There’s no surer sign that life has become too comfortable for the rich than when they try to buy immortality. The first Chinese emperor enlisted scholars in his search for the elixir of eternal life and, after none was discovered, had them buried alive, figuring that if any of them was a true alchemist, he would return from the dead to share his secrets. (None ever did, but the emperor’s penchant for drinking mercury—which he believed also had life-giving properties—probably didn’t end up helping him live a long life.)
Leonard “Live Forever” Jones, a 19th-century US presidential candidate who accrued his fortune the American way—through speculation—believed that death could be overcome through prayer and fasting. Embarrassingly for his supporters, Jones died after refusing treatment for pneumonia on the grounds that illness was a moral, not a physical, concern. Later in the century, Gilded Age tycoons deified themselves through portrait-sitting, palace-building, and philanthropy, hoping this might at least sustain their image after their death, though it was then up to their heirs to maintain the memorials and the union-breaking that built them.
These acts of hubris pale in comparison, however, with the determination of today’s global elites to modify their bodies and transcend mortality. Ray Kurzweil, the computer scientist and spiritual docent to Silicon Valley, has predicted that by 2045, it will be possible to download a human brain to a computer. To make it to that year, Kurzweil drinks alkaline water, takes 100 pills a day, and spends one day a week at a clinic having supplements delivered directly to his bloodstream to preserve his flesh for the time when humankind will finally merge with machines. It may sound like a 9-year-old’s vision of the future, but Kurzweil isn’t a kid or a cultist; he’s a best-selling author who has been honored by multiple universities and three American presidents.
In Natural Causes, Barbara Ehrenreich explores the stories told by death-defying elites to make her own biological and political point: “no matter how much effort we expend, not everything is potentially within our control, not even our own bodies and minds.” In death, we will once again be equals—and so an egalitarian politics also means accepting this outcome.
At 76, Ehrenreich tells us, she is old enough to die, and over the past few years she’s given up preventive screening for breast cancer, scaled back her punishing exercise regime, and chosen to spend her time doing the things that bring her joy, like hanging out with her grandchildren. For Ehrenreich, this embrace of death is not merely a matter of biology but also of politics and ethics: “You can think of death bitterly or with resignation, as a tragic interruption of your life, and take every possible measure to postpone it,” she writes. “Or, more realistically, you can think of life as an interruption of an eternity of personal nonexistence, and seize it as a brief opportunity to observe and interact with the living, ever-surprising world around us.” Accepting death, for Ehrenreich, means being able to live more fully.
Over her long career as a journalist and activist, Ehrenreich has primarily made her name writing works of social history and cultural and political critique. Her first work, Witches, Midwives & Nurses: A History of Women Healers, written with Deirdre English soon after Ehrenreich received her PhD in biology, was composed in “a blaze of anger and indignation” at the exclusion of women as decision-makers in their own health care and the low status of the nursing profession. In 1983, at the height of the conservative backlash against feminism, Ehrenreich published The Hearts of Men, an examination of how cultural conceptions of masculinity entrap both men and women in resentment and dependence while preventing any economic reckoning with the generalized assault on the working class. The book sought to locate the appeal of figures like Phyllis Schlafly and the antifeminist movement. It was also a brilliant defense of feminism and socialism: “By simply asserting women’s right to enter the labor market on an equal footing with men,” Ehrenreich observed, “feminism undercut the dependent housewife’s already tenuous ‘right’ to be supported.”
Ehrenreich followed up these early works with her seminal Nickel and Dimed, for which she spent three months struggling to survive on the wages earned while working in retail and as a maid, house cleaner, and waitress. A firsthand account of low-paid service work, Nickel and Dimed was made all the more powerful by the author’s awareness that no matter how many shit stains she scrubbed away, she couldn’t possibly convey what it really meant to “experience poverty” in America. Published just before the financial downturn of 2001, the book sold over a million copies.
