I never went to Dixmont, though lots of my high school
classmates and friends did. My parents mildly discouraged me from venturing up into
the thickly wooded hills where it sat, not because kids went there to drink and
smoke and scare each other (which they did) but because the dilapidated
buildings were full of friable asbestos and the underground tunnels were probably
even more structurally unsound than the buildings. The property, at the time I
was a teenager, had been essentially abandoned for more than a decade.
Dixmont was named after Dorothea Dix, the nurse and reformer
whose lobbying efforts were instrumental in creating the asylum system in the
United States. The asylum movement, originating in the 1840s, aimed to improve
the treatment of people with mental illnesses, who were typically subject to a
litany of esoteric forms of abuse and neglect including, but not limited to, exorcism,
bloodletting, and warehousing in jails. Dix, who worked in a jail as an English
teacher, was shocked by the conditions that psychiatric patients were subjected
to and made it her life’s work to advocate for more humane treatment. She spent
decades campaigning for state governments to open asylums, and in this she was
successful. Dixmont State Hospital in Kilbuck Township, Pennsylvania—roughly 12 miles up
the Ohio River from downtown Pittsburgh—was one of the fruits of her labors. At
its peak, the hospital held more than 1,000 patients in therapeutic
incarceration on its (originally) state-of-the-art campus including several
buildings, manicured grounds, and even its own cemetery.
The reform movements that created the asylum system produced
a myriad of new problems, cruelties, and abuses in the attempt to address the
old ones. Dixmont, like other institutions around the country, came to embrace the
disquieting practices of midcentury psychiatry, with the extensive use of
restraints (including, when it became available, use of the antipsychotic drug
thorazine as a “chemical” restraint), hydrotherapy (worse than it sounds), and
electroshock. By the 1970s, Dixmont was in financial trouble, and in 1984 it
was finally closed for good. The buildings were demolished years later, and all
that remains today is the overgrown Dixmont cemetery, where patients were
buried after they died in the hospital.
Why and how would a reform movement dedicated to improving
treatment, and to treating psychiatric patients with humanely and with dignity,
result in something like a Willowbrook or a Danvers? A recent book by Beatrice
Adler-Bolton and Artie Vierkant, Health Communism, suggests an answer: The asylum
movement operated by, through, and according to the logic of surplus. The
authors propose that, in capitalist societies, the distinction between a
productive worker and an unproductive surplus drain on the public is at
the heart of contemporary notions of sickness and health. The authors argue
that this dividing line between worker and surplus is imaginary—and
consequently that “health” is not the individual physiological state that we
are accustomed to thinking of like a private property right. Rather, they
argue, what we call health comes down to the capacity perform waged work, to
sustain oneself without help or public expenditure. Though the division between
worker and surplus is imaginary, it is an ongoing process of negotiation and
certification with real effects. The division is enforced not only by
institutions like Dixmont but by the entire structure of contemporary health
care.
The economic valuation of life is at the root of the variety
of ills enacted by and through the health care system. Contemporary
preoccupations with cost containment, the “overconsumption” of health care, and
the ideological preference for “cost-sharing” or making individuals bear part
or all of the “costs” of their care all flow from the economic valuation of
life. This, per Adler-Bolton and Vierkant, is why the logic of health insurance
in the United States relies (and must rely, stubbornly and in the face of
widespread and well-known inefficiencies) on rationing and means-testing care
provision. Rationing occurs first and foremost by employment status—50 per cent
of Americans have employer-sponsored health insurance—but also through
notoriously opaque and uneven price, ability to pay, and the variety of
profit-seeking tactics insurance companies and hospital systems pursue, such as
prior authorizations for certain procedures or medications.
If you’re too sick to work, you will be forced into poverty
twice over: First by the loss of wages, and second, if you’re lucky, by the
grueling process of securing Social Security Disability Insurance, or SSDI (a
process Adler-Bolton has been through). Eligibility for SSDI is determined via
strict federal determination of a qualifying disability and accrual of
enough “work credits” to receive the income support payments. Supplemental
Security Income, or SSI, strictly limits the assets or non-work income that a
beneficiary may have: Individual recipients may not have more than $2000 in
so-called countable assets, including money in savings accounts, and to have an
asset (like a piece of jewelry) exempted from the limit involves a byzantine
process of actuarial determination (jewelry may be exempted if the individual
can establish that they wear it regularly or that it holds sentimental
significance). SSDI does not place limits on these assets, but does limit the
income beneficiaries may earn through work.
The reality is that even if a person can access the SSDI
benefit—Adler-Bolton and Vierkant refer to the typically two-year-or-longer
application process as the “death window” for the number of people who perish
waiting for their benefits to be approved—they will be subject to periodic
federal reviews of their medical status to determine that they are still
disabled and severely restricted in their ability to earn money above and
beyond the low payments. The logic underpinning SSDI is that a person who is
able to earn sufficient income through work is not disabled. The ability to
work is how the bureaucratic state distinguishes the truly sick from the truly
healthy; the equivalence of health with productivity determines how miserly
public benefits are rationed and distributed.
Institutionalization, the process that
filled asylums like Dixmont, and deinstitutionalization, the process that
emptied them, are also related to the economic valuation of life. Both
institutionalization and deinstitutionalization furnish examples of one of the
central concepts of Health Communism, what Adler-Bolton and Vierkant
term “extractive abandonment.” (Health Communism is strongly influenced by Ruth Wilson Gilmore’s 2007
abolitionist classic Golden
Gulag, and their term takes off from her term
“organized abandonment.”) Extractive abandonment describes how unproductive
“surplus” populations are not just abandoned politically (and warehoused in a
prison, asylum, or nursing home, for example) but are also exploited, as
corporations and other private interests extract whatever profits they can wring
from them or their care and maintenance.
