EDITORIAL

Revolutionary medicine

Seiji Yamada, MD, MPH; Arcelita Imasa, MD, Gregory Gabriel Maskarinec, PhD

As we are aware that younger people are more socialist principles. The New York Times article likely to be progressive than older people,1 we equates communism with the political systems of address these remarks to young health workers and the Soviet Union and China and notes “no federal health science students. This essay might be official or Democratic candidate advocates construed as something of a missive in the vein of communism.”4 Kropotkin’s “An Appeal to the Young,”2 from This does not, however, exhaust the taxonomy older radicals who accomplished little, to young of socialism. While popular conceptions of the radicals who must accomplish much. We intend political spectrum often range along a single x- our remarks as preliminary, for it will be the axis of left (collectivism) to right (capitalism), young who will re-make the world, and in the consider the addition of a y-axis of ranging from process, they will learn much to teach their individualism (libertarianism, a premium placed descendants. on freedom) to totalitarianism (authoritarianism), as appears here.5 On the left side of this two- The taxonomy of socialism. dimensional grid, individual collectivism = The Harris Poll recently found that four in ten libertarian socialism = anarchism, while Americans, as well as 55% of women aged 18 to totalitarian collectivism = state communism. Of 55, would prefer to live in a socialist country. The note, many anarchists do not concede the term respondents expressed various degrees of support “communism” to the statists, though for specific aspects of socialism. For example, “Communism” (capitalized) is often equated with 76% support universal health care, while 48% Marxism-Leninism-Maoism. agree with “Workers own and control their places What are the implications for medicine? For of employment.”3 This widespread popular the benefit of health workers and health science support for socialism in the U.S. ranges from students, we examine here the ideological bases of agreement with social democratic to democratic different strains of socialism, focusing on the

anticapitalist and revolutionary end of the Seiji Yamada, MD, MPH spectrum. http://orcid.org/0000-0002-5258-4488 E-mail: [email protected] Richard Horton on Marx, Luxemburg, and Arcelita Imasa, MD Goldman. E-mail: [email protected] In his “Offline” columns, Richard Horton, the University of Hawaii John A. Burns School of chief editor of The Lancet, has been suggesting Medicine, Department of Family Medicine and Karl Marx,6 Rosa Luxemburg,7 and Emma Community Health, United States. 8 Gregory Gabriel Maskarinec, PhD Goldman as guiding lights of where we need to University of Hawaii, go in medicine. What does Horton mean by this John A. Burns School of Medicine, Departments of choice of forerunners? In his column on Marx, Native Hawaiian Health & Family Medicine and Horton points to the imperative to combat the Community Health, United States corporate takeover of medicine. Horton is thus http://semioweb.msh- calling for an anticapitalist turn in medicine. Marx, paris.fr/AAR/161/introduction.asp?id=161 Luxemburg, and Goldman certainly share a E-mail: [email protected] critique of capitalism. However, their Received: June 2019. revolutionary zeal is another shared characteristic. Accepted: December 2019. Sources on Marx abound. Vicente Navarro’s Conflict of interest: none. Medicine Under Capitalism9 and the writings of

