This is the second and final part of a Rankandfile.ca interview with Baijayanta Mukhopadhyay, author of Labour of Liberation. The book is published by a new, radical publisher, Changing Suns Press.
Providing care to the sick is one of the most universal labours that exists across human societies. How do we understand the work that goes into this vital collective task? How do we arrange different forms of caregiving labour? How do we decide what forms of labour remain informal and unregulated, while others remains more controlled and institutionalised? What has led to the way we prioritise and the way we value caregiving labour types? 
Baijayanta Mukhopadhyay’s Labour of Liberation explores the forms of labour – from the cognitive to the emotional, from the physical to the administrative – that go into contemporary healthcare, tracing the lineage of the hierarchies that have developed in alliance or complicity with state and capital. Through analysing the repercussions of these relationships on the care of the sick, the book questions the role of coercion and extraction in health work, and poses an argument for a more liberatory future for caregiving labour.
You write in your book that “labour has often been co-opted in the service of more nefarious agendas.” Explain how this applies to medicine and the practice of health care.
Angry people tear through the daily routine that papers over the injustices in our society. We as a society do not take kindly to such disruptions on the whole, and we find ways to suppress those responsible. Emergency rooms are one of them. Those driven mad or desperate by the hostility of their environments are often brought in to them by police, only occasionally by those who care for them. Medicine collaborates closely with the obliteration of such demonstrations of resistance and dissent. We medicate people into submission, and sometimes, even have recourse to the coercive power of law to institutionalise people against their will until their rage dissipates. If it ever does.
I have personally tried to resist these recourses when such situations present themselves to me, but there have certainly been times when I have exhausted all other options, and I am truly worried for a person’s capacity to understand the consequences of their self-harming behaviour. I cringe at the paternalism involved, when I try to build my practice first and foremost on the ethical principle of respect for autonomy. But self-destruction seems like an achingly sad way for me to resist injustice, though it may seem the most viable option. At least part of my job is to present people other options for their rage.
But this normative pressure on behaviour in medicine isn’t just at these dramatic junctures. On routine well-child care visits, I often find myself confronted with flagging developmental milestones which have been missed in children, which are considered warning signs for intervention in paediatric care, but which some parents are simply not concerned by, shrugging and saying “Well, he’s a good child even if he can’t draw a circle yet, anyway.”
Every culture of care has its normative pressures and/or coercions, so I certainly don’t think it wise to oppose one tradition of care with another apparently pristine, noble one, but I reflect on the inherent pressures of competition and measurement that have infiltrated what we think of as good care. We are all primed to intervene, to fix things, to make them “normal.” Does it really have to be this way, this desire to ensure children have a predetermined range of function that we think necessary to be capable, productive citizens? Another way to care for children’s health might be to embrace them just as they are.
You could argue that this system of primary care, this preventative nature of medicine, which I consider progressive, is actually simply to ensure that a docile labour force is forever in preparation, never interrupted. We need to have able citizens who won’t disrupt operations with dysfunction or disease, so we send the doctors in ahead of time to prevent them.
I want to know more about your claims that the medical field has effectively co-opted struggles. Is modern medicine inherently colonial and wedded to capitalism?
I don’t see how structures that are so intimately connected to the grander narrative of capitalism’s progress cannot be inherently wedded to it. I don’t know the language that critical thinkers might use to describe the major themes that have shaped our capitalist societies – but medicine has not been sheltered from those trends at all. The ultra-specialisation and alienation of labour, the divorce of decision-making from the people affected by the decision, the pressures of extraction of profit and commodification on the Commons, mechanisation and militarisation, the devaluation of women’s labour, submission to the interests of expansion of empire: I’d say you can trace medicine’s history through all such themes, and you can see how its practice has been shaped by those dynamics.
Perhaps all societies have liked to see healers as something mystical and apart, but I’m a strong proponent of demystification of healing work, partly because it’s important to know that we all have some capacity to do it. Certainly, those who have developed discipline in the art are priceless. The work is not as algorithmic as the pressures of capitalist efficiency would have us believe: there is intuition and experience, creativity and curiosity, tenderness and nurturing that drives the work in its most pristine form. But it is also not particularly superhuman or exalted work – very ordinary people do it. Evolution compels us to know how to support healing in our lives, and in the lives interwoven with our own; it is basic survival work. But the demystification is also critical because the interests of profit and power that maintain control over bodies and health in today’s world are otherwise deliberately obfuscated. Medicine is not rarefied science alone; it is a social product. Wherever it emerges, the desire to heal in its unvarnished purity is inevitably warped by its social context.
