protected. Solidarity needs to be refreshed and redrawn between people whose interests are fundamentally in common. Decisions need to be made on a participatory basis with decision-making about health care system dilemmas communicated to/from the people as a priority. Communication and health care visibility can also be much more prominent throughout society as an aspect of system design, and in terms of visibility, cures should not necessarily be valued above quality care. The physical health care space itself should be designed to reflect these values, and—as there is no such thing as a neutral interaction—actions throughout everyday life amongst healers, staff, and patients should reflect the fact that life itself is a choice. Such a perspective can be a tremendously valuable input to desirable health care interactions. All of these aspects Gesundheit! deems capable of being (re)designed.
Central to all of this is the fact that the project of whole-system design rests on creativity: “We need a variety of new ideas, projects, designs, configurations, proposals—alternatives to look at and weigh. There are some problems where the solutions are not there yet. Action to be taken: we have to make up solutions.” As it does this, it is targeting the culture of health care and opposing and exposing the “undesirability of market-controlled health care.”[xxxi]
Piecing together a Possible Social Framework for Health-Focused Anarchist Organizations.
The glaring question still remains as to defining the social framework within which anarchistic organizations can thrive and can influence the formulation of public health policy. Around what social structures can anarchist groups coalesce to articulate collective voice, and how?
The two main concerns with the examples mentioned in the previous section are that they (1) coalesce around a pre-existing identity (therefore fall short of representing the vast majority of a more diverse population thereby making broad application difficult), and (2) are effectively isolated. The Zapatistas coalesced around the shared identity of politically-marginalized and heavily-localized indigenous communities. The Gesundheit! Institute was (and remains) heavily localized and largely insulated into its own operations (despite its outreach efforts). As such, the questions remain: what do these operations have to say to the vast majority of the population that is not in an illness-identified community, not locally grouped and organized, and freed of the catchall designation, “the public”? How would an anarchist arrangement take place and would it be anymore effective and efficient than things as they stand?
As mentioned earlier, anarchist organization goes against the “expanding bubble” model that seeks to take a single subcultural space and expand it to include increasingly more people, attempting to be the model for all. This is the same logic of letting diversity thrive as when the notion of “the public” is picked apart. What we are left with then, in terms of this anarchist project, is what I would argue to be a two-part process.
The first part regards looking at collective identity as the basis for organization. Local health communities arise out of the common band of shared locality and the shared interests that arise from it. Disease-identified communities (shared identities around particular shared health conditions) arise usually on a more national scale. It would seem here that common ground could be uncovered that would appreciate the participatory aspect of locality while fortifying mutual resources on a much wider scale as local groups are linked together more broadly. This directly supports the idea of not promoting the “expanding bubble,” but rather promoting diverse groupings pursuing the particular interests of particular constituencies, while collectively working together as a federated whole and rallying around the general idea of health (after all, one obviously does not have to have a particular interest in a certain condition or disease to have an interest in health more broadly or to be able to recognize the dimensions of their health at stake). So, as such, a federation of communities rests on expanding the idea of collective identity markers from just those of specific illnesses and conditions to much broader interests in health, in that everyone has a stake in their health in a diverse array of manners.
The second aspect of this process concerns the foundational units that would make up such a federation (or federation of federations). These are largely the alternative practices (the work of Gesundheit! or the Zapatistas, for instance) described in the previous section. After the notion of “the public” is picked apart, what is essentially left is an array of dynamic and varied bodies and constituencies that make up the real world. The problem is that they are largely isolated. The Zapatistas and the Gesundheit! Institute are effectively disconnected nodes of what could be a broader and more effective system. Connections are lacking where these nodes should be linking together, where these communities would be acting together for some things and rearranging for others—project to project. The Zapatistas are vocal about international network building as they always reply to the question of “How can we help?” with “Organize yourselves”—reflecting the need to create and link nodes of action. Essentially what this refers to in the context of health provision are health councils and federations (linking locally-based health cooperatives and broader organizations with each other) around common interest in good health.