Ehrenreich has always had a deeply personal aspect to her writing, but it was only with 2009’s Bright-Sided that she put her own life at the center. In it, she used her breast-cancer diagnosis as the occasion for a striking critique of the positive thinking that runs through health-care treatment in America. Puncturing the insistence that people with cancer are more likely to survive if they think optimistically about recovery, Ehrenreich also explored the big business around prescribed optimism, from Dale Carnegie to the snake-oil salesman who “recommended positive thinking as a cure…for the entire economic mess” of the Great Recession.
Like Bright-Sided, Natural Causes was inspired by a particular moment in Ehrenreich’s life: her acceptance of her own mortality. But that moment gives way to a broader inquiry into the biological, social, and political implications of the American denial of death. In fact, one reason the book is so compelling is that Ehrenreich moves fluidly back and forth between discussing our physical limitations, our social and political limitations, and the relationship between the two.
Ehrenreich begins with microscopic observations of cell behavior to paint a detailed yet accessible picture of the body in conflict with itself. Macrophages, she tells us, are the “blue collar workers” of the body, cells that dispose of dead and injured cells and eat microbes that have made their way past the barrier of the skin—so it’s easy to see them as the good guys, “the vanguard of bodily defense,” as Ehrenreich puts it. But more recently, scientists have discovered a sinister role played by these cells, at least “from the point of view of the organism”: They can serve as “cheerleaders on the side of death,” accumulating at the site of cancerous tumors and encouraging their growth.
Macrophages—and the cancers and autoimmune disorders these cells promote—increasingly seem to be not just an error or mutation, but something happening within the natural responses of the body. For Ehrenreich, this opens up a much more philosophical question about the very nature of human autonomy and control: “If cells are alive and can seemingly act in their own interests against other parts of the body or even against the entire organism, then we may need to see ourselves less as smoothly running ‘wholes’ that can be controlled by conscious human intervention, and more as confederations, or at least temporary alliances, of microscopic creatures.” Just as our efforts to control our individual bodies are doomed, Ehrenreich argues, so are our efforts as individuals to uplift ourselves. The interdependence and chaos created by the body also lead to the same conclusions as the interdependence and chaos created by modern life: We can’t just go it on our own.
For Ehrenreich, this is demonstrated by the very nature of health. It’s only because of the collective medical advances of the past century or so that people living in a postindustrial world can conceive of “wellness” as a natural state and nature as harmonious or wise. Sure, herbal remedies, breastfeeding, and at-home childbirth are “natural,” but so are famine, epidemics, and high infant- and maternal-mortality rates. (The first-century philosopher Epictetus instructed parents, “When you kiss your child, say to yourself, it may be dead in the morning.”) Today, with good reason, we expect children in postindustrial societies to survive their parents, and we have the dedication of rigorously trained doctors and devoted scientists to thank for that. But this doesn’t mean that nature itself is on our side or that medicine and science will be able to save us. From this recognition, Ehrenreich begins to weave together an ethics rooted in not just accepting but embracing the realization that humans are united in suffering, that we will all experience the ravaging effects of nature and time, and that rather than try to run from that knowledge by controlling our minds and punishing our bodies, we must address it together, as a society.
At a time when American life expectancy is falling because of lack of access to health care—and when the abject failure of private insurers and health-care companies to provide the most basic care to their customers without bankrupting them has made “Medicare for All” a popular rallying cry in one of the most libertarian countries on earth—an indictment of the health-care and wellness industries may seem like a curious undertaking for a self-proclaimed socialist. But Ehrenreich’s message is not that we should do away with health care; it is that we should think more critically as a society about how, when, and why we use it. Screenings and lab tests can be lucrative for doctors, but seeing the patient as a chart of numbers can lead to serious mistakes and oversights. Doctors for whom the perfect patient is a silent patient miss out on hearing symptoms—or a lack thereof—that should influence their diagnoses. But it “isn’t easy to protest from the lithotomy position,” Ehrenreich notes sardonically, referring to the position that women are placed in during childbirth.
