No one should pay for a coronavirus test. This is not a moral judgment but a statement of fact; the US government has decreed it so. Insurers are supposed to cover the tests, at no cost to the consumer. But hospitals recognized an opportunity for profit. The prestigious Lenox Hill Hospital in Manhattan billed one patient $3,358 for a test in March, The New York Times reported. Northwell Health, the nonprofit that operates the hospital, justified the bill as a necessity: Its emergency room care is simply that good, it claimed. The hospital billed another family $39,314 for 12 tests.
The Lenox Hill bills are shocking not just because they are so high but because they should not exist. They violate a principle that has come to the fore during the pandemic: that the public’s health transcends all other concerns, including the profit margins of hospitals and insurers. The tests should be and are free. The same for the Covid vaccines; in many cases, they are administered by local, state, or federal agencies at sites set up for this purpose for the sole benefit of the public. For now, at least, a world of health care that’s very different from the one we’re used to is not only possible but exists.
What the pandemic reminds us is that this alternative world has long been possible. Yet we are still mired in a system that extracts profits from people’s health and puts thousands of families and individuals into crippling debt. In their new book, Inflamed, Rupa Marya and Raj Patel chart the human costs of this for-profit health system and look beyond it to what they call “colonial capitalism,” the root system of our moribund world. They also argue for an alternative: a society informed by “deep medicine,” which can heal what’s gone so terribly wrong. Comprehensive in scope, Inflamed moves from environmental pollution to debt to misogyny to settler colonialism and empire, arguing that this vast array of maladies are all consequences of capitalism.
When something upsets our ecosystems, whether it’s pollution or a pandemic, the consequences show up in our bodies, the authors write. “So: salmon are to rivers as hearts are to blood vessels. They both function as nutrient pumps in systems of circulation.”
Our inflamed condition is ultimately, Marya and Patel argue, a political one. Politics has failed us by not creating a society that seeks to increase the health—physical, emotional, financial—of all its members. As Renee Hsia, a professor of emergency medicine at the University of California, San Francisco, told the Times, Lenox Hill’s billing practices are what to “expect from a market-oriented approach to health care. It’s the behavior our laws have incentivized.” If the public is a kind of body, it needs a cure: a politics that can confront and replace our current market-based approach.
To tell their story, Marya and Patel reject the standard military analogies for the immune system. Inflammation, they argue, is a sign that the body is trying to heal itself—not so much that it is under attack but that it is ailing from within. While they indulge in this metaphor perhaps a bit too much, they aren’t comparing contemporary life to, say, cancer. Rather, they’re asserting that capitalism forces people to live in a way that causes higher rates of illnesses like cancer—and that alternatives have always existed.
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Debt, the authors note, is a tool of the colonizer. It is the means by which European governments accumulated the funds to build their imperial armies and to trap the Indigenous into body-destroying labor and a way to continue to suppress them. In Peru, colonizers adopted the Incas’ mita system and stamped their own image on it, using it to pay silver miners low wages that kept them indebted. “Mita was debt,” Marya and Patel write, “and debt was death.” Debt provided an early rationale for policing and a way to keep the Indigenous population in servitude. It is unnatural, especially in the context of health care, where it inflicts great stress on those who must go into debt in order to survive. With trade as the global circulatory system, debt becomes “a choke point,” a source of stress and thus the cause of biochemical reactions.
When someone receives a surprise hospital bill, the anticipation of future debt causes a physical as well as a psychological response. The body knows something harmful has occurred. “Stress is a state of real or perceived threat to homeostasis,” the authors write. Without relief, the body remains in that state of stress, activating chemicals and initiating “a cycle of alarm” that “feeds back on itself.” The consequences can be severe: “When chronic stress is the background noise of life, it impacts our cells, our DNA, and our children.”
The planet, Marya and Patel argue, is undergoing a similar process of depletion and destruction. For example, the disappearance of salmon in the Pacific Northwest can upset the region’s ecological balance for good. What’s bad for the salmon, and for the Indigenous people who have long relied on them, will eventually be bad for everyone else, creating a chronic background of stress and inflammation in the environment, in the same way that the stress and inflammation of debt hovers in the background of individuals and their families. The salmon are an early warning sign, and so are the human beings who are closest to them.
