Excerpted from Health Communism (2022)

Eleanor Antin, Dance of Death from Femfolio, 2009

The production of death under capitalism is well understood. Innumerable terms and theoretical formulations exist to define the endpoint of capital’s immiseration, the one constant to human life that our political economy is particularly adept at expediting. “Social murder” is the term used by Engels and his contemporaries. “Its deed is murder just as surely as the deed of the single individual; disguised, malicious murder, murder against which none can defend himself, which does not seem what it is, because no man sees the murderer, because the death of the victim seems a natural one, since the offence is more one of omission than of commission.” Likewise “statistical genocide,” or “democide.” Lauren Berlant called this “slow death”—“mass physical attenuation under global/national regimes of capitalist structural subordination.”

Beatrice Adler-Bolton and Artie Vierkant, Health Communism. Verso Books, 2022. 240 pages.

The finality of death in the social imaginary as the ultimate conclusion of capital’s violence can produce fantasies of a moral or ethical capitalism. This is arguably the dream chased by capital’s true believers: with modifications to its systems, we can slow slow death to a crawl, render statistical genocide statistically insignificant. With “premature” death the imagined enemy of capital’s internal narrative of its own beneficence, minor reforms become enshrined as a legible mirage. But the primary sites of violence under capitalism are not those that lead directly to death. They are instead the quotidian forms that situate capitalist belonging; the reproduction of norms socially as well as legally and administratively, abetted by a “cynical din of knowledge production” that institutionalizes logics of eugenics and austerity.

For this reason, we focus not on how capitalism reproduces death but on how and why capital keeps you alive. We consider what is elsewhere called administrative violence; in the words of Dean Spade, “how law structures and reproduces vulnerability.” We follow how those marked as vulnerable by administrative violence are not only immiserated, but also become the object of capital accumulation.

Central to this is the figure of the surplus population(s), the necessarily amorphous and indefinable category that is the focus of our project. How the political economy has evolved in the last century to maximize its exploitation of the surplus populations—pathologizing with one hand while generating capital with the other—is a process that must be understood by those mobilizing for health justice or health communism, and to begin to imagine a world free of the eugenic philosophy of capitalism. It is toward this understanding that Health Communism begins.

The surplus population was initially defined in economic terms in separate writings by Engels and Marx in response to the moralizing, demographic panics of industrial capitalism’s early philosophers, among them Adam Smith and Robert Malthus. (Smith: “The demand for men, like that for any other commodity, necessarily regulates the production of men”; Malthus: “A distinction will in this case occur, between the number of hands which the stock of society could employ, and the number which its territory can maintain.”) Both Engels and Marx, in referring to the surplus populations as capital’s “general reserve army,” make clear that their formulation has to do in large part with the population of unemployed people who could otherwise be a part of the labor force. Engels refers to the surplus populations as “keep[ing] body and soul together by begging, stealing, streetsweeping. . . It is astonishing in what devices this ‘surplus population’ takes refuge.”

Health, disability, and debility are largely absent from early discourses around the surplus populations that Marx and Engels responded to, except in cases of characteristic pathologizing of the poor. (Malthus again: “The labouring poor . . .seem always to live from hand to mouth. Their present wants employ their whole attention, and they seldom think of the future.”) Engels and Marx do, however, share concerns for the public health of the surplus population and the disablement wrought by industrial production. Engels’ The Condition of the Working Class in England can be regarded as an early work of “social” epidemiology, locating capital’s impact on the social determinants of health just as the idea of public health was at its formation. Marx notes of the relationship between health, private sector industrialization, and the state, that

health officers, the industrial inquiry commissioners, the factory inspectors, all repeat, over and over again, that it is both necessary for [factory] workers to have these 500 cubic feet [of space per person], and impossible to impose this rule on capital. They are, in reality, declaring that consumption and the other pulmonary diseases of the workers are conditions necessary to the existence of capital.

A contemporary understanding of what it is to be “surplus” is necessarily more expansive. Major societal shifts in the late modern period, discussed at length in our chapter LABOR, solidified the worker/surplus binary in public consciousness in part by incorporating a conception of workers’ health or disability as a central facet in their certification as surplus.