Ehrenreich also insists that viewing health care differently will allow us to see the ways in which the inequalities produced by class, race, and gender are much more central in determining one’s health than individual choices and screenings. It is not the specific choices of a poor person that lead to diabetes, cancer, obesity, and so on, but rather those inequalities produced by capitalism. While physician and Rockefeller Foundation president John Knowles may have pronounced in 1977 that most illnesses can be chalked up to a person’s bad habits, and thus the “idea of a ‘right’ to health should be replaced by the idea of an individual moral obligation to preserve one’s own health,” Ehrenreich wants to remind us that it’s almost always not just one’s own choices, but also the randomness of nature and the inequalities produced by human societies, that have the power to destroy us.
These days, Knowles’s view of health is everywhere. It is a common line of reasoning found in the health-care and related industries, which are eager to “empower” consumers through the use of apps, personal devices to monitor everything from steps to sleep to heart-rate stats, and discounts offered by insurers for annual exams (the utility of which, like preventive screening, is now the subject of scientific scrutiny). But it’s a line of reasoning that is also often used to justify opposition to the creation of a national health-care system.
This view of individual accountability has migrated from the health-care industry into the workplace, Ehrenreich argues. Mindfulness, for example, has become a religion in boardrooms—“Buddhism sliced up, commodified, and drained of all reference to the transcendent.” Individuals are supposed to build control over their emotions through practice, just as we aim to control our bodies through exercise. Mindfulness promoters draw on the concept of “neuroplasticity” to sell training programs with a thin veneer of science to the business world; but there is no evidence that meditation offers benefits beyond those we get from other forms of relaxation—say, a mandatory five weeks of vacation time a year, as is the case in Scandinavian countries. The problem, again, is not the practice itself, but how it’s expected to transform us into “an ever more perfect self-correcting machine capable of setting goals and moving toward them with smooth determination.” As Ehrenreich observes, “the word ‘enlightenment’ never arises in the mindfulness lexicon.”
Indeed, for Ehrenreich, mindfulness is as dangerous as the myths found in medicine about the power of individual choice. Just as medicine offers a reassuring illusion that we have more control over our life spans than we actually do, the mindfulness industry actively and insidiously serves to depoliticize the realm of work and other spheres of social life: It tells us that our mental as well as physical health is up to us, and discourages us from seeking collective solutions. What Ehrenreich instead proposes is confronting the chaos of the body, embracing the uncertainty of life and the limits of fitness and medicine, and finding comfort in our collective humanity.
There are some shortcomings to Ehrenreich’s argument, however. It’s fine for a retired woman who’s financially secure and doesn’t have any dependents to accept the chaos and uncertainty of nature, but many others still have families to think about and so need to keep on living in order to provide for them. There are also other issues of class: Some may have the resources at a certain point in their lives to embrace death more actively than others—but if you haven’t built up savings or inherited some, you really need to live as long as you can if there are others relying on you.
Ehrenreich would likely agree that this is a fair objection, as it’s absolutely true, at least in the United States, that capitalism has taken not only retirement but the prospect of a worry-free death from many of us. But she would also respond by noting that part of the problem with this line of reasoning is that it still assumes that, as individuals, we are in the driver’s seat, when in fact nature doesn’t care about what our families need from us any more than it cares what we need from it—which has always been the point of creating a social safety net in the first place, from the banding together of hunter-gatherers to the post–World War II nationalization of health care in Europe.
There is also a different kind of criticism of Ehrenreich’s argument. It’s difficult to agree with her when, writing about gynecological and other annual checkups, she suggests that “one problem, though certainly not the only problem, with these regularly scheduled invasions of privacy is that they do not save lives or reduce the risk of illness.” For example, while a 2016 study found that the reduction in breast-cancer-mortality rates was due to treatment rather than screening, the adoption of routine cervical-cancer screening in the US has reduced mortality rates of cervical cancer from the leading cause of cancer death in women to the 14th. One can recognize the inevitable way in which nature works, the lack of individual choice, and the inconsistency of our personal decisions in shaping our own health outcomes, without entirely rejecting preventive screening.
