Anarchy and Its Overlooked Role in Health and Healthcare

Abstract

In this paper, I will argue that a number of well-known health interventions or initiatives could be considered anarchist, or at the very least are consistent with anarchist thinking and principles. In doing this I have two aims: First, anarchism is a misunderstood term—by way of example, I hope to first sketch out what anarchist solutions in health and healthcare could look like; second, I hope to show how anarchist thought could stand as a means to improve the health of many, remedying health inequalities acting as a buffer for the many harms that threaten health and well-being. On this second point, I will argue that there are a number of theoretical and instrumental reasons why greater engagement with anarchism and anarchist thinking is needed, along with how this could contribute to health and in addressing broader injustices that create and perpetuate poor health.

What Is Anarchy?

On August 21, 1893, Emma Goldman spoke to a crowd of approximately 3,000 people in Union Square, New York, where she encouraged unemployed workers to take action in response to an economic crisis that became known as the Panic of 1893. Goldman was later convicted of inciting a riot and was sentenced to 1 year in Blackwell’s Island Penitentiary. At the time Blackwell’s Island (now Roosevelt Island) housed over 8,000 prisoners, medical care was limited and there were few nurses. Goldman was recruited by one of the prison doctors who treated her for an illness. She was put in charge of a 16-bed ward after only informal nursing training. She observed that her patients were like “victims, links in an endless chain of injustice and inequality.”[1] Almost all were poor, had little opportunity for employment, and were often imprisoned for sex work. Goldman was released from prison after a year and her experiences in prison set her on a course as a nurse and activist. When she was released Goldman began to work as a nurse and shortly after sought formal training abroad. When she returned to the United States in 1896, she worked primarily as a midwife and was struck by the high rates of maternal mortality amongst the working class and the unsafe conditions in which many gave birth. From this work Goldman was convinced that birth control was essential to women’s sexual and economic freedom, supporting Margaret Sanger’s campaign to make birth control widely available. Goldman published literature about contraception in an effort to empower women to make informed choices about their reproductive health.[2] In the early 1900s, Goldman was arrested at least twice for distributing information about contraception and for giving lessons on its use. In 1916, she turned one of her trials into a forum on birth control, attracting national attention and garnering support from academics, activists, and artists, among others.[3]

As well as a nurse, Goldman was an anarchist and is today considered one of the most important figures in the history of anarchism. Throughout the late 1800s and early 1900s, she spoke frequently about anarchism and its potential for liberation, in her own words:

Anarchism, then, really stands for the liberation of the human mind from the dominion of religion; the liberation of the human body from the dominion of property; liberation from the shackles and restraint of government. Anarchism stands for a social order based on the free grouping of individuals for the purpose of producing real social wealth; an order that will guarantee to every human being free access to the earth and full enjoyment of the necessities of life, according to individual desires, tastes, and inclinations.[4]

Anarchism refers to a diverse tradition of political theory and action, which is drawn together by its opposition to hierarchy, government, and other authorities or powerful institutions. Proudhon[5] defined anarchy as “the absence of a master, of a sovereign” and as the “denial of government and property.” Anarchy is usually grounded in claims of individual liberty, but also in a positive theory of human flourishing, “based upon an ideal of non-coercive consensus building,”[6] in this sense anarchy is also concerned with order. Although traditionally anarchy was most concerned with state authority, more recent attention has been given to other oppressive forces—gender and racial hierarchy, for example—with such thought providing broad grounds for social critique. Anarchy, therefore, not only calls for a new economic and social order, but also for a complete reorganization of society[7] not only by eliminating hierarchy and economic structures but also through challenging oppression and domination of all kinds. Although there is debate on this point, anarchists generally agree that “property in land, natural resource, and the means of production should be held in mutual control by local communities.”[8] Noam Chomsky[9] argues that a “consistent anarchist… should be a socialist, but a socialist of a particular sort” —that is, anarchists should not only seek the appropriation of capital by all workers, but also “that this appropriation be direct, not exercised by some elite force.” Goldman similarly contended that individual freedom was “strengthened by cooperation with other individualities” and that “only mutual aid and voluntary cooperation can create the basis for a free individual … life.”[10]