In terms of what anarchism offers here in many ways plays out as a derivative of what is known as anarcho-syndicalism. This is a labor-oriented arrangement where workers see themselves as a specific class, and form self-managing workers’ councils to collectively articulate their voices and interests. Rudolph Rocker, in his work, Anarcho-Syndicalism, outlines two central purposes of the practice: (1) to safeguard the demands of workers while raising their standards of living; and (2) to serve as a school for training workers and acquainting them with the technical management of production and economic life in general so that when a revolutionary situation arises they will be capable of taking the socioeconomic organism into their own hands and remaking it according to socialist principles.[xxxii] Its hardly beyond the imagination to construct something similar related specifically to health-oriented constituencies: working to safeguard health-related interests, seeing themselves as part of a whole, all with investments in their health, and seeking to increase participation in decisions that affect their health, while working to empower others to participate as well, serving as a base through reinvigorated popular agency toward rebuilding society as a whole along participatory lines.
This idea of interest councils has been dealt with more recently and more deeply by many. Michael Albert describes both workers’ and consumers’ councils and federations of both as central components of a functional vision for a participatory economy (see: Parecon: Life after Capitalism). An arguable advantage (amongst many) these arrangements have over convention is that they are inherently more participatory and egalitarian. This comes from their basis in the implementation of balanced job complexes, or, in more relevant terms to what we are after, of forms of organization that are not inherently empowering for some and disempowering for others, so everyone can participate equally if they so choose. As such, councils would be based on self-management (people can participate if they so choose or create new ones more relevant to their needs and interests); they would be based on appropriate information dispersal, appropriate means of expressing preferences, and decision-making processes that would work to ensure (as best as possible) that each individual has influence over outcomes proportionate to the outcome’s effect on her or him.[xxxiii]In terms of efficiency—of not wasting things we value as we pursue our goals—direct participation in terms of health councils provides a much more responsive arrangement, cuts out the current bureaucracy that has become increasingly financially draining and counterproductive, provides for a non-competitive atmosphere where councils link with one another to address interests, and as such is guided by the interest of the constituencies and not by profit-driven, expansion-bent, unsustainable industries.
There is obviously so much more to say about this to do justice to the idea of health councils. It should be mentioned though that there are already some forms of health councils in operation. The desired vision for these would be to link with each other in federations dedicated to safeguarding the health of citizens, raising health standards, and continuing the education and empowerment of those citizens in terms of being able to engage and manage the factors that affect their health, broadly-defined.
Interfacing with Conventional Infrastructure.
To the extent that social determinants of health are themselves set within broader institutional systems, how can anarchistic organization work well when it needs to interface with these more conventional infrastructures? What can be done immediately?
The answer to these questions is primarily predicated on vision: what is it we are trying to create? The previous section discussed building alternative structures for health institutions. This section concerns the manner of interaction (resistance and reconstruction) within existing institutions, as both resistance and building anew are needed.
In terms of creating new forms of health care provision, it is difficult for alternative institutions to jump right in and be highly competitive with the conventional modes of doing things. Communities must be familiarized with the alternatives, and in a basic market system, new institutions predicated upon self-management and participatory values tend to corrupt as they attempt to succeed in the market and be participatory as well (as market decisions lean toward alienation and the disruption of participatory practices). It is not that alternatives cannot succeed, but it is nearly impossible to succeed in the market and succeed as truly self-managing systems.[xxxiv]
The key is to recognize this incongruence and then fight against it. The fight comes in terms of finding ways to raise the costs of conventional ways of doing things so that shifts and reconsiderations will (have to) be made. In economic terms, this could come as a reorganization of the workforce to the extent that it either costs the structure more to fight it or that it forces the structure to allow the workforce to reorganize. The general trajectory of development here is that it involves winning larger reforms that continue to empower the movement to seek more—working toward building relevant interest councils and eventually toward a new institutional structures altogether.
The philosophy behind Patch Adams’ Gesundheit! Institute refers to this manner of increasing costs to the system as creating “perturbations”—ideas/actions that put the system on the spot with the aim of destabilization and making it trip on itself.[xxxv] The points of entry to increase costs to the conventional provision of health care involve challenging hierarchical relationships, seeing health more as a collective condition as opposed to only a quality of an individual, focusing on the complementary importance of staff/provider health, understanding health as a people’s popular movement, promoting solidarity, participatory decision-making, etc..