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Howard Waitzkin are useful introductions to man and the value of life has been eliminated; applying Marx to health and medicine. coercion at every step has made effort bitter, Luxemburg engaged in polemical debates labour a punishment, has turned the whole of contra Lenin in the Second International, which existence into a scheme of mutual deceit, and was limited to Marxist-style socialism in the early has revived the lowest and most brutal th instincts of man. A sorry heritage to begin a 20 century. Luxemburg called for a more new life of freedom and brotherhood.10 democratic form of socialism than did Lenin, who While Goldman did not completely disavow may have called for “All power to the soviets violence in defense of the revolution, she came to (workers’ councils)” but actually arrogated all believe that the resort to violence encouraged a power to the Bolshevik Party in the name of the descent into brutality. Her view of the ultimate end “dictatorship of the proletariat.” On the national of revolution was a de-centralized, organic society question, Luxemburg argued that the socialist that valued health, beauty, art, and science. revolution needs to occur internationally and must Real wealth consists in things of utility include the advanced industrial countries, which in and beauty, in things that help to create th early 20 century Europe included Germany and strong, beautiful bodies and surroundings Great Britain. Lenin maintained that socialist inspiring to live in. But if man is doomed to revolution can be implemented in a single country, wind cotton around a spool, or dig coal, or even an agrarian one such as Russia. At the outset build roads for thirty years of his life, there of World War I, the Second International died can be no talk of wealth. What he gives to the when German Social Democracy and British world is only gray and hideous things, Labor voted for war credits for their respective reflecting a dull and hideous existence, too weak to live, too cowardly to die. Strange to nations, essentially selling out to the war fever say, there are people who extol this deadening promoted by their capitalist classes. method of centralized production as the Thus, to invoke Luxemburg is to call for more proudest achievement of our age. They fail democratic formations on the path to socialism utterly to realize that if we are to continue in and for international solidarity against capital, and machine subserviency, our slavery is more to critique capital’s drive toward imperial war. complete than was our bondage to the King. Others may cite Lenin’s "Imperialism: the highest They do not want to know that centralization stage of capitalism." With the 20th century and the is not only the death-knell of liberty, but also historical experience of Lenin, Stalin, and Mao of health and beauty, of art and science, all behind us, we look to re-invigorate the drive for these being impossible in a clock-like, mechanical atmosphere.11 socialism that avoids their errors. This is not the “By any means necessary” is a phrase place to engage in a litany of the historic "crimes popularized by Malcolm X. Do the ends justify the of communism" (capital’s apologists do enough means? To achieve the desired society of the for us all) - for the contemporary crimes of future, should we countenance violence? Should capitalism are what we, embedded in global we countenance the dictatorship of the proletariat? capitalism, need to focus and act upon. Should we put our hands in the fate of a central Goldman was an anarchist, and anarchists had authority? Emma Goldman counsels us against been ousted from the First International when doing so. Marx expelled Mikhail Bakunin. Nonetheless, she Therein, perhaps, lies the problem with visited Revolutionary Russia, where she was anarchism. Anarchists tend to believe that humans disillusioned by the Bolshevik takeover. are by nature good, that if humans were freed from Witness the tragic condition of Russia. The methods of State centralization have unjustified authority, that they would naturally paralysed individual initiative and effort; the organize themselves for mutual benefit, tyranny of the dictatorship has cowed the theoretically possible but undocumented in people into slavish submission and all but practice. extinguished the fires of liberty; organized terrorism has depraved and brutalized the Social medicine and revolutionary medicine. masses and stifled every idealistic aspiration; The revolutionary medicine espoused here is institutionalized murder has cheapened grounded in social medicine. As noted by human life, and all sense of the dignity of