Throughout the book you address the political economy of medicine in terms of the pharmaceutical industry, private and public spending, long-term care, and so on. How do you deal with this reality as a physician working in this system yet is still committed to anti-capitalism and anti-colonialism?
We all do some rationalising to get through life, don’t we? I don’t know if it’s possible to reconcile the practice of contemporary medicine with an anti-capitalist or an anti-colonial stance at all times. But I am a believer in the concept of crawl-spaces – that even in repressive, oppressive institutions, you can start to dig out little nooks and crannies of alternate ways of being and doing. And if enough people start digging enough nooks and crannies, eventually they connect into a labyrinthine network of tunnels that may be undermining the entire structure itself.
But I certainly don’t think that’s sufficient in isolation. I think you have to be in connection with external pressures and movements, and you also have to be able to be that bridge, to walk that uncomfortable role of mediator/meddler, with all the challenges that such a position can bring. Personally, I’m abysmal at it. It’s taken me a while to learn that I can’t be all things to all people: not in social relations, nor in movement work. I have learned that there are very specific tasks and roles that I am capable of performing well for movements, and that’s where I should focus in being useful – although of course it’s also important to be challenged out of comfort zones as appropriate, in order to learn.
So I try to make peace by contributing to movements that oppose the colonialism and capitalism inherent to healthcare. One of my biggest desires is to remove health from being defined and controlled by such interests, and instead let it be defined by movements and by people most affected by injustice. It’s that sort of work, through networks like the People’s Health Movement, that make me feel a little bit more at ease – that I can funnel information on how things work internally in order to help movements make more strategic decisions about how to push for transformation. Right now, a lot of my energy is going into building the North American People’s Health Assembly happening in August in Montreal. I highly encourage organisers and activists interested in movement-building in healthwork and politicising health in its broadest definition to attend!
A mentor once told you that patients will help take care of physicians. Does this challenge the conventional training and professional identities that doctors form through their education and practice?
In some ways, yes – we’re meant to be invincible, not subject to the emotional demands of the work we do. I remember the first time I experienced the unexpected death of a patient to whom I had grown close as a medical student, a major event where I felt a huge burden of responsibility, a sense of failure. I walked somewhat stunned back to the nursing station. I stood briefly in front of the charts, trying to collect my thoughts. My senior resident was next to me. She caught my eye, and all she said to me was “You OK?”
That intervention was actually gentler than I expected from her, and I nodded quietly. She nodded back and walked off to deal with the next patient, and on cue, I too pulled out the chart of my next patient to move on as well. And that was it, the end of the debrief of this huge milestone in a medical trainee’s trajectory. I was just supposed to store it for processing at another time, if processing was necessary at all: there was work to do.
But that processing does have to happen, and someone absorbs that cost. Hopefully, we find healthy ways to work through that tumult of emotions that we’re not necessarily supposed to feel. If not, other patients bear the pain of us trying to avoid feeling those emotions again, or people at home have to try to fathom our brooding, or we let it eat away inside us, causing ourselves pain. I find it difficult to state explicitly because as a physician I am probably more than adequately compensated for the emotional cost of what I do, but someone does need to care for the carers. I try very hard to park my own emotional stresses outside the hospital, but when depleted of the things that nourish the spirit, I am all too aware of how easy it is to be irritable and impatient with patients and colleagues.
And that’s why this work of healing is such a collective effort, a network of caring relationships that sustain each other. There’s an entire team taking care of the patient, yes, but to keep that team alive and sustained, it requires collaborative, collegial relationships at work; we need supportive networks at home; we depend on a society that distributes resources fairly enough to make tasks feasible to accomplish; we lean on patients’ families who feel free and secure enough in their lives to share the burden of their loved one’s care too. We can care for people only when we’re cared for too. So I don’t do this work on my own, I rely on pretty much everyone else to make it happen. It’s a labour we all do together.
Check out the first part of Rankandfile.ca’s interview with Baijayanta Mukhopadhyay here.