As costs rise, the struggles going on within particular institutions can help and support alternative institutions even while the market and conventional competition still exists. The Gesundheit! Institute serves as a fitting example here as well as its pursuit of “whole system design” is the alternative/prefigurative project working beside other projects confronting conventional infrastructure, namely those focusing on single-payer/universal coverage. As the Institute seeks to be a prefigurative alternative in its work, those focusing on funding/access issues serve more as a direct challenge (perturbation) to the conventional infrastructure of business-dominated health care.
Meant to work side-by-side with single payer/universal coverage efforts, whole system design is a call to think universally, design locally: to design local contexts that protect the distinguishing core of the health care relation…between doctor/nurse and patient.[xxxvi]
Brief Concluding Remarks
[i] Navarro. “What is a National Health Policy?” International Journal of Health Services, Volume 37, Number 1, Pages 1-14, 2007.
[ii] The precautionary principle is a moral and political principle which states that if an action or policy might cause severe or irreversible harm to the public or to the environment, in the absence of a scientific consensus that harm would not ensue, the burden of proof falls on those who would advocate taking the action. Raffensperger C. & J. Tickner (eds.) (1999) Protecting Public Health and the Environment: Implementing the Precautionary Principle. Island Press, Washington, DC.
[iii] Much of this content on radical theory and vision comes out of lectures and discussions with Michael Albert and other staff at the Z Media Institute during the 2007 summer. It is also covered well in Albert’s Thought Dreams: Radical Theory for the 21st Century (2004).
[iv] From the collective brainstorming of Michael Albert, Lydia Sargent, Noam Chomsky, Holly Sklar, Mel King, and Leslie Cagan (and many others, I’m sure). Adapted from M. Albert, Thought Dreams.
[v] Michael Albert. Thought Dreams.
[vi] Cindy Milstein. Lecture: “What is Anarchism? Should you be afraid, or should you join up?” Unwelcome Guests Collective Podcast. 2004-08-29. http://www.radio4all.net/proginfo.php?id=9944
[ix] All from Milstein’s elaborations.
[x] Jensen, Derrick. Endgame, Volume 1: The Problem of Civilization. Seven Stories Press. 2006. p189.
[xi] Graeber. Fragments.
[xiii] This was largely Naomi Klein’s criticism of Jeffrey Sachs problematic global anti-poverty campaign.
[xiv] Cindy Milstein.
[xv] Cliff DuRand. “A Health Care Model for the World: Humanitarianism and Solidarity Cuban-Style.” Z Magazine. November, 01 2007
[xvi] Richard Levins. “Is Capitalism a Disease?”
[xviii] Cliff DuRand. “A Health Care Model for the World: Humanitarianism and Solidarity Cuban-Style.” Z Magazine. November, 01 2007
[xxi] Ginna Villarreal. “Health Care Organized from Below: The Zapatista Experience.” Narco News Bulletin. January 11, 2007.
[xxiii] Fischer-Hoffman, Landreau-Grasmuck, Weidman, & Skinner. “Experiencing the Women’s Encuentro.” Z Magazine. March 2008.
[xxviii] Susan Parenti. Re-Designing the US Health Care System: Think Universally, Design Locally. November, 2006. www.patchadams.org/hospital_project/positions.pdf
[xxxii] Rocker, Rudolf. 1998. Anarcho-Syndicalism. 2nd ed. Pluto Press.
[xxxiii] Albert. Parecon: Life After Capitalism.
[xxxiv] Micheal Albert. “Real Utopia” talk at the 2008 Left Forum. New York City.
[xxxv] Susan Parenti. Re-Designing the US Health Care System: Think Universally, Design Locally. November, 2006. www.patchadams.org/hospital_project/positions.pdf
[xxxvii] Å½iÅ¾ek, Slavoj. The Parallax View. 2006. p. 333.
[xxxviii] Marcuse, Herbert. “To What Extent is the Revolution Possible Today.”
[xxxix] Å½iÅ¾ek, Slavoj. The Parallax View. 2006. p. 381.
[xl] Jensen, Derrick. Endgame, Vol. 2. Seven Stories Press, 2006. p. 771.
[xli] Ibid. p. 778.
[xlii] Ibid. p. 780.
[xlv] Klein, Naomi. The Shock Doctrine: The Rise of Disaster Capitalism. Metropolitan Books. 2007. p6.