The Medical Law of Accumulation: Putting the Sick on the Line

Turning down Dividy Road and onto the Bentilee housing estate in a rural corner of Stoke-on-Trent, I am struck by two images. First, an unavoidable eyesore – a house adorned with a Trump 2024 flag – is followed by three houses each receiving visits from three individual health professionals. Then, amid a sea of semi-detached ‘sunhouses’ sits the Bentilee District Centre Project: its health centre gushing with people walking in and out. Once the largest council estate in