People who favor a radically different society do not write much about healthcare. I’m not speaking of liberals or social democrats, but individuals who prefigure a society that empowers communities in which decisions are made directly by people in those communities.
It is understandable why they are reluctant to write about healthcare at great length; for a real, democratic, free health care system based on the needs of the community, in which decisions are decided collectively by health care personnel together with members of the respective community, a complete transformation of extant communities is required. Even when it seems that capitalism is imploding with or without revolution, this is still the epoch dominated by this detrimental economic model. The likelihood that radicals will ever see a society that functions according to the needs of communities through mutual aid, voluntarism, and a dismantling of social hierarchies is highly unlikely. This doesn’t discourage me in the least bit, however, from prefiguring this society, and healthcare’s not an exception.
It is not terribly shocking that people who have more meaningful and creative visions for health care change often de facto support a single-payer option in the current tumultuous situation within the United States. People in the U.S. who have to make decisions like paying their electric bill or medical bills are more than feeling the detriment and affects of capitalism and for-profit healthcare (a mere symptom of capitalism); many are dying because of it. For this reason, it is certainly a moral choice to support the creation of a public healthcare system in the United States, even only as a “less-worse” option.
A “medicare-for-all” model is not revolutionary, nor is it radical. It is not something that challenges domination on a macro scale including, but not limited to, capitalism, government by parliamentarian bodies, poverty, racism, homophobia, environmental destruction, etc. For something to be radical or revolutionary, I argue, something must challenge all of these separate but equally devastating examples of domination. The notion of a single-payer system is understood as radical in the United States, however, since the federal government, including the executive and legislative branch, shows no interest in such a system, while a majority of citizens do.1 Hence, it seems that for anything to challenge the status-quo there must be direct action taken by communities.
Articulating what a society would look like that is organized according to radically different principles is in some ways infinite, and some ways it is impossible; so many of us have different visions for what the new world will look like. And in many ways I would think that the new world will consist of a never-ending experiment, i.e., many different kinds of economic models and communities co-existing and always trying new things. So why not strive to articulate this nearly-impossible vision? Is there a problem with organizing and planning as a community? Even though, I argue, that the very concept of revolution has changed, i.e., it is more a process that occurs within the present than a dramatic event, it seems that building alternative institutions, refining ideas about the new world for which we strive, whether fully articulated or not, is a good thing. In other words, planning is a form of prefiguration.
In order to achieve mass successful direct action like what I will describe in this essay as a possibility, a great deal of society will have to do extensive planning. The direct action that I envision would take citizens from communities working in tandem with health care workers throughout the U.S. It is not very attractive to a complacent, overworked population to take part in direct action and civil disobedience, but it looks as if, assuming we want a dramatically different system, we’ll have to participate in direct action, anyways. The Obama administration and Congress show no signs of listening to the population for even a single-payer plan a la Canada.
I want to approach this conversation on two fronts: (1) I want to discuss what I think could be meaningful direct action to dismantle private health care, and (2) to discuss what health care might look like in a free, decentralized, and voluntary society. The reason I think it is necessary to include both elements in the conversation is because it is easy for anti-authoritarians to prefigure a new society, or a new health care system. What’s damned hard is finding people, not only in health care but in communities, willing to dedicate extensive amounts of time to actually building an alternative, whether this means health care practitioners providing free health care in people’s homes, or building free clinics that are neither private, nor governmental.
Ten Points of Prefiguration
In regards to this kind of unjust system putting our communities in a chokehold, certainly a plethora of tactics should be utilized to combat private health care and try to build meaningful alternatives. I must make clear, however, that what I will discuss as a personal vision of what could, and should be done, would only be effective, and libertarian in nature, if these uprisings occurred from the bottom-up in communities. If some aspects of what I will discuss are carried out by a minority of the population I think two problems could arise: a minority movement attempting to carry out some kind of revolutionary goal could be at risk for becoming a vanguard, or, conversely, it would be a futile resistance that would surely get crushed by the state.
Also, I must clarify something I will mention. When I speak of ad hoc defense collectives, I purposefully chose to be ambiguous. This could mean a number of different things: a defense collective could be a group analogous to the EZLN of the Zapatistas; it could operate like the libertarian militias during the Spanish Civil War; or it could be a critical mass of community citizens who form blockades peacefully. There are endless ways in which these defense collectives could serve as deterrents to state-perpetuated violence; I think individual communities will determine what they see fit.
I argue that some kind of defense body is necessary, though. Communities will be made up of different kinds of participants in such a struggle. For example, the medical personnel may simply choose to serve the communities, to use their knowledge to provide free health care. Others may choose to feed and offer shelter to said individuals. If there are hospital occupations, certainly food and water may have to be provided from those within the respective community.