The surplus, or surplus populations, can therefore be defined as a collective of those who fall outside of the normative principles for which state policies are designed, as well as those who are excluded from the attendant entitlements of capital. It is a fluid and uncertifiable population who in fact should not be rigidly defined, for reasons we discuss below. Crucially, this definition also elides traditional left conceptions of the working class or the “worker.” As we will describe at length throughout Health Communism, the idea that the worker is not a part of the surplus populations, yet faces constant threat of becoming certified as surplus, is one of the central social constructions wielded in support of capitalist hegemony. Similarly, the methods the state employs to certify delineations between surplus populations constitute effective tactics in maintaining this hegemony. An understanding of the intersectional demands of those subjected or excluded by capital constitutes the potential for building solidarity, which is definitionally a threat to capital. An understanding that the marking and biocertification of bodies as non-normative or surplus constitutes a false, socially constructed imposition of negative value is also a threat to capital. An understanding that illness, disability, and debility are driven by the social determinants of health, with capital as the central social determinant, itself constitutes such a threat. We argue therefore that in order to truly mount a challenge to capitalism it is necessary that our political projects have and maintain the surplus at their center.

While the surplus population does contain those who are disabled, impaired, sick, mad, or chronically ill, the characteristic vulnerability of the surplus is not inherent to their existence—that is, it is not any illness, disability, or pathologized characteristic that itself makes the surplus vulnerable. Their vulnerability is instead constructed by the operations of the capitalist state. The precarity of the surplus population is made through what Ruth Wilson Gilmore calls “organized abandonment,” the deliberate manipulation and disproportionate dispossession of resources from Black, Brown, Indigenous, disabled, and poor communities, rendering them more vulnerable to adverse health.

Understanding the shifting social constructions of surplus under capitalism, and the organization of this “organized abandonment,” is uniquely illustrative of the imbrication of health and capital. At the time of its initial formulation, surplus populations are largely discussed in the sense of surplus constituting “superfluous” (another term wielded synonymously for this population at the time) or otherwise irrelevance, waste. We can see this literalized in early American labor benefits: the few national unions that offered a permanent disability benefit paid a sum equal to the meager benefit a worker’s family would receive on the worker’s death. A worker becoming disabled thus not only constitutively passed the boundary from “worker” to “surplus”—their social value following disablement was, effectively, as good as dead.

This categorization and certification of surplus has become a focal struggle in the history of capitalism, socially reproducing a collective imaginary of who is a worker, who is property, and who is surplus—and to what degree of personhood each category is “entitled” under the scope of law. Those who are deemed to be surplus are rendered excess by the systems of capitalist production and have been consequently framed as a drain or a burden on society. But the surplus population has become an essential component of capitalist society, with many industries built on the maintenance, supervision, surveillance, policing, data extraction, confinement, study, cure, measurement, treatment, extermination, housing, transportation, and care of the surplus. In this way, those discarded as non-valuable life are maintained as a source of extraction and profit for capital.

This rather hypocritical stance—the surplus are at once nothing and everything to capitalism—is an essential contradiction Liat Ben-Moshe identifies this characteristic through the intersection of disability and incarceration: “Surplus populations are spun into gold. Disability is commodified through [a] matrix of incarceration (prisons, hospitals, nursing homes).” Jasbir Puar, in The Right to Maim: “Debilitation and the production of disability are in fact biopolitical ends unto themselves . . . Maiming is a source of value extraction from populations that would otherwise be disposable.

In much of the following, we situate our analysis of the social construction of surplus through the lens of disability, as one of the many contingent embodiments of surplus identities. Disability not only operates as one perceived extreme of the worker/surplus binary but is also understood within the capitalist political economy as constituting, or at least including, a state of being irremediably ill or unwell. In this sense, it is a total ideological reduction of the subject into a valuation of what role they are certified as “capable” to adopt under capitalism. Far from being left as an abstract category, the state, including the constituent social-reproductive apparatuses upholding it, has developed over time an array of tools to certify the exact boundaries of what qualifies an individual as “surplus.” For the surplus, this regime of biocertification shapes both how the state interacts with them and the boundaries of their participation in social life. In Fantasies of Identification, Ellen Samuels analyzes how certain forms of state assistance, resource allocation, or support are often understood within the popular imaginary as a “kind of currency.” These benefits are gatekept by abstract bureaucratic systems of eligibility predicated on the verifiability of someone’s biological state and identity. As such, Samuels argues, the role of biocertification, namely the process of assuring that only “legitimate” claimants receive this “currency”-in-kind, is reinscribed with a simulated social “banking function,” reinforcing the idea that the process of biocertification itself is an efficient means of allocating economic resources. Biocertification is assumed to be a necessary gatekeeping mechanism or checkpoint to prevent the “wasting” of resources on fakers, cheats, imposters, and malingerers: “invoking both a model of scarcity, in which resources must be reserved for those who truly deserve them, and a distrust of self-identification, in which statements of identity are automatically suspect unless and until validated by an outside authority.”