Although more traditionally anarchism has been associated with violence and revolutionary upheaval, there have also been a number of nonviolent anarchists. That is, many feel that tactics should mirror the ends that are sought. As anarchists should be opposed to hierarchy or coercion, many argue that anarchism is inherently nonviolent.[11] This has been reflected in practice, with anarchists not only engaging in nonviolent forms of resistance, but also participating in initiatives or projects such as organizing food shelters, aiding the homeless, and building schools.[12] Again, while there is no consensus, activities such as mutual aid, localized (or grass-roots) initiatives, and social initiatives that are organized horizontally with little hierarchy are all widely accepted and practiced forms of action within anarchist circles.

Although anarchist theory and praxis have long been discussed, their relation to health, along with what they could contribute to health and well-being, has been surprisingly limited. In this article, I want to start a conversation and add to existing discussions about how anarchist thought could support health and well-being and enrich related disciplines, such as bioethics. In anarchist thought, health is a central consideration. Niall Scott,[13] for example, argues that, although anarchist challenges to forms of oppression are not often put under this banner, anarchist thinking is very much centered on health; as noted above, anarchist thought is concerned with all forms of oppression; diet, work, and the workplace and more generally the climate and environment are all pressing contemporary anarchist concerns. Beyond this, anarchism is also concerned with flourishing, how we live and achieve good health in a society where communities determine what works for them and where society is organized with little or no hierarchy or political authority. Many of these values and thinking are not that far removed from much mainstream thought in bioethics. Scott[14] argues that many of the values found in anarchist thinking have the potential to promote health, including autonomy and responsibility and solidarity and community. Beyond this, however, there are numerous examples where health, healthcare, and well-being intersect with anarchism. I would even argue that many who read this article may have been engaging in anarchist praxis without knowing it. Like Scott,[15] I want to show how anarchist thought can contribute to health and well-being, but I want to expand on this position to show that not only is anarchist thought compatible with many common principles found in medical ethics, but also that anarchist thought and praxis are far more common than most of us realize. By way of example, I will show what anarchist solutions in health and healthcare could look like, illustrating how many healthcare endeavors are (perhaps unwittingly) already consistent with anarchist thinking. My point here is twofold, that anarchist thought could help us overcome a range of issues in healthcare and protect the health of the most vulnerable and also that many health acts, programs, and initiatives could be seen as an anarchist. Second, I will argue that a greater engagement with anarchist thinking is warranted, outlining several theoretical and instrumental reasons, identifying how anarchist thought could contribute to health, and challenging broader injustices that create and perpetuate poor health.

Some brief notes before moving on. I do not argue for one version of anarchist theory or praxis, in advancing the arguments below, I have had to take some nuance and controversy for granted. However, in saying this, I assume for many, I do not stray into territory that is overly controversial, at least in anarchist thought. I do not veer into more controversial aspects of anarchist theory and the examples I outline below draw on actions, mutual aid, grassroots organizing, and direct action, which are largely consistent with most thinking on anarchism. I also have no intent to outline what health and healthcare could look like in an anarchist society, or under ideal circumstances. In this sense, the focus of this article is prefigurative,[16] that is, I largely focus on what anarchist thought and action look like given the realities that we are presented with today, initiatives and actions that largely seek to address the harms and failings of those in power with action that seeks to model the organization, and relationships that could form in the future.

Anarchism in Health and Healthcare

We begin our discussion about the intersections of anarchism and health in the UK, which today has a centralized, top-down, healthcare service, the National Health Service (NHS). The NHS was introduced in 1948. Prior to this and without the state, the working class often took healthcare into their own hands, through grassroots self-help and mutual aid. This was particularly exemplified by the Friendly Societies in the UK, which first took shape in the 1600s. Friendly Societies were mutual aid/insurance associations, often built around a workplace, industry, or community. Healthcare was one of their main functions, providing medical insurance with independent doctors and hospitals employed by societies. Throughout the late 1700s and early 1800s, Friendly Societies resisted attempts at government regulation, recognizing this would be the end of self-governance. For similar reasons, Friendly Societies were often opposed by the medical establishment, including the British Medical Association (BMA), which ran campaigns against Friendly Societies, as they saw them “as an ‘appalling’ example of doctors being told what to do by their ‘social inferiors’ as well as a brake on their incomes.”[17]