Others may have an absolutist stance against violent direct action; they too would be legitimate in this struggle. With that said, those that would not shy away from using violence in defense, or certainly property destruction, can contribute to the struggle. Communities are diverse, and if such an uprising were to occur, I think all tactics should be explored. I favor the exploration of all of these tactics, as none have alone yielded successful results.
Below are ten elements of what I believe could make such a struggle successful, but also elements of a health care system in a different kind of society, i.e., one in which capitalism and the state have perished. It is a hybrid of ideas; while one side argues for creating the circumstances for which radically different health care could be provided, the other side discusses a complete prefiguration of a system that actually serves individuals within communities.
1. Occupy Hospitals, Medical Labs, Medical Supply Factories, and Re-Establish Hospitals as Free, Community Clinics
If communities, and health care personnel, do not demand that these institutions change their tune, they simply won’t. Ad hoc, anonymous defense collectives, well-trained in the art of defense, not force, must stand as a deterrent to external forces, so said communities may occupy the hospitals in ways that they deem fit. This will require a majority of the hospitals coming under workers’ control, and the communities working in tandem with the workers. While the workers must have their autonomy, ultimately, they are within a community. For such an occupation to be successful, they would have to be on the same page (this is if the struggle is to remain libertarian).
Health care supply factories in the U.S. and labs that the hospitals utilized must be occupied by their respective communities, come under worker’s control, and also contain defense collectives for such an operation to be successful. The main goal will be to keep these entities functioning so as to serve members of the community for free.
2. Health Insurance Companies Must Be Expropriated
Not only must communities and their respective defense collectives occupy buildings and headquarters of insurance companies, but they must also assure that business is not being conducted. Also, a majority of citizens must stop paying their premiums. Communities then can decide what they will do with the buildings after the employees have either left or joined the struggle. For example, they could turn the buildings themselves into health clinics, or shelters and soup kitchens for homeless people, etc. It must be stressed that this step only makes sense if the hospitals are occupied and functioning successfully as free health clinics.
3. De-Monopolizing Medical Knowledge
Students across the U.S. have a role to play. For such a radical transformation of the system, and in fact society, to occur, we must go to the source of information for medical practitioners. Students must occupy medical schools, nursing schools, physical and occupational therapy programs, psychology programs, etc., and insure that every institution has the same quality of knowledge. In other words, the so-called “best” institutions must be on par with every institution. The line must be blurred between teaching facility and free, community clinics. So, all teaching/learning facilities should have access to the same technology, same information, and function as clinics that serve the community.
4. Decentralize the Medical Bureaucracy
Nurses, doctors, therapists, psychologists, and other health care personnel, if competent, should be given the knowledge and know-how to become primary-care practitioners. This provides more access to communities, but also decentralizes the bureaucracy and hierarchy within medicine. The current system, overly specialized and divided, places doctors as the main decision-makers in medical facilities. This places both stress on the physician and on other personnel that feel subordinated. In a more egalitarian health care system, competent, willing personnel should be granted equal decision-making power. The system could become more democratic and participatory, and could prevent many medical errors since more cooperation will be utilized.
Prefiguring a new society has often been critical towards the division of labor itself. I think this must be applied to health care. Trained professionals could work as a nurse or a therapist on Monday, and on Tuesday work as a doctor, if they chose to and were adequately trained.
5. Embed All Communities With Advanced Medical Facilities
We need to reconsider space and how we use it. Eventually, if the aforementioned points of prefiguration were successfully executed, society would, without a doubt start to restructure itself according to more democratic and anti-authoritarian principles. With the success of health care coming under workers and community control, it is doubtful that these communities would tolerate domination in other spheres of their life. So, in this society, it is very doubtful that urban planning will be what it is now. Ideas like buildings being built on a smaller and lesser scale between areas for which food is to be grown for the communities, community-regulated public transit, prohibiting the manufacturing of cars (save for ambulances and community-owned buses), and far fewer roads may become commonplace in some areas.
Having state-of-the-art facilities on every corner of every community, instead of gas stations, fast-food restaurants, or liquor stores would make life much more efficient. There’s no reason state-of-the-art neurological facilities, cancer-treatment facilities, or cardiology emergent treatment facilities should be centralized in huge, ecologically taxing buildings. Every community will be in need of these specialized treatment and emergency treatment; these communities should be designed ecologically sustainably, and so that every community has top-notch facilities.
6. More Practitioners, Less Hours
It is safe to say that a free, voluntary society is one in which capitalism is a relic of the past. In such a society, re-thinking the notion of the division of labor seems tantamount. The very goal of the division of labor was for efficiency to maximize profit. It is doubtful that in a society that focused on need and human desire (which certainly doesn’t seem to be to work 40-plus hours a week) that a person would be confined to doing the same task for 8-plus hours, five-to-six days a week, for 40 years. A society that focuses on the well-being of all and is based on libertarian socialist principles would avoid this at all costs.
