Health from Below in a Global Pandemic

Health from Below in a Global Pandemic

The fact that the current coronavirus pandemic has spread conditions of dystopia tells us a great deal about the politics of health. A virus may be a natural phenomenon, but the destruction wrought by this pandemic is a product of the way our society is organized. The scale of suffering and dislocation created by a health emergency is the result of human actions and inactions, just as the differential impact on various communities follows along the lines of prevailing social inequalities, disproportionately hitting people who are racialized or Indigenous, with specific devastating consequences for those who are homeless, incarcerated, elderly, living with disabilities and migrants without status.

The 2020 global health emergency has demonstrated how close we live to the edge. I find myself inhabiting a sci-fi movie I would never choose to watch: empty public spaces, shuttered buildings, economic collapse, new waves of racist and anti-migrant violence, and headlines charting the rising toll of illness and death particularly among specific vulnerable populations. The whole lockdown is overlaid with creeping authoritarianism, with cops in parks patrolling who is sitting on benches and the expansion of surveillance through our devices.

Of course, a lot of people have been living a nightmare this whole time, negotiating conditions of impossibility in their daily lives. Settler colonial capitalism creates everyday cataclysms for so many: Indigenous communities facing genocidal government policies without access to potable water or decent housing, destitute people without roofs over their heads, those dislocated from their ways of life by war, land theft, economic restructuring or brutal regimes. The present dystopic sensation is only a tiny taste of the lives of those for whom the emergency is ongoing, whether in Palestine or Kashmir or in Toronto.

The devastating impact of the current pandemic highlights the reality that health is inherently political. Governments made a choice not to prepare, despite years of warnings of the threat of a global pandemic much like this one. Politicians, policy makers and health advisors will decide when and how to ease the current conditions of lockdown, and that choice will be political as well, with profits certain to be at the centre of calculations. Socialists have an important contribution to make to mapping out an insurgent health-from-below politics. Such a perspective aims to build the knowledge, power and resources we need to sustain well-being in the face of the power of capital and the state, neither disregarding the impact of the pandemic nor trusting the authorities to protect our well-being. 

Crisis of Caregiving

The horrifying toll of the current pandemic highlights the crisis of caregiving in capitalist societies. To put it simply, capitalism doesn’t care. The system revolves around profits, and any social good that results in this society is at best a by-product of processes that enrich employers, often developed in response to pressure from below to sustain ourselves. “While capitalism as a system only cares about profit, profit being capital’s life blood and motor,” Tithi Bhattacharya reminds us, “the system has a relation of reluctant dependence on processes and institutions of life-making.”[1]

A system that feeds off the labour of living workers must “reluctantly depend” on a certain minimal level of caregiving to sustain and replenish the workforce, but this is primarily treated as a private responsibility falling onto members of working class households (and landing disproportionately on the shoulders of women). This private responsibility is supplemented by deliberately second-rate social assistance, generally stigmatized and designed to encourage “self-reliance” through the market. Welfare payments set well below subsistence and insufficient public housing that is not adequately maintained are examples of services deliberately impoverished.

Caregiving is systematically devalued and under-resourced in capitalist societies, taking the form of unpaid or poorly paid work done disproportionately by women and often women of colour. The devastating impact this pandemic is taking among elderly people and people living with disabilities in long-term care facilities or supportive housing is the result of the crisis of caregiving integral to capitalist societies. On the one hand, resident in these settings are seen as disposable, categorized as “unproductive” and cast aside. On the other hand, the staff who work in these residential settings are deeply undervalued, often working part-time in facilities that are understaffed and under-resourced, without the protocols or protective gear they need for their own health, as well as that of residents and others in their lives. The set-up forces staff members to take on part-time jobs at more than one facility to try to make ends meet, and face brutal challenges trying to reconcile their complex shift schedule in paid employment with their own personal caregiving commitments.

The closure of schools and childcare centres in this public health emergency shows the depths of the everyday household caregiving crisis in capitalist societies. This is not simply an issue of poor caring conditions in underfunded institutions, but also of women struggling to sustain loved ones with inadequate resources, at the same time as bringing in required income where possible. Even with all systems go, women struggle to reconcile the demands of paid labour with those of caregiving for children, parents and partners. The tightness of the schedule even in normal times is clear when a sick child is sent home from child care, interrupting the rhythm of paid labour with inadequate sick days. The burdens of attempting school or work from home while caring for children around the clock are crushing.

Further, lockdown conditions intensify the situation of everyday violence that many women and children face in the household. Caregiving is deeply interwoven with ongoing gendered violence and violence against women that makes the household a place of great danger for many.