The extractive nature of colonial capitalism reserves its heaviest burdens for a class that Marya and Patel call the “immunes,” borrowing a term from the ancient Romans. Because of “a legal quirk of the Roman Empire,” they tell us, the “immunes” lived in “nonmunicipal” cities under Roman control, exempt from some of the responsibilities of the typical citizen but also deprived of some basic rights under Roman law. The immunes were never quite Roman—they were imperial subjects without the privileges of citizenship. Modern immunes, Marya and Patel write, occupy a similar position. Those who live in a society without the full benefits of its rights and protections—such as Black Americans and Indigenous people—may find that they have shorter lifespans, a greater likelihood of contracting and dying from Covid, and more illness in general. “Immunes know that the time is nigh for fire,” they write, “and it’s time to get to work.”
Puerto Rico provides Marya and Patel with particularly rich material for consideration, because the material damage of colonial capitalism can be found everywhere: “While Puerto Rico’s money matters to its colonists,” they write, “the bodies of the island’s inhabitants don’t.” Puerto Ricans “live like immunes in their own homeland,” with the United States wielding “tight fiscal control over the [its] debt repayment regimes, through a Financial Oversight and Management Board.” As a direct result of colonial rule, Puerto Ricans lack reliable medical care, infrastructure, and, often, access to fresh food. In Puerto Rico—indeed, wherever the immunes dwell—trauma leaves a physical mark as well as an emotional one, a phenomenon that Marya and Patel examine at some length. “Discrimination, PTSD and adverse childhood events,” they observe midway through the book, “all set adults up for chronic inflammation, mediated through pathways of stress.” Yet these experiences can be the basis for something new: Out of the immunes’ “current state of emergency,” a “radically different future” might emerge. “The immune is oppressed,” the authors argue, but also the potential source of change.
What, then, is the solution? Marya and Patel return frequently in Inflamed to the notion of deep medicine. “Rather than taking things apart to know (dia-gnosis),” they write, “deep medicine puts the pieces back together to understand and to heal what’s been divided. It never separates a person or a community…from the web of relationships that confer sickness or health. It is from that place of understanding that healing actions become possible.”
Deep medicine, they add, “requires new cosmologies.” Capitalism doesn’t just take; it severs, breaking the bonds between people and between people and the land. A deep medicine approach can begin to suture these wounds and restore the sufferers to a state of wholeness.
One example they offer: declaring a debt jubilee for poor countries. “Reparations for the historical harms caused by colonial debt are a moral requirement,” they write, “as is the need to make public goods of energy, shelter, education, and health care.” Toward the end of the book, they advocate a “global Green New Deal,” observing: “Part of colonialism’s sleight of hand is its normalization of the capitalist political, economic, and ecological framework in which care is practiced. The economic system that allocates care as a good, on the basis of ability to pay, turns something inherently relational into something to be consumed like a hamburger.”
A new model is clearly in order. But when it comes to discussing how to create one, Inflamed is short on specifics. No book can be all things, and this one is ultimately a work of diagnosis more than one of prescription. At once empathetic and skeptical of power, it is bold and searching in its examination of the ways in which the human body has exhibited the consequences of a specific economic and political system. Yet Marya and Patel might have reserved more space to consider the kinds of political solutions that will be needed to abolish such a system. The immunes must drive whatever change occurs, but how is another question altogether. Change implies a process, and its shape remains blurry at the end of the book. Perhaps that’s a problem no author can solve: Outside fiction, a person must write about what exists. A world without colonialism, without capitalism, belongs to the past—and the past is replete with its own horrors. Even so, Marya and Patel argue, the cultures and traditions of those oppressed by colonial capitalism offer us “the way forward,” even if the path isn’t always clear. “Settler ideologies have circumscribed the imagination,” they write. The future is creative work.
As the world plots a course past Covid, we will need new institutions as well as new medical practices and a new way of imaging our place in the world. To get there, we will also need power. A nearly $40,000 hospital bill is a horror at any time, but Covid unveils its true inhumanity to the world. The time for healing is here.