In place of the division of labor, we can imagine people following their bliss a majority of the day while also tending to communal needs minimally, i.e., food, water, energy, health care, scientific research, etc.
There’s no reason communities could not be embedded with facilities that staff practitioners for no more than two or three hours per day, if the number of practitioners increased dramatically. This is something that is largely missing from the conversation: we must consider the quality of life of the practitioner. I think it is likely that a number of people who, because of a classist society and capitalism, were excluded from becoming a health care practitioners, or simply of getting out of poverty, would likely be interested in becoming health care practitioners. And I believe enough individuals would receive training so that facilities could be staffed 24 hours a day, while upholding the standards of minimal work-hours for members of the community.2 For example, if health care practitioners worked 10-12 hours per week, i.e., two or three hours a day, the system could flourish. Practitioners could also have the opportunity to train in many different areas of health care, so as to prevent the division of labor from re-establishing itself.
Striving for dramatically shorter work weeks, and questioning the existence of a great deal of work we do, I suggest, should be part of a new society.
7. Make Violent Crime A Health Care Issue: Health Care Personnel And Prison Abolition
Prison in a classist society dominated by a virulent economic model (capitalism) has failed twofold: (1) they don’t deter crime, and (2) they do not rehabilitate. Of course, this is overly simplistic; many believe a great deal of American prison inmates are being held because of the color of their skin. Primarily white neighborhoods, at least in my experience as a white man with a middle-class background, house all the same “criminal” acts that plague black and brown neighborhoods, i.e., theft, drug-dealing, and drug-using. The police were conveniently never around in our neighborhoods, whilst the black and brown neighborhoods are overpopulated with police officers.
Drugs are largely a problem that can be dealt with by health care personnel: psychiatrists, psychologists, occupational therapists, nurses, and others all receive adequate training as is to help people with drug-addiction problems. It is doubtful that many would sell drugs by choice in black and brown communities. The victimless “crime” is committed out of desperation in a profit-based society in which the individual selling drugs is often excluded from the white world of affluence. Many users many not use anymore in a free society. Without capitalism, perhaps, drug-use itself would slow down dramatically.
Regardless, it is a medical problem. Also a problem that health care personnel can address is the issue of those who commit violent crimes and rape. The same aforementioned practitioners are equipped to address behavioral issues, as well as mental illness. While a great deal of crime, I would extrapolate, would cease in an anti-authoritarian society, there would still be anomalies. They should be treated by medical personnel, not prison-cells that only further alienate those who haven’t committed serious crimes or suffer from mental illness.
Like physical ailments like strokes and hip replacements that require a great deal of physical rehabilitation, people who commit sadistic acts should be treated as people with mental ailments, and subject to rehabilitation. Mental health facilities should replace prisons, which are largely places to house drug-addicts, people of color, and people with mental-illness. Certainly, the healthcare crisis extends to the prison population.
8. Eliminate Rationing
It is true that both health care models ration care, with the private model rationing just as much, if not more than national health care programs. This system that excludes many from health care, a basic need, would be done away with via loose federations of communities. The fix is simple: if there is not available system in one community, the individual will be treated in another community. However, embedding all communities with state-of-the art facilities and increasing the amount of educated, competent practitioners in all communities, which is certainly attainable, would curb a great deal of rationing. As food and water should never be rationed on the grounds that they are necessities of life, emergent health care procedures, and procedures that improve the quality of one’s life, should be treated the same way.
This implies a need for medical federalism across the nation, but also across the planet. A decentralized health care system should certainly be something that strives for international status. Hence, health care in Chiapas should be the same quality as that in New York State, or in Ethiopia, for that matter. All health care facilities should have an open-door policy to all people, not just the members of the community for which they serve. There should be networking and communications kept at all times health care facilities in other communities, and other geographic regions.
9. Community-Regulated Research
Medical scientists and others who contribute to medical research should be strictly regulated by the community. While those who contribute to medical research should be autonomous, if they are wasting resources on things in which the communities they operate in find superfluous, this should be rigorously debated, and the final decision should involve not only the medical scientists, but also the respective communities. For example, if time and resources are being wasted on further developing cosmetic surgery like breast implants and face-lifts, a community might decide this is unnecessary when a community close by, or their own, has an epidemic virus that is killing children and senior citizens. This is something that should not only be regulated by the medical community, but the entire community, especially if research is not being allotted for issues that affect the community.
10. Democratic Utilization of Technology and Resources
And finally, communities should, together with the health care workforce, decide what technologies to utilize and what technologies shouldn’t be utilized. If something like, say, a certain kind of x-ray use has a correlation with cancer, this should be looked into and decided by everyone who uses it or is affected by it.