This emergency has also highlighted the breadth of caregiving activities in this society. The ability to obtain food to eat, for example, depends on the often undervalued labour of a chain of workers from the grocery stores to the warehouses to the meatpacking factories and the fields. These essential caregiving workers are neither adequately paid nor supported with the protocols and equipment required to ensure their well-being. United Food and Commercial Workers (UFCW) local President Thomas Hesse, representing workers at the Cargill meatpacking plant in High River Alberta, wrote to the employer about an outbreak of COVID-19 infection among workers at the plant. He noted that the organization of the work process pushes employees into close proximity with each other: “Unfortunately, the employer is just not doing enough to protect its employees in this environment. You need to do more.”[2]

Capitalism and Health Politics

The systematic devaluation of caregiving undermines health. But employers and state policy-makers cannot totally ignore health issues in a system that profits from living labour. The current emergency demonstrates clearly the impact a health crisis can have on employers’ bottom lines.

The default position for employers and state policy-makers is to treat workers as disposable and replaceable, ignoring health issues in the workplace or more broadly in society. Clearly, there was plenty of warning and lots of knowledge to prepare for this pandemic, but it simply was not a priority. Already in 2006 the Canadian government had a detailed plan to prepare the health sector for a pandemic much like the present one, but it was not implemented.[3]

The neoliberal strategies that employers and state policy-makers have embraced over the last thirty years have actually undermined the ability to prepare for potential health threats. State services, including public health and health care, have been cut again and again. Further, employers and state policy-makers have sought to increase profits and reduce costs by minimizing stockpiling and preparation in favour of rapid movement of goods along global supply chains and “just-in-time” delivery. The everyday supply of food, medical supplies and other goods depends on this rapid movement without preparation for adverse conditions.[4] We have seen the impact in terms of insecure stock of desperately needed equipment and medication, as well as in the opening up of lines of transmission through people working along supply chains.

But there are times when this default position of human disposability becomes untenable, and health-oriented interventions are required to sustain profits by reluctantly saving lives. State public health interventions have tended to be based on a health-from-above frame, in which medical experts and state authorities work together to instruct or compel the population to do what is required for well-being. The idea is that state and medical authorities must step in to sustain productivity by saving the supposedly ignorant populace from their own worst instincts, including hedonism and shortsightedness. Think of how the AIDS epidemic developed, with public health and state authorities blaming gay men’s erotic choices and trying to shut down gay sexual activity without regard for the impact on peoples’ lives.

Indeed, the history of public health in capitalist societies is full of blaming and shaming that serves to draw lines between the supposedly respectable, moral members of society and the outsiders or “bad actors” who violate norms and serve as vectors of transmission. Yes, viruses travel globally as people move and there are very specific times when some form of travel control makes sense as part of physical distancing to reduce transmission. But this is often overlaid with moral judgment, racism and colonial fixations.

Ill health does not come from outside or from moral non-conformity, but is an essential feature of a society that treats the lives of much of the population as disposable and undermines ecological relations by treating the environment, including other species and indeed human beings, as resources to be extracted. Indeed, the hedonism and short-sightedness authorities claim to be regulating in the name of health are in fact simply the internalization of dominant values of capitalist relations among the population. Most of us in capitalist societies have only limited access to the knowledge, power, or resources we need to practice good health, which includes everything from good nutrition to housing to genuine democratic self-determination to caregiving relations with others.

The health-from-above frame is evident in the use of the language of warfare to describe health promotion in this emergency. Ontario Premier Doug Ford said on April 3, “Everyone has a price to pay in this war.” As Jesse McLaren explains in Spring Magazine:

Like all wars, a ‘war on coronavirus’ demands ordinary people sacrifice their health, financial security and freedoms for a supposed national interest. Like all wars, this diverts spending from health, worsens epidemics, breeds racism, and undermines democracy and civil liberties.[5]

Indeed, pandemic planning in capitalist societies is often focused around national security and economic competition rather than the well-being of the population. The idea of a war for health is used to justify a state of exception in which people are forced to accept a much greater degree of authoritarian intrusion into everyday life, for example through cellphone data collection or police presence in parks. 

The alternative to health-from-above and war-against-coronavirus is not the libertarian assertion of individual rights to disregard our shared health circumstances. The competitive individualism that characterizes capitalist societies undermines our ability to think of health as a communal rather than individual outcome – to recognize the well-being of each of us depends on the situation of all of us. The physical distancing measures associated with this health emergency are about protecting the most vulnerable members of our community, but this society is not organized around social solidarity, and capitalist social relations teach us to think of our own health first.