And yet Ehrenreich is ultimately right that we need to know when to let go—or, at least, how to prepare for it. Shortly after I gave birth, I developed a complication and was given a CT scan, which found a tumor on my adrenal gland. I was referred by the ER team for an MRI, and two days later, I opened an attachment to an e-mail from my doctor’s office showing the results: The radiologist had concluded that the tumor was likely malignant. I searched “adrenal carcinoma,” only to find that the life expectancy for this highly aggressive cancer is about five years. In three weeks, while I waited for the results from the lab work, I lost 30 pounds and woke up many times in the middle of the night to write letters and record videos for my son, so that one day he would know his mother’s voice. When I was finally able to get an informed opinion from a specialist, I was told the MRI image was misleading (for complicated reasons I won’t get into here) and the test unwarranted in this case, since the original CT scan had strongly suggested that the tumor was benign. The overabundance of caution on the part of the ER doctors led to such anxiety in the first weeks of my child’s life that my breast milk dried up. This did not have to happen; it was the product of a medical system rooted in fear, a desire to avoid professional liability—I’ve been told many times by oncologists that radiologists have to cover themselves—and rapid intervention without consideration for a patient’s symptoms or circumstances.
It’s better than the alternative, you could say—but is it? Even after the fact, I concluded that I’d rather not have known, and enjoyed the one or two good years left to me, instead of five miserable years of chemo. There’s little doctors can do in the case of adrenal cancer—as is the case with many disorders—besides let you know you have it and give you an estimate of how much time you have left. Death is inevitable; the question is how much foreknowledge we really want.
And fear is not the only consequence of overscreening and misdiagnosis. An estimated 70 to 80 percent of thyroid-cancer surgeries performed on US, French, and Italian women (who are far more prone to thyroid tumors) from 2003 to 2007 were later deemed unnecessary, Ehrenreich tells us. All surgery carries with it the risk of death, and thyroid surgery usually makes patients dependent for the rest of their lives on hormone medication, which isn’t always effective and can leave them feeling profoundly exhausted.
My own experience with misdiagnosis did lead to a few positive outcomes: an extraordinarily vivid investment in the present—I lived each day to wake up to my son’s smile—and the conviction that my child would need to bond not just with me, but with my husband, parents, sisters, and friends (not incidentally, a common strategy in societies with high maternal-mortality rates). More important, it confirmed my commitments to demanding universal child care and health care as a human right, already ignited by an earlier cancer diagnosis. When we are forced to rely only on ourselves and our own private regimes of health and fitness, we are just one malignant tumor or a few cheerleading macrophages away from leaving our families without providers.
And here we arrive at Ehrenreich’s final point. Since nature operates randomly and is not often guided by individual choices, we must act together as a society to try to equalize health outcomes as much as we possibly can. (And even then, they will still be grotesquely unfair.) Contemporary society, Ehrenreich writes, is “so deeply invested in the idea of an individual conscious self that it becomes both logically and emotionally impossible to think of a world without it.” And yet, “there is one time-honored salve for the anxiety of approaching self-dissolution”—not endless rounds of chemotherapy, or the insistence that you’re a fighter and that you’re going to make it, which has practically become the recommended etiquette for those with a cancer diagnosis—but the submergence of “oneself into something ‘larger than oneself.’”
What this “larger than oneself” means for Ehrenreich is largely left unsaid—and when she does discuss it, she does so in vague and ephemeral terms. In contrast with much of her previous work, Ehrenreich here offers an original, multifaceted critique without a political prescription, other than the vague reminder to hold your loved ones every day. But if one looks back at her earlier work, one can find clues as to the kinds of policies she might suggest.
Natural Causes may be a book that offers little comfort to many. But it is radical. It’s now strange, almost quaint, for those of us living as consumers in a capitalist society to be told to accept the fragility of our bodies and place our faith in the power of our collective humanity. Given that most of us are supporting others and will likely have to do so for the rest of our lives, whether it’s our children or our parents without Social Security, the need to postpone death is not antisocial; it is a pressure felt by anyone who’s not an heiress. But Ehrenreich gives us something else instead, reminding us how important it is to build social “utopian” supports that can mitigate the pain of a dystopian body. In this way, Natural Causes is, if nothing else, the culmination (though hopefully not the last book) of a career spent insisting on a common-sense morality that is actually visionary.