Reclaiming Public Health: The Communalist Healthcare Model
Above photo: New York City nurses and other hospital professionals protest dangerous working conditions and a change in sick leave policies during the Covid-19 pandemic on April 17, 2020. Andrew Lichtenstein/Corbis via Getty Images.
The pandemic has exposed the failures of hierarchical, profit-based healthcare systems — but social ecology offers a model to democratize public health.
Voltaire famously said that “The art of medicine consists in amusing the patient while nature cures the disease.”
In my 20 years of experience practicing medicine, his words ring true. It takes more than medications and surgeries to heal a patient. They recover from disease because of the social support that care workers provide.
During the Spanish Influenza outbreak of 1918, Alfred W. Crosby, a Professor Emeritus of History, Geography, and American Studies wrote that nurses were more important than doctors during this period: “[N]either antibiotics nor medical techniques existed to cure influenza or pneumonia. Warm food, warm blankets, fresh air, and what nurses ironically call TLC — tender loving care — [kept] the patient alive until the disease passed away.” When Voltaire said that nature cures the disease, I like to think of him referring to care workers’ TLC.
However, care work and the nursing profession, in particular, are devalued because they are seen as women’s work. When I was choosing my own path in the medical field, my father told me to become a doctor because nursing is a woman’s profession. “It’s derived from the idea of the wet nurse,” he said, “when a woman breastfeeds someone’s child when the mother cannot.” The word “nurse” indeed derives from the Latin root nurtire which means “to nourish.” This undoubtedly had an impact on my choice to become a Physician Assistant.
I have come to see nursing not as a lesser profession but as essential work by venerated colleagues. Without them, a patient’s recovery would be next to impossible.
Capitalist “Support” for Nurses
Because of the COVID-19 pandemic, society, in general, is finally recognizing the army of unnoticed care workers. Even though many colleagues have privately expressed their skepticism at the community’s outpouring of support, I do not share this sentiment. At the grocery store, I sometimes wear my scrubs and people smile at me and thank me for my service. These are genuine expressions of love by people who feel powerless in the face of incomprehensible horrors.
It is rather the people managing and administering the healthcare system in the US who do not see the people performing the care work. They see hours worked, benefits paid and how this all detracts from the bottom line.
In Seattle, the same week that Jeff Bezos, the richest human alive, was projected to become a trillionaire, local hospitals announced layoffs and furloughs of nurses and other frontline workers. In May, at the end of “nurses week,” UW Health system, in which I worked, confirmed that they would be furloughing and laying off thousands of frontline workers. The workers who I talked to all expressed feelings of betrayal. After spending the past few months keeping our community healthy and sacrificing so much for their patients, one nurse remarked, “This is the thanks I get?”
As a health worker, this system does not work for me, my co-workers, or my patients in the same way it does not work for most people. While nurses, hospital assistants, therapists, housekeepers, respiratory therapists, radiology technologists and so on are barely scraping by, people pushed to the margins of society are deprived of autonomy, power, or a voice when it comes to their health.
While city and state governments could do more to keep hospitals stable, I have little faith in the system to maintain the health of the community or the livelihoods of care workers. We must look for alternatives to the declining nation-state model replete with the excesses of capitalism.
There is an alternative. By combining the latest practice and theory, we have the potential to develop a functional health system that serves the community and values healthcare workers. Yet this requires a reconstructive and radically democratic approach. A just healthcare system is one without managers or leaders, organized at the grassroots level by patients, their families, care workers and the communities that we serve. This sort of system is based on the ideals of communalism, through which autonomous communities cooperate through a confederation to self-govern all aspects of shared daily lives.
A Communalist Healthcare Model
The central thesis of social ecology, originally developed by Murray Bookchin, is that ecological crises are social crises. The accumulation of wealth and power comes at the expense and exploitation of others all throughout the world and nature itself. Capitalists and oligarchs plunder the natural world as if it were infinite as they do with the labor of those working the earth. However, natural resources have limits and their overuse has catastrophic consequences. The same is true with human resources.
It is now well understood that the emergence of zoonotic diseases such as COVID-19 are due to habitat destruction. As we are in close contact with animals, we are exposed to novel infections. To prevent future pandemics and develop a system where care work is valued, we need to systemically rid ourselves of hierarchical, top-down relationships. This happens not by abolishing power but by democratizing it. Society must adopt a complete framework that takes ecological, social, political and economic harmony into consideration.
A society based on social ecology would employ socialized medicine, removing the profit motive, untenable administrative and overhead costs, overpriced medications and treatments, as well as value stolen in the way of health insurance and hospital profits from the equation. In such a system, everyone’s basic needs would be met. This is known among anthropologists and social ecologists as the “irreducible minimum.”
Decisions would be made at the smallest level possible, with the understanding that we are all connected to and interdependent on each other. Traditional hierarchies in hospitals could be dissolved through the creation of smaller directly democratic sub-units, often referred to as communes or councils. These sub-units work together in good faith through consensus or majority vote to solve local problems while confederating with other small sub-groups in a neighborhood or city to discuss common goals and come up with mutually agreeable solutions to problems.