Also, a great deal of technology that could be utilized by everyone in the community is not because of profit-margins. For example, a physicist told me a few years ago that GE has x-rays that can show the individual if they are HIV positive immediately, or if there are other viruses in the blood. Doctors, he explained, cannot afford to have this technology in their clinic. These are the type of technologies that most communities would want in a free space so that they may utilize it, instead of inefficiently waiting months, and getting referred to several different specialists.
Technology can be both wretched and life-saving. A hospital does many great things for human-beings, but it is also a very wasteful and ecologically taxing facility. They are almost always extremely large, never utilize sustainable energy, and are open 24 hours a day. Besides this plastic is used (fossil fuel use) in thousands of products in the hospital, ranging from coffee cup lids to syringes. This must all be overseen by community councils and strictly regulated. Since environmental degradation can have catastrophic health effects on individuals ranging from toxins in breast milk, mercury in fish from the burning of coal and other fossil fuels, lung damage due to automobile exhaust, and viruses turning into pandemics because of climate change, it would only make sense that health care facilities shouldn’t perpetuate these practices. It would only make sense that health care facilities do not omit carbon dioxide and toxins through the use of burning coal for electricity.
The Strength of Prefiguration
Prefiguring, or foreseeing, a very different kind of society has its benefits. It can give us optimism in an era that is very tumultuous. And if we can prefigure the new world, it is likely that we can build it, even within the old world, with its dilapidated features. Community centers can house volunteer health workers providing free health care, creating a third way to receive health care that is neither private nor governmental. The new world can be created by a vast network of small, liberated spaces; certainly revolutionary health care shouldn’t be an exception. This guerilla health care, if you will, can offer a small glimmer of hope, and stand as an example that the onslaught of capitalism does have active resistance.
Yet the problem has to be addressed in a confrontational element to create any real change. Whether we’re liberals, or progressives, or radicals, it doesn’t matter; U.S. policy-makers are, not surprisingly, acting in the interest of big-business, not the population. So, while creating free, non-profit clinics is a symbolic gesture and a tiny glimpse at what health care should be, if we do not confront our oppressors, who are the state-supported private tyrannies that perpetuate for-profit health care, the ominous status-quo will continue.
Yet, my optimism lies in the potentiality of organized masses of communities. The Paris Commune, the Spanish Revolution, the Zapatista movement, and the civil rights movement here in the U.S., are all reminders that miraculous things can be accomplished in a world dominated by ominous status-quos when communities unite against domination. While none of the aforementioned scenarios yielded a new society, they all prefigured dramatically different circumstances. It was in this that these people acted. Perhaps the U.S. population, in its current tumultuous circumstances in regards to the health care crisis, should take a cue from these folks.
Endnotes
[1] CBS News and the New York Times conducted a poll that showed, overwhelmingly, that the U.S. population supports universal health care as opposed to a system that is dictated by health insurance companies. This is the crux of the findings:
Americans are more likely today to embrace the idea of the government providing health insurance than they were 30 years ago. 59% say the government should provide national health insurance, including 49% who say such insurance should cover all medical problems.
The CBS/NYT poll is available at: http://www.cbsnews.com/htdocs/pdf/SunMo_poll_0209.pdf?tag=contentMain;contentBody. The CBS/NYT poll is so interesting because it comes from sources that rarely reflect the public interest; these institutions typically reflect interests of big business and government. The notion that the New York Times and CBS is reporting on this is a testament to how important health care is to the public.
[2] I will preface this explanation by saying that this is my vision and hypothesis for how such a system could work. Ultimately, however, communities and health care practitioners could decide what they would like health care to look like and become in their own neighborhoods.
The work-week can be broken down into seven days, each having 12 shifts of two hours. For the week, in the facilities mentioned within communities, there are a total of 84 shifts. If one practitioner works 4 shifts, this means 21 practitioners will be needed for a 24 hour staffed facility. However, for an area in which 1,000 people live, 10 practitioners per 2 hour shift are needed to provide proper health care to such a community. Hence we have a ratio of 210 practitioners per 1,000 individuals. While this number sounds incredibly high, individuals will have the freedom to specialize in multiple areas. I prefigure a society in which an OB GYN may also be a nutritionist, someone who grows food, or a musician. I believe such a work schedule could enable people to do this.
Communities' needs vary, e.g., cancer treatment specialists, mental health care practitioners, neurological and cardiology specialists, practitioners who perform abortions, tubal ligations, etc., will all be needed. Practitioners would be allotted more time to specialize in multiple areas, work minimal hours, and still have time to pursue leisure. So a practitioner that works as a psychiatric nurse one day a week could work as a pediatrician on a later date, for example.