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Anderson, Smith, and Sidel, the fundamental the position of the minute hand takes into account precepts of social medicine are that worsening climate security, the clock is largely known for indicating the proximity of the threat of 1. Social and economic conditions profoundly nuclear war. The Bulletin currently cites the U.S. impact health, disease, and the practice of withdrawal from the Iran nuclear agreement and medicine. the Intermediate Nuclear Forces Treaty (INF), the 2. The health of the population is a matter of unresolved North Korea situation, and the turn 15 social concern. toward high-tech, automated weaponry. 3. Society should promote health through both Another, mediating threat to human survival individual and social means.12 is severe inequality – among nations and within nations. For having contributed little historically to In The Second Sickness, Howard Waitzkin the greenhouse gases in the atmosphere – many identifies the forerunners of social medicine to be developing states are most vulnerable to climate Friedrich Engels, Rudolf Virchow, and Salvador catastrophe. Sea-level rise poses a threat to the Allende.13 Social medicine counts among its very existence of small island states and low-lying practitioners Ernesto “Che” Guevara, the Barefoot coastal regions. States in the pathway of tropical Doctors of Revolutionary China, and Cuban cyclones are particularly vulnerable. Those who doctors around the world. The Declaration of experience racial discrimination, and the poor are Alma Ata, i.e. The Declaration on Primary Health particularly vulnerable to severe weather events. Care of the Joint WHO/UNICEF Conference in They live in inadequate dwellings. Their houses Alma-Ata, USSR, 1978, drew on these forerunners are in low-lying areas which experience more as the key to attaining the goal of Health for All by flooding. Large regions of the world also face the Year 2000. deteriorating social, political, economic, and Obviously 2000 has come and gone, and we environmental conditions due to conflict, do not yet have Health for All. Unfortunately, we pollution, corruption, famine, population are no longer in a position to hanker for Health for displacement. The Anthropocene Age is All. Rather, we must focus on the survival of the characterized by catastrophic loss of biodiversity human species. whose global consequences will be disastrous for all species, including our own. Possible Why we need revolutionary medicine unanticipated consequences of synthetic biology now. Climate catastrophe, threat of nuclear war, and artificial intelligence conjure unimaginable inequality. future threats to all humanity. Noam Chomsky (who calls himself a Globally, health, health care, and health libertarian socialist or an anarchist) points to two delivery systems are in crisis. Despite major existential threats to the survival of the human advances throughout the last two centuries species: climate catastrophe and the threat of extending life-spans, reducing infant mortality, nuclear war. The effects of global warming and eliminating smallpox, the promise of caused by human activity, the loss of ice, the rise improved health and better health care for all in sea levels, and altered weather patterns with people everywhere recedes. Individuals and more severe weather events are already communities, particularly the poorest and most evident. Our planet has crossed a tipping point at marginalized in every country, continue to suffer which the greenhouse gases already in the from avoidable infectious diseases such as atmosphere will affect the climate for the tuberculosis, malaria, HIV, cholera, Zika, dengue, remainder of the Anthropocene age. Will it be Ebola, and COVID-19, even as antimicrobial called the Anthropocene after human civilization resistance increases and vaccination refusal results has collapsed? The time scale for that collapse in a resurgence of preventable childhood diseases; draws ever closer, with an Australian think tank populations everywhere (not just the poorest and predicting that it may occur before 2050.14 least privileged, though they are less likely to The Doomsday Clock, which appears on the receive treatment) have rising rates of chronic cover of the Bulletin of the Atomic Scientists, is noncommunicable diseases, including diabetes, currently set at 100 seconds to midnight. While cancer, heart disease, and obesity. Other threats

Social Medicine (www.socialmedicine.info) -114- Volume 13, Number 3, September December 2020 urgently needing to be addressed include the cancer in the long run, but as one of the few surveillance state, automation and job loss, ways he has of coping with stress, it may save imperialism, racism and xenophobia, sexism, the lives of his wife and children. Our LGBTQ exclusion, and reproductive injustice. assumption of conditional rationality means Incremental reforms will not be enough to that we cannot expect to change behavior by education alone: rather, we must alter those mitigate these existential threats to human circumstances that make such harmful survival. It is increasingly evident that we cannot choices seem optimal. 18 eliminate these threats unless we throw off From the reductionist, individualist capitalism as the fundamental basis of our perspective, we might say in the name of harm economic and social life. This situation demands reduction, “Go ahead and smoke.” From the of us that we adopt revolutionary thinking and revolutionary perspective, we need to work with revolutionary practice. the man, the woman, their workplaces, and their societies to combat alienation, addictions, and The scientific basis – against reductionism. violence against women and children. Revolutionary medicine is the medicine The perspective of most who work in wherein health workers understand the social medicine is a scientific one. Throughout our origins of illness and the need for social change to primary and secondary education, we become improve health conditions. It is created from the familiar with the scientific world view. The practice of the people’s struggles against their perspective is also a materialist one. An aside: oppressive conditions. Revolutionary medicine Both Bakunin and Marx wrote extensively about serves the oppressed classes in advancing their their commitment to materialism and atheism. Of struggles. course, there are many people who are deeply religiously committed and who disagree with the Proletarianization of health workers. philosophically materialist viewpoint. Yet many Writing in the New York Times, Danielle Ofri religious people are anticapitalist and participate in notes that the increasing complexity of patient care revolutionary action. and administrative burdens, including the In health professional schools, we delve into electronic health record, are accomplished by the basic biological sciences. The perspective of nurses and doctors who work harder and longer much of Western science is reductive and hours. She wonders if this exploitation of health Cartesian. If a phenomenon can be explained by workers is simply the business plan of the the more reductionist science (e.g., a biological corporations that increasingly control the health phenomenon via biochemical mechanisms) – that care system.19 In Marx’s labor theory of value, makes it more scientifically plausible. Physicists difference between the price that a good (in this are thus wont to see themselves as having a front case, health care) commands in the marketplace - seat to reality. The underlying assumption is that and the cost of producing this good, which is science is “the paradigmatic human activity, and largely labor – is the profit margin, that is the that natural science discovers truth rather than surplus labor that is extracted from the worker. makes it.”16 Thus, commodified medicine leads to the As Marx noted, however, in his eleventh proletarianization of health workers.20 That is to thesis on Feuerbach: “The philosophers have only say, they find themselves alienated from their interpreted the world, in various ways; the point is patients, the products of their work (better health to change it.”17 For the practitioner of for their patients), and their workplace. revolutionary medicine, there may be reasons to Consequently, we become alienated from our think not reductively, but rather dialectically, as in fellow workers, and ultimately, from ourselves. Levins and Lewontin’s The Dialectical Biologist. Health worker alienation from oneself is In the most public health of the chapters, sometimes described as "burnout," but a more “Research needs for Latin community health,” accurate term would be "moral injury." Health as a Levins notes For instance, a man's decision to smoke commodity is unacceptable, not only diminishing may increase his risk of heart disease and