The several distinct waves of deinstitutionalization,
beginning around the 1950s, were in part a response to the widespread
institutional abuses exposed by journalists and advocates. Yet deinstitutionalization
did not always return psychiatric patients to community living, and rarely accomplished
their seamless integration into community life. Instead, as the authors write,
deinstitutionalization generally “redistributed the asylum’s responsibilities
into a vast, chaotic network of public and private entities” like nursing homes
and general hospitals.
The causes of this shift were political-economic as much as they
were moral. Medicare and Medicaid, the safety-net health insurance programs in
effect from 1966, were powerful drivers of deinstitutionalization. Medicaid, for
example, covered psychiatric services provided in hospital settings, but not
the same services provided in state-run psychiatric hospitals. This state
preference for private, non-asylum care built into Medicaid (and probably
motivated by the horrific reputation of state asylums, in addition to
capitalistic ideology) precipitated rapid growth of acute care beds for
psychiatric patients in general hospitals. The effect was to essentially
privatize psychiatric care, folding it into the private health care and
specifically the hospital system. Partially as a result of this, mental and
behavioral care are, today, some of the most inaccessible health services.
(Another brief example: since states split Medicaid costs with the federal
government, states could save money by moving patients from 100 per cent state-funded
institutions into private, for-profit nursing homes, for which the federal
government will match the state’s Medicaid contribution.) The incentives of
Medicare and Medicaid funneled people in need of psychiatric care into general
hospitals where their treatment generates profits for the hospital system, all
while imposing costs on sick individuals.
The worker-surplus dividing line is permeable—people cross
it whether they want to or not. Today’s workers are tomorrow’s surplus, and
vice versa. The political economy of capitalism, not biological destiny, yoked
the concept of health to economic productivity. As just one example, American
psychiatry facilitated a long process of surplus-making over a period of a
century, consigning people to lonely life terms in state asylums on the basis
of shifting, historically contingent diagnostic criteria.
What’s more—someone (anyone) can be both worker and surplus
at the same time. Until 2020, “essential worker” was an obscure administrative
term that the Department of Homeland Security used to refer to workers in
sectors and occupations (like health care or the power grid) crucial to
national public health and safety. At the beginning of the pandemic, for a
brief moment of unity, these workers were celebrated for their bravery and
resilience as they showed up to extremely hazardous jobs with very little
protection. Quickly and in tempo with the relentless march of Covid normalization, this term came to encompass anyone who could be impelled (either
by administrative fiat or economic desperation) to resume in-person work, who
didn’t have the economic or political power to work from home—that is to say,
working class people. Many epidemiological investigations conducted since the
start of the pandemic confirm that working class people have suffered and died
disproportionately.
The work—of intubating patients, cleaning hospital rooms,
delivering packages, stocking shelves, waiting tables, and staffing hotels so
that organizations that booked in-person conferences pre-2020 don’t lose huge
amounts of money—is so essential that it must not go undone. The workers,
however, are treated curiously like surplus in the context of unchecked viral
spread: exploited as usual, and
abandoned to constant exposure to potentially debilitating or lethal harm. As
Adler-Bolton and Vierkant argue, and many have said—in the world post-2020, we
are all surplus. This realization has explosive political potential in that the
very necessity of surplus populations to industrial capitalism carries within
it both the threat and promise of refusal.
This revolutionary potential is treated in the latter
chapters of Health Communism, which
are devoted to one of the first and most comprehensive English-language
accounts of the radical German patients’ group Sozialistisches Patientenkollektiv, or SPK. The work of SPK is the
other major influence on Health Communism
in both theory (“under capitalism, not all of us are sick, but none of us are
well”) and practice. The title alone of the SPK pamphlet Aus der Krankheit eine Waffe machen (“make illness into a weapon”)
neatly encapsulates the core argument and core purpose of Health Communism. The carpal tunnel and high blood pressure of an
office worker, the missing limbs and eyes of a steel worker, the administrative
and financial burdens of seeking mental health treatment, or the constellation
of long Covid symptoms affecting people from all walks of life are all evidence
that, as literary critic Terry Eagleton has put it, “capitalism plunders the
sensuality of the body.”
They also demarcate a class—the surplus class—with the
collective power to create serious political problems and opportunities that,
for example, the Biden administration has not reckoned with. Experiencing
symptoms of long Covid is a problem for individual people; four million people
unable to work because of symptoms of long Covid is a political and economic
crisis for the government, whichever party holds it.
Mapping the connections between health, debility, and
sickness is akin to a consciousness-raising activity, crucial to building the
type of solidarity it will take to realize Adler-Bolton and Vierkant’s goal of
“all care for all people.” Health
Communism is, most fundamentally, a call for a new and expansive concept of
health as a commons, a collective experience and a collective commitment to
human flourishing, freed from the ideological and financial strictures of
market discipline.
In 1999, 15 years after it closed, the Dixmont property was
acquired by a private family partnership. In 2005, that partnership sold the
property to developers, with plans to turn the site into a shopping center with
a Walmart Supercenter as the anchor. By the following year, the buildings had
been demolished in preparation for the redevelopment and then, two years later,
the hillside on which the property sits shrugged up and gave way in a massive
landslide that temporarily covered the highway below. Walmart abandoned the
plans, suing the other developers to try to recover some of its costs on its
way out. All that remains today is a fenced-off section of denuded hillside,
and the Dixmont cemetery.