The generosity of these currencies-in-kind is often extraordinarily overstated in the social-reproductive imaginary. Cultural perceptions dictate a picture of disability, illness, and marginalization which is not reflective of the material “gains” that come as a result of being biocertified for social welfare supports like the United States’ Social Security Disability Insurance (SSDI) or Medicare/Medicaid. This is what Samuels describes as a tendency to commonly perceive “these [eligible] identities as lucrative commodities.” The boundaries and borders of qualification are guarded by a combined medical-legal authority and rest on the understanding that identities are readily measurable, verifiable, and fixed, ascribing meaning to biological observation and institutions of authority which seek to standardize the line between social citizenship and exclusion.

This constructed preference for standardization and biocertification arises out of the imbrication of health and capital. If the economy of health is to be bled for excess profit, then the fundamentally inefficient process of facilitating our mutual survival must be made to be efficient. The modern welfare state measures and quantifies metrics of individual health against a picture of the individual’s economic resources and labor power in order to restrict the administration of aid. To determine eligibility for SSDI in the United States, for example, the Social Security Administration (SSA) “uses formulas and charts to transform bodily conditions into percentages of ability.” Physical conditions of the body and its organs are clinically evaluated to determine their relative distance or deviance from an abstract ideal normal body (worker). To the SSA, all impairments, symptoms, circumstances, and conditions are of equal value and attention; all health is equally neutral. This is because the severity of illness, impairment, or disability is not actually the metric the SSA uses to determine eligibility. The crucial axis is instead the individual’s relationship to work. What emerges from these phenomena is a shadow biocertification regime that hides in plain sight as a means test to ward off would-be “waste, fraud, and abuse.” Labor power is equated to bodily state, and health is measured through this contradictory lens.

To the SSA, illness is only relevant in relation to whether and to what degree it impacts a person’s capacity to work. As Rosemarie Garland Thompson argues, this presumes that ill-health, disability, and impairment are located only in the body and not also in the broader social, political, and geographical context that comprises the individual’s social determinants of health. Impairments and disabilities are reduced to numbers on a page: “On one scale, for example, limb amputation translates as a 70% reduction in ability to work, while amputation of the little finger at the distal joint reduces the capacity for labor by a single percentage point.” Garland Thompson’s critique of the disability eligibility schema in the US questions the ability of the state to meaningfully measure such complex and dynamic situations as a person’s health and worth using a precise “mathematical relation.” Labor power, social and material conditions, and bodily states are collapsed into a single metric, measuring all health along a continuum of relative currency.

The ideological framing of wage work as a mitigating factor in an individual’s eligibility for health and welfare benefits attempts to map economic valuations of life onto regimes of biocertification, as is readily evident in SSDI determinations. Social Security disability eligibility is a legal process of decertifying a body for work, not the certification of a body for any type of qualifying disability or impairment demonstrating need for care and additional social supports. These notions have become replicated in social security and social insurance programs internationally. Countless states limit or adjust their benefits dependent on the amount of productive labor the individual has already participated in during their life. This has become particularly prevalent alongside the spread of social insurance privatization schemes by international financial firms, as discussed at length in BORDER.

The authority of medical opinion is widely used as a means to measure the truth of a body’s impairment and certify to the state’s satisfaction that the benefit applicant is truly biologically incapable for work, through “no fault of their own.” This arguably subjective perspective of medical authority is treated as if it is a visible and clearly quantifiable fact. The state relies upon the signifier of medical authority as a means of depersonalizing and depoliticizing the biocertifi cation process writ large. Relying on claimed scientific or medical frameworks, biocertification schemes seek to identify and sort bodies, placing each within the context of their correct category, which is reflective of the intersections of their race, gender, citizenship, wealth, or ability, as a means of validating the social truth of a person’s identity. This framework assumes that a person’s biological identity can in fact be scientifically measured, rendering their ultimate categorization or eligibility as if depoliticized—a procedural, objective, binary decision. An individual’s material conditions or identity cannot be understood as in any way fluid or abstract under this biocertification preference. Existing outside of certification means categoric exclusion.

Biocertification regimes assume that validating characteristics are readily obvious or apparent, falling squarely in the category of “common sense” generalizations, meaningful or not, about various observed metrics. Despite little scientific basis, strategies of biocertification are treated as fact and reinscribed through law and policy, leveraging medical authority to consolidate the power of the state to determine life chances—who lives and who dies. Importantly, none of this is to say that states of being, “conditions,” ailments, and so on do not exist. Far from it. Instead, it is to say that the intersection of those conditions of health—or simply of being, of states of existence—have become of signifi cant use to capital in its demarcation of ontological boundaries within society and the resulting distribution of resources. Resisting biocertification does not mean resisting “diagnosis” or identification. It means resisting the leveraging of these certifications by capital and the state.


Health Communism by Beatrice Adler-Bolton and Artie Vierkant is now available from Verso.