In Eleanor Finley’s essay on communalism, she distinguishes between power and administration. “Administration encompasses tasks and plans related to executing policy,” she writes. “Power, on the other hand, refers to the ability to actually make policy and major decisions . . . In communalism, power lies within this collective body, while smaller, mandated councils are delegated to execute them.”
In a communalist hospital, administrators would not have “power” as they do in the current system, but would serve the workers and carry out the mandate of the collective bodies. In this case, the “collective bodies” corresponds smaller sub-units such as the ICU or the Emergency Department. Each of these sub-units would hold regular assemblies where decisions are made through face-to-face democracy. These units would then be confederated with each other to form a larger body.
Decisions would be made at the most grassroots level possible. For example, the decision to purchase new equipment for the ICU would be made at the ICU level, or the decision to add a new role at the hospital would be made at the level of the hospital, while the decision to add new responsibilities onto nurses’ scope of practice is made at the regional level. Such decisions would not made by “leaders,” but by sub-units and their delegates who collectively discuss their respective groups’ needs and perspectives. These delegates must be recallable, rotatable and have a limited mandate.
A communalist healthcare framework would also involve unions, ones that are organized horizontally. The labor movement in the US is experiencing a resurgence that we have not seen in recent decades and nurses’ and teachers’ unions are leading the way. These professions are predominantly filled with working class women. The victories from these unions did not come by union leadership but by the grassroots organizing of workers within the framework of the labor union. Real equity means that healthcare workers, who know the day to day issues within the hospitals, would be involved in the decision-making process in a democratic fashion.
Direct democracy does not mean control of the workplace by the workers only, but would also empower patients and the broader community to have meaningful input and democratic control over the processes that govern healthcare. This is the essence of communalism. This system is directly controlled by the people within society and not just interest groups or hegemonic leaders.
An ideal system is one that values the interdependence of human beings and acknowledges how we are all connected and rely on each other. This year, nurses and care workers around the world have saved millions of lives. A communalist system would value care work and care workers every single day, not only in times of crisis.
In traditional medical education and healthcare administration programs, we are not taught about systemic social issues. We go about life thinking things are the way they are supposed to be — that doctors give the orders and nurses must listen. Solutions to the problems of the current system will not come about simply having more representation of token leaders from oppressed identities, but by building a new system that roots out hierarchy, oppression and subjugation in the first place.
Struggling Toward Communalist Healthcare
There are examples of self-organized systems around the world that set a precedent for a communalist healthcare project. This includes how the people of Rojava in North and Eastern Syria administer their society including healthcare, the Black Panther Party’s Free Medical Clinics, Vio.me in Greece, the Mondragon Cooperatives in Spain, among others throughout the world. These grassroots projects are often able to get more return on their investment with fewer resources than the US Healthcare system. This does not even do justice to the vast traditional healing knowledge and group decision-making structures practiced by Indigenous peoples from all over the globe.
Here in Seattle, in the wake of the murders of George Floyd and Breonna Taylor, we saw the cracks within the system widening and average citizens are questioning the validity of this system. This also included nurses and other healthcare workers. With the formation of Seattle’s Capitol Hill Autonomous Zone (CHAZ), many healthcare workers participated by giving first aid to protesters. These brave care workers were then explicitly targeted by the police, an institution that claims its job is to “serve and protect.”
The people who care for patients are now seeing the links between different hierarchical systems such as racism, law enforcement and public health crises, and are participating in direct action to end these systems of oppression. On June 6, healthcare workers organized a march against the racist Seattle Police Department (SPD). This protest brought to light “the links between racism, COVID-19 and police brutality . . .”
Then, on June 18, healthcare unions were among the majority who voted to expel the racist police union out of the King County Labor Council. During the hearing, Jane Hopkins, a registered nurse and union organizer said, “At this point, I just can’t justify to our members, ones who are staffing the medical tents and getting gassed by SPD, having SPOG at the table, using our unity as a shield to justify contracts that go against our principles and mission.”
However, hierarchical systems are still at play within our institutions. We will not see a just society until we rid ourselves of these systems of oppression. This is not done by simply destroying the old but in positively envisioning the new and working to build it.
Care workers should be at the forefront of organizing in a grassroots fashion to actualize a communalist healthcare project. Those who want to show their appreciation for healthcare workers in the wake of COVID-19 ought to stand in solidarity with them as they assert their autonomy and fight for a new system that values the people and public health over the profits. As care workers fight and reclaim the commons in the name of public health and not profits, we must be feeding and caring for them as they care and support us through our darkest days.
Acknowledgements: The author would like to thank Debbie Bookchin and Brian Tokar for their advice, and Elsa Muñoz Garcia for her valuable contributions in shaping this essay.
Justin B. Gifford is a Hospitalist Physician Assistant with the Neurosurgery Department at Harborview Medical Center. He is a former Army Combat Medic deployed to Iraqi Kurdistan from 2003-2004.