Social Medicine (www.socialmedicine.info) -115- Volume 13, Number 3, September December 2020 the health care of individual patients but causing mind, without ever becoming hunter, the entire society to be ill, dis-eased. fisherman, herdsman or critic.21 We have less and less control over how we The post-revolutionary health care worker work: insurance corporations require adherence to will not be limited to being a neurosurgeon or a their specific formularies. They pile burdensome nurse anesthetist. She will be a family doc that just prior authorization work on us. They deny has to upload a program. One can imagine a scene treatments we order for our patients. Our taking place in the near future in a remote hospital: employers escalate their documentation demand in Nurse Neo to family doctor Trinity: Can you a coding arms race with insurance corporations. fix this subarachnoid hemorrhage? Granted, nurses and doctors are professionals who Dr. Trinity: Not yet. (She speaks into her command salaries far higher than trades workers phone.) Tank, I need a program for the or unskilled workers – they are increasingly surgical approach to clipping an aneurysm. proletarianized. Nonetheless, we health Hurry. (Her eyelids quiver briefly.) Let’s professionals need to develop class consciousness go. 22 as a class of workers that is having surplus labor She will not waste her evenings and weekends value extracted from us, that is increasingly remotely accessing her EHR. She might write alienated from the service we perform, and from some science fiction, or she might kick some our own humanity. counter-revolutionary agent butt. Solidarity among health care workers will Throughout history, empires have flourished ensure that health is recognized as a human right, and collapsed without threatening the existence of not something to be bought and sold, that surplus the entire human population. Epidemics typically labor should not be extracted for profit within the (with notable exceptions) had very limited health care profession, but used by the health care geographic distribution. Neither scenario now fits workers themselves to ensure healthy lives for the world today. We are now global citizens, who themselves and their communities. In the future, need to create cohesive, equitable, socially just electronic algorithms may do much of the societies that address health everywhere, or all of diagnosis, treatment, and "curing" of common us will face increasing threats to our own health complaints, allowing health care workers to once and well-being. Revolutionary medicine is more focus on patient-centered "healing," not on required to create such a society. electronic charts, billing, and administrative hoops, instead aiming for a healthier population in Conclusion its widest sense, and at the individual level of the health care team themselves. This essay has drawn on both Marxist and For as soon as the distribution of anarchist currents in its formulation of labour comes into being, each man has a revolutionary medicine for the current situation. particular, exclusive sphere of activity, Marx is necessary for his analysis of capitalism, which is forced upon him and from which his historical materialism, for his labor theory of he cannot escape. He is a hunter, a value, for his formulation of history as the history fisherman, a herdsman, or a critical critic, of class struggle, for his emphasis on praxis. and must remain so if he does not want to Anarchism is necessary for its hatred of lose his means of livelihood; while in capitalism, emphasis on freedom, its defiance of communist society, where nobody has authority, and its radical democracy. For you, the one exclusive sphere of activity but each reader, who is inescapably free (as Sartre tells us), can become accomplished in any branch you are free to choose what you like from this he wishes, society regulates the general essay. May it help you with your own praxis. production and thus makes it possible for me to do one thing today and another References tomorrow, to hunt in the morning, fish in the afternoon, rear cattle in the evening, 1 Pew Research Center. The Generation Gap in criticise after dinner, just as I have a American Politics. Cited 13 June 2019. Available