Health from Below

The real alternative to health wars for national security is “health-from-below,” oriented around life-making. There is a long history of oppressed people – workers, women, queers, people who are racialized, Indigenous people and people living with disabilities – mobilizing to demand the resources, knowledge and power to build health-from-below.[6] Health-from-below draws on the self-activity of vulnerable communities, taking charge of their well-being through mobilization and sharing knowledge.

People learn a great deal about their health from the everyday experience of living in a body in engagement with others. This knowledge is built through informal and formal organizing among vulnerable communities who recognize that those in power cannot be trusted to take care of the well-being of the population. This first hand embodied experience is necessary but not sufficient for effective health mobilization; it needs to be further developed through engagement with expertise and high-quality scientific knowledge and politicized to connect health to dominant power relations.

The AIDS activist movement figured out guidelines for safer sex through collecting and reflecting on community experiences, in the face of experts advising or demanding that gay men give up sex.[7] This embodied knowledge was crucial, but AIDS activists also drew on expertise, devoting great effort to placing demands on state policy-makers, medical experts and scientists to share knowledge and to develop prevention and treatment practices built around the experiences and needs of those most at risk. Such a popular reappropriation, democratization, and reorientation of scientific knowledge toward meeting human needs is especially important at a time when scientific evidence per se – from climate change to the present pandemic – is being written off by right-wing populists, from Trump in the United States to Bolsonaro in Brazil, with a devastating death toll.

Workers’ health-and-safety mobilizations operate on the basic assumption that management will not protect the well-being of workers unless forced to by resistance. There have been important work refusals and wildcat strikes during this pandemic, as workers have demanded access to the resources they need to protect their own well-being and the health of others with whom they work or live.  Some degree of cynicism about the measures introduced by those in power certainly makes sense given the long experience workers share of their health being undermined by work conditions and practices, including the absence of sick days, lack of protective equipment and silencing knowledge of the risks involved in many different work processes. 

There are so many important examples of health-from-below mobilizing to draw on. Trans activists have fought for access to the medical support needed (for example for transition for those who choose it) on their own terms, not dictated by for example psychiatric criteria of who does or does not qualify. Women’s health movements have focused on, in the name of the famous book, Our Bodies Our Selves. Indigenous nations have drawn on traditional healing practices and also demanded access to the means of health in their own communities, ranging from decent housing to potable water to professional health services on the community’s own terms.

These mobilizations share a commitment to building health-from-below, which is about mobilizing popular power and collective expertise. Of course, scientific expertise and professional practice still matters. I personally do not want to crowdsource surgery. But the expertise must be there as a resource for communities on their own terms, not as an authority structure reinforcing subordination and individualization.

Health-from-below brings back relations of reciprocity and mutuality, as opposed to the competitive individual accumulation of health as a contest. People pursue health from below by engaging in collective action to take on health threats by developing the knowledge, resources and practices to pursue communal well-being.   

Utopia against Dystopia

Health-from-below opens up spaces to imagine a better response to the current pandemic, a utopian vision to inspire mobilization so that we never need to repeat this experience of dystopia. Imagine if serious planning had begun years ago, when epidemics such as the 2003 SARS outbreak sounded the alarm about the threat of pandemics. Every neighbourhood, school and workplace should have a democratic health committee that, among other things, runs a community health centre, staffed by accountable practitioners providing a range of services while also offering resources for community education and mobilization.

This is actually not as utopian as it might seem. There were elements of this community-services-from-below model in the development of the Centres Locaux de Services Communautaires (CLSC) in Quebec through the militant mobilizations of the 1960s and 1970s.[8] There are elements of this model in safe drug use sites, women’s health clinics and workers’ health-and-safety resource centres among others, that combine service provision with community mobilization, drawing on the knowledge and experience of service users rather than treating them as passive and ignorant.    

Each neighbourhood and workplace needs to plan at a granular level, engaging community members and workers in the activity of mapping needs and resources and building networks of action to ensure the well-being of all. At the same time, wider processes of citywide, provincial, pan-Canadian and global planning need to take place, with delegated bodies reporting back to local assemblies.

Health-from-below requires a commitment to solidarity, building around the knowledge, experience and needs of the vulnerable communities hardest hit in this pandemic and every other health emergency. Shiri Pasternak and Robert Houle note that Indigenous communities in the Canadian state often lack the basic resources for well-being, such as secure food supplies, potable water, decent housing and effective access to health services. The long historic pattern of Indigenous people facing disproportionate loss and hardship in health emergencies will repeat itself without transformative mobilization.  