Perhaps more widely known, the Peckham Health Centre operated from 1926 to 1950. The Peckham Health Centre was an experiment in health and well-being, George Scott Williamson (1884–1953) and Innes Hope Pearse (1889–1978), two doctors opened the center in the working class neighborhood, Peckham in south London. The center sought to create a place not for the sick or the treatment of disease but as a means to promote health and well-being, to detect the onset of disease, and advise on necessary treatment or intervention. Most importantly, it was an environment centered on the family with “members” not “patients.” Any family living within one mile of the center could join with the only condition being a small weekly subscription fee and a willingness to undergo a health check on arrival. Within the center, a range of activities were open to members including physical exercise, swimming, and workshops. The center was purposefully designed with Williams and Pearse observing members in this setting. Members were otherwise largely left to themselves. Within the center, there were “no guiding planners, no cliques, no closed doors, no hierarchies.”[18] There were multiple findings from this experiment. Most notably, it was found that after a brief period of disorder, people began to organize into a more orderly coexistence. Furthermore, many began to show a greater interest in their health and those around them.[19] That is, members had taken ownership of the center and their health. Over the longer term, this resulted in generally better health for all members and created an open atmosphere within the club. These results gave weight to the idea that environment played a critical role in health and well-being, and that health was more than just an absence of disease. Despite its success, the Peckham Health Centre was refused admission to the newly formed NHS and closed its doors in 1951. David Goodway[20] argues that this refusal had to do with the core values of the project, namely, that it was about promoting health and well-being, rather than the treatment of disease, and furthermore that it “was based exclusively on a locality, having no ‘open door’. Its basis was contributory, not free. It was based on autonomous administration and so did not conform to the lines of administration laid down by the Ministry of Health.” The Peckham Centre was later described as “a laboratory of anarchy.”[21] by George Williamson who was quoted in a lecture to the London Anarchist Group, noting that “I was the only one with authority, and I used it to stop anyone exerting any authority!”[22]

For two further examples, we turn to the United States. During the 1960s in the United States, prehospital “care” was generally provided by untrained responders, police, and morticians. This was a particular problem for Black Americans, many could not afford private services and even if they could, many of these services were avoided Back communities. Also, then, as now, Black Americans faced significant discrimination and abuse at the hands of the police. In this context, Freedom House, a community-based sociomedical program, trained a group of Black laypeople which was established to serve the largely Black Hill District of Pennsylvania. The training was rigorous and involved basic anatomy, physiology, disease recognition and diagnosis, and common emergency conditions. The Freedom House Ambulance Service was the first emergency medical service in the United States to be staffed by paramedics with medical training beyond basic first aid and the program became a model for paramedic training that ultimately set the U.S. standard. The course ultimately became the pilot course for emergency medical training for a number of U.S. government departments. As the success of the program grew, so did political opposition. Freedom House eventually lost funding, while at the same time the city of Pittsburgh funded a new, predominately white ambulance service, undermining the goals of Freedom House by excluding the Black men and women who had pioneered this training and these standards.[23]

Nearby, in Chicago at about the same time, the Young Lords were founded. The Young Lords were the Puerto Rican counterpart of the Black Panther Party, who sought empowerment and self-determinations for the Puerto Rican community. Health and healthcare formed a central part of their work, utilizing a combination of confrontational and educational strategies to make their demands heard and empower the community.[24] At the height of their influence in New York, the Young Lords paralyzed neighborhood traffic with uncollected garbage, took over a church and a hospital, and occupied the office of the Department of Health. The Young Lords also led a series of campaigns, aimed at reducing exposure to lead, providing tuberculosis screening for working neighborhoods and perhaps most notably, their occupation of Lincoln Hospital. This action occurred in the early hours of the morning on the July 14, 1970. With the support of medical and health staff within the hospital, the entrances to the hospital were barricaded. The action exposed medical discrimination and inequality in the delivery of healthcare among Puerto Rican and Black American residents in the South Bronx, at the time one of the countries most deprived districts. Although the hospital was occupied the Young Lords held a press conference, highlighting the government failure to build new facilities, which were promised over 10 years earlier. They also criticized the privatization of healthcare and for-profit medical companies that were built around powerful institutions. That same year the Young Lords drafted the first-known patient bill of rights, it asserted that patients had a right to be treated with dignity, have the treatment explained and make an informed decision about what treatment may be in their interest, and to have continuity of care in relation to who treated them.[25]