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from: https://www.people-press.org/2018/03/01/the- 13 Waitzkin H. The Second Sickness: Contradictions of generation-gap-in-american-politics/ Capitalist Health Care (Rev. And updated ed. 2 Kropotkin P. An Appeal to the Young, 1880. Cited 13 Lanham, MD: Rowman & Littlefield, 2000. June 2019. Available from: 14 Spratt D, Dunlop I. Existential climate-related https://theanarchistlibrary.org/library/petr- security risk: A scenario approach. May 2019. Cited kropotkin-an-appeal-to-the-young 12 June 2019. Available 3 "Axios on HBO" poll: 55% of women prefer from: https://docs.wixstatic.com/ugd/148cb0_e86d7 socialism. Cited 11 June 2019. Available 809ba9745239d177488d4b967a9.pdf from: https://www.axios.com/axios-hbo-poll-55- 15 Science and Security Board. Closer than ever: percent-women-prefer-socialism-f70bf87e-34fd- It is 100 seconds to midnight. Bulletin of the 4b63-b1f6-2f2b6900f634.html Atomic Scientists. Cited 14 February 2020. 4 Astor M. What Is Democratic Socialism? Whose Available from: https://thebulletin.org/doomsday- Version Are We Talking About? New York Times, clock/current-time/ 12 June 2019. Cited 13 June 2019. Available 16 Rorty R. Contingency, Irony, and Solidarity. New from: https://www.nytimes.com/2019/06/12/us/polit York: Cambridge University Press, 1989. ics/democratic-socialism-facts-history.html 17 Marx K, “Theses on Feuerbach,” Marx/Engels 5 Christie S, Meltzer A. The Floodgates of Anarchy. Selected Works, Volume One. Moscow, USSR: 1970. Cited 13 June 2019. Available from: Progress Publishers, 1969. Cited 13 June 2019. http://theanarchistlibrary.org/library/stuart-christie- Available albert-meltzer-the-floodgates-of-anarchy#toc11 from: https://www.marxists.org/archive/marx/works 6 Horton R. Medicine and Marx. Lancet. 2017 Nov /1845/theses/theses.htm 4;390(10107):2026. 18 Levins R, Research Needs for Latin Community 7 Horton R. Rosa Luxemburg and the struggle for Health. In Levins R, Lewontin R, The Dialectical health. Lancet. 2019 Jan 12;393(10167):114. Biologist, p. 246. 8 Horton R. Liberty vs equity in global health. Lancet. 19 Ofri D, The Business of Health Care Depends on 2018 Mar 24;391(10126):1134. Exploiting Doctors and Nurses. New York Times. 9 9 Navarro V. Medicine Under Capitalism. Ann Arbor, Jun 2019. Cited 10 Jan 2021. Available from: MI: Prodist, 1976. https://www.nytimes.com/2019/06/08/opinion/sund 10 Goldman E. My Further Disillusionment in Russia. ay/hospitals-doctors-nurses-burnout.html Cited 12 June 2019. Available from: 20 Waitzkin H, Doctor-Workers: Unite! Medscape https://theanarchistlibrary.org/library/emma- Internal Medicine. 20 May 2016. Cited 30 Jun 2019. goldman-my-further-disillusionment-in- Available from: russia#toc13 http://www.medscape.com/viewarticle/863297 11 Goldman E. Anarchism and Other Essays. Cited 12 21 Marx K. The German Ideology. 1845. Cited 30 Jun June 2019. Available 2019. Available from: from: https://theanarchistlibrary.org/library/emma- https://www.marxists.org/archive/marx/works/1845/ goldman-anarchism-and-other-essays german-ideology/ch01a.htm 12 Anderson MR, Smith L, Sidel VW. What is Social 22 Yamada S. Doctors should start watching more Medicine? Monthly Review. 2005 Jan 1;56(8). science fiction. Here’s why. Kevinmd. 12 Dec 2017. Available from: Cited 30 Jun 2019. Available Http://www.monthlyreview.org/0105anderson.htm from: https://www.kevinmd.com/blog/2017/12/doct ors-start-watching-science-fiction-heres.html

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