Echoing the events of a century ago, when the 1918 Spanish Flu pandemic decimated First Nations communities across the country, this is a crisis that will be defined by three factors: pre-existing divides; the extent to which those in political power are held to account for upholding them; and our ability to seize the moment to transform them.[9]

Similarly, Black Americans are facing particularly dire consequences from this pandemic, as they did from health crises in the past. Rather than solidarity, the dominant response has been blame:

The American medical-industrial complex likes to explicitly or implicitly blame Black Americans for their health outcomes rather than provide the resources and tools to eradicate health inequities…In the past as in today, social factors that are beyond the control of communities of colour are responsible for the increased incidence of illness and are now putting them at a higher risk of a fatal outcome in case of a COVID-19 infection.[10]

In the face of resurgent reactionary nationalisms, the politics of solidarity around health-from-below need to be global and internationalist. The maldistribution of resources that leads much of the population of the Global South to be particularly vulnerable to health emergencies is built into the dominant system of political and economic relations:

The ways that most people across Africa, Latin America, the Middle East and Asia will experience the coming pandemic is a direct consequence of a global economy systemically structured around the exploitation of the resources and peoples of the South. In this sense, the pandemic is very much a social and human-made disaster – not simply a calamity arising from natural or biological causes.[11]

Ultimately, the accomplishment of health-from-below requires a massive, indeed revolutionary, transfer of power to make possible democratic community health planning built on principles of solidarity. Health-from-below is integrally connected to overturning capitalism. But that does not mean that health-from-below must wait until after the revolution.

Mobilization around health-from-below provides the means to save and improve lives right now, by building the collective power aligned with principles of solidarity to take control of key decisions, such as winning access to required protective equipment and protocols for front-line workers by going on strike or refusing unsafe work. Health from below is explicitly political and in this way goes beyond networks of mutual-aid, as important as those are in moments like this. We cannot just be spectators as employers, politicians, policy-makers and medical experts make decisions that are critical to our health, such as when and how it is safe to end stay-at-home requirements.

Here we face a specific challenge. Health-from-below thrives on collectivity, and in this health crisis we are atomized and cast apart. Physical distancing is essential for health right now, and we need to reconcile disruption of everyday community with provision of the resources so that people can both distance safely and sustain networks of love and caring. We also need to be activating every network we can for the urgent work of mobilizing to ensure this dystopia is never repeated. In this emergency, we have seen widespread examples of inspiring wildcat strikes and work refusals for protective equipment and life-saving protocols. These mobilizations provide a crucial example of the struggle we need to build in every workplace, school and community to remake the world around power-from-below and active solidarity. 

[1] Tithi Bhattacharya 2020. Social Reproduction Theory And Why We Need it to Make Sense of the Corona Virus Crisis.                 

[2] David Bell 2020. “Union says 38 confirmed COVID-19 cases at Cargill meat plant cause for closure,” CBC News, April 13, 2020:

[3] Public Health Agency of Canada. 2006.  The Canadian Pandemic Influenza  Plan for the Health Sector.

[4] Kim Moody 2020. “How “Just-in-Time” Capitalism Spread COVID-19 Trade Routes, Transmission, And International Solidarity.

[5] Jesse McLaren 2020 What’s wrong with a “war on coronavirus”? Spring Magazine

[6] I am drawing here on Hal Draper’s conception of “socialism from below” in “The Two Souls of Socialism.”

[7] For rich analysis of the lessons of AIDS activism for the current crisis, see Gary Kinsman 2020 “Some notes on learning from AIDS activism for our responses to the Coronavirus (COVID-19) pandemic” Europe Solidaire Sans Frontières, and Colin Wilson 2020 Safer sex – lessons from the AIDS crisis

[8] Xavier Lafrance told me about this example, mentioning important analysis of the CLSCs in Anne Plourde’s 2019 dissertation, “État-Providence Et Système Socio-Sanitaire Au Québec : Les CLSC Comme Étude De Cas D’une Analyse Matérialiste Et Dialectique De L’état Démocratique Dans La Société Capitaliste”

[9] Shiri Pasternak and Robert Houle 2020, No Such Thing As Natural Disasters: Infrastructure And The First Nation Fight Against COVID-19. Yellowhead Institute

[10] Edna Bonhomme 2020. “Racism: The most dangerous ‘pre-existing condition’ Black Americans are dying disproportionately from COVID-19 and there is a reason for it.” Al Jazeera April 14, 2020

[11] Adam Hanieh 2020. This is a Global Pandemic – Let’s Treat it as Such. Verso Blog

Alan Sears is a member of the Toronto New Socialists and author of The Next New Left: A History of the Future, (with James Cairns) The Democratic Imagination: Envisioning Popular Power in the Twenty-First Century, and Retooling the Mind Factory: Education in a Lean State.

Photo credit: Richard Pedroncelli / AP