For our final example, we move to the present day. Much has already been said about COVID-19 and the failure of governments and other centralized authorities across the globe. At the time of writing, the pandemic has claimed millions of lives and touched almost everybody in one way or another. It might seem strange to talk about anarchy during a pandemic, a time when we need cooperation and solidarity more than ever, however one of the many lessons that we can take away is that, in many respects, government and health authorities failed in relation to managing the pandemic. This has led to many communities and individuals stepping up and providing critical services, where none would otherwise exist. In Brazil, community volunteers have gone door to door distributing food, masks, and educated communities about mask use, social distancing, and handwashing. Social media has been used to counter misinformation. Activists have converted schools into isolation wards and have been fighting for the accurate documentation of COVID-19 deaths.[26] Similar stories have emerged from the United States, where mutual aid and grassroots organizing has made up for the shortfall of “the chaos, incompetence, irrationality, and often cruel misguidedness of the centralized government response.”[27] Outside of the Americas, similar initiatives have been seen in South Africa. In early March 2020, a small group of public health experts, activists, and community organizers identified the need for a collective, community-led response to COVID-19, from this Cape Town Together was born. The group formed with the premise that many of the challenges presented by COVID-19 were best tacked at the community or neighborhood level. With this, the group developed a toolkit for others to organize autonomously in their neighborhood. This encouraged neighbors to connect and identify the needs of their community, including those who were more vulnerable and those who had the capacity to help. Within two months, over 170 community networks were formed. These networks exist across the socioeconomic spectrum in Cape Town, from lower to higher socioeconomic neighborhoods.[28]

Anarchy and Its Role in Fighting Oppression and Advancing Health

One of the central arguments in this paper is that anarchism and anarchist thought has and will continue to act as a positive force in shaping health and well-being, whether this is through mutual aid and grassroots action, to more disruptive action, demanding change in relation to injustice. Moving from the examples above intended to support this position, (and more will be said about this below), an issue needs to be addressed head on––namely that many of the above examples were not explicitly anarchist. Without proof, it seems reasonable to conclude that many of the above examples were not done with anarchist thought or principles in mind (perhaps with the exception of the Peckham experiment); even the Young Lords were not technically anarchist, they self-identified as revolutionary nationalists and Marxists.[29] On this point, there is, of course, ongoing discussion on what anarchism is[30] and perhaps unsurprisingly there is no one answer. Alejandro De Acosta[31] argues that rather than looking for a unifying theory, it may be more useful to look for anarchist traits in existing thinking and action. In many respects, I have taken the latter approach. Even if one thinks the above examples are not anarchist (by whatever standard), it is inarguable that all of the examples above sit comfortably alongside anarchist thought and praxis and demonstrate many widely accepted anarchist principles. They also highlight how anarchist thought has potentially a great deal to offer in thinking about how we approach health and healthcare. As I noted above, Scott[32] argues that many of the principles found in anarchy are consistent with those found in broader medical ethics. I largely agree, but also believe anarchist thought has far more to offer. Below I will argue that anarchy has the potential to provide important theoretical and instrumental insights that could serve to advance and protect health and well-being.

On my first point, how anarchist thought could theoretically enrich discussions related to health and well-being, most fundamentally, anarchy provides a baseline against which other forms of organization can be compared, that is, organization that includes some form of hierarchy. Most fundamentally, anarchism could be seen as “a condition of permanent revolution, a continuing rebellion against our own tendencies toward entrenchment and domination”[33] and as “perpetually exploring new ways to perfect and imperfect reality.”[34] In other words, anarchism makes us question ourselves and our relationship to oppression and domination: Do we oppress others or are we complicit and how might things be otherwise? Beyond ourselves, anarchy is about organization, and how might society be organized differently. As Chomsky notes, “the burden of proof is always on those who argue that authority and domination are necessary. They have to demonstrate, with a powerful argument, that that conclusion is correct. If they cannot, then the institutions they defend should be considered illegitimate.”[35] Anarchy has the potential to inform different forms of organization; organization that is not built around coercion, domination, or exploitation. This could intersect with health in numerous ways, anarchy could inform new social relations, but could also be applied more narrowly to critique power relations within institutions for example.[36] For example, the issue of hierarchy in healthcare has already been widely discussed in the literature, in many cases hierarchy and its failure to be questioned or challenged has been as an impediment to improving patient safety.[37][38]

Beyond a critique of hierarchy anarchist thought provides a further means to inform community led, grassroots action that promotes and protects health and well-being. Such action is remarkably common, not only as I have shown above, but beyond this paper and even outside of anarchist circles few would disagree that grassroots strategies have an important role to play in improving the health of many. This is particularly salient for the majority of the world who lack access to healthcare; anarchist thinking could not only inform grassroots strategies and mutual aid, helping us better understand how these activities serve health, but also how we could better reach and involve others. It would also show that these are not isolated acts, allowing us to join the dots, identifying broader structural failings. For the relatively fortunate and rather small percentage of the world who have access to healthcare, anarchist thought could also help. Let’s again turn to the UK and the NHS. The NHS has been in place for over 70 years, it provides access to health services free at the point of delivery. Despite this, however, it has many shortcomings, for example, that ethnic minorities still fare far worse, despite also having access to similar care.[39] Furthermore, the UK government has over the last decade consistently underfunded this service and failed to take meaningful action to address these inequalities. Like the above examples, there is a role for grassroots action here in protecting the health of those who have been failed by the system and also to buffer against its harms. There is also a case however for grassroots agitation to demand change. In short, anarchism could inform how we support those most failed by the state, no matter where we are in the world.

Beyond the theoretical contributions anarchy could make to health, anarchist thought also has practical and instrumental value, that is, it has been and will continue to be both needed and impactful, buffering against the most egregious threats to health, but also simply functioning to improve the health of individuals and communities where authorities have failed. Returning to COVID-19 again, it has not only highlighted many failings of government and other centralized authorities but the success and effectiveness of local, grassroots organizing. The experiences of community mobilization in the face of a threat such as COVID-19 provide important opportunities for re-thinking community health systems, in particular, the challenges of sustaining collective action that is community-initiated and -driven, rather than state organized. Arguably a silver lining of the pandemic, in many communities, a foundation has been laid to re-think how they organize and support one another.[40] As noted by Nathan Jun and Mark Lance[41]:

Every time a neighbour delivers loaves of homemade bread to each house in their block, each time someone provides a ride to a medical appointment, a toy to a child, or a grocery run, we learn who we can count on and why. Each time we get together and build a food distro, a community porch singalong, or an online gaming night, we learn both that we can organize ourselves non-hierarchically and that we care enough to do so. These actions teach us new ways of being that capitalism and a capitalist health system systematically hide. In the immortal words of the Industrial Workers of the World, it is building a new world in the shell of the old. And that would be worth doing even in the context of a competent government.

Returning to the examples above, we see vastly different actions in response to vastly different issues; all were impactful in different ways, all achieved tangible health gains. These examples however only scratch the surface; we can find many examples across the world of agitation, mutual aid, and grassroots action all aimed at improving health. In Greece, because of austerity, free clinics were organized for those who could not afford health services.[42] In response to increasingly inaccessible pharmaceutical treatment, many have turned to DIY pharmaceuticals.[43] We see healthcare provided pro-bono across the globe for those who have arguably been most egregiously failed by state authority, refugees and asylum seekers,[44] action which actually has quite a long history.[45] Just looking at the Americas, we see over 800 health centers, clinics and hospitals maintained by the Mexican Zapatistas and healthcare programs created by indigenous organizations in Ecuador and Colombia.[46] In the United States, the Common Ground Health Clinic, part of a mutual aid collective set up to fill the vacuum left by the state in the wake of Hurricane Katrina, still provides primary care services for the local community.[47]

I have only scratched the surface of what anarchist thought and praxis could do to enrich discussions about health and well-being. But in short, anarchist thought and praxis could be seen as both a necessity but also as effective in protecting and promoting health. Anarchist praxis can be found almost anywhere where central authority has failed; mutual aid and grassroots organizing take up the slack, supporting individuals and communities. Anarchy not only provides us with a means to look after ourselves, chart our own destiny, and take care of our health, where authority fails, but also it provides a basis from which we can demand better. The specifics of how we go about this is a discussion for another time; however, it should go without saying and even from the examples above, agitation and mutual aid take a multitude of forms as do the oppressions against which they act. What might already be obvious to many is that the state more often than not fails when it comes to health. Beyond the state, health is threatened by a range of other oppressive forces. Good health has been and will continue to be fought for and in many cases, without a central authority, when we provide people with the resources, they will take care of themselves and their communities.

The Future of Anarchist Thought and Praxis in Health and Healthcare

When we think about the future, anarchy is often described of what it is not, a society absent of coercive and oppressive structures, not what it could be. As anarchism promotes a vision where individuals and communities can arrange their lives as they see fit, thinking about the future when it comes to anarchism can be quite difficult. In this paper, I am not talking about utopia or what an ideal society might look like; instead, I will offer some brief reflections on the ongoing need for anarchist thought in health and how it may continue to buffer against the many harms that continue to threaten health.

Most broadly, the need for anarchist thought appears to be increasingly pressing. Globally, inequality continues to grow, we continue to sleepwalk toward climate catastrophe, and the impact of COVID-19 will be felt for decades to come. We have seen the number of displaced people increase steadily over the last several decades. This is not only a failure by states from which people have fled, but also the rest of the world, which has failed to offer sanctuary. If we continue on the same trajectory, the poor, vulnerable, and those who have the least say will be most disproportionately impacted. Closer to home, underfunding and disregard for health will remain a pressing issue. In the UK alone, it was estimated that austerity and underfunding have caused hundreds of thousands of extra deaths.[48] Beyond this, there is the ever-present threat that public services will continue to be transferred to private hands. The simple point is, that we should at the very least be skeptical of authority acting in our best interests or even caring about our health or well-being. COVID-19 dredged up many of these issues, it seems reasonable to remain skeptical that there will be any substantive change in the foreseeable future.

Despite this rather bleak outlook, I remain hopeful for a number of reasons. There is of course the obvious, my argument above, that anarchist thought has the potential to enrich discussions about health and well-being and even buffer against many harms. But beyond this, all of us have the power to imagine and create new ways of being, without hierarchy and domination. I also believe that many of those who read this may be engaging in anarchist praxis without realizing it, day to day; who has not felt coerced into doing things that are not in a patient’s best interests, who has not (perhaps subsequently) bent or broken the rules in advocating for a patient, who has not seen the potential in grassroots, community-led actions that support health. Such acts are important, arguably more so than barricading a hospital, as John Holloway[49] argues social change often occurs as a result of “the outcome of the barely visible transformation of the daily activities of millions of people…the millions and millions of refusals and other-doings, the millions and millions of cracks that constitute the material base of possible radical change.” In this respect, we can all be anarchists.

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[14] See note 13, Scott 2018, at 217–27.

[15] See note 13, Scott 2018, at 217–27.

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[22] See note 17, Parker, Ferrie 2016, at 1754–8.

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[29] See note 25, Fernández 2020, at 339–47.

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[32] See note 13, Scott 2018, at 217–27.

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[39] Adebowale, V, Rao, M. It’s time to act on racism in the NHS. British Medical Journal 2020;368:1.

[40] See note 28, Van Ryneveld et al. 2020.

[41] See note 27, Jun, Lance 2020, at 361–78.

[42] Malamidis, H. Social Movements and Solidarity Structures in Crisis-Ridden Greece. Amsterdam: Amsterdam University Press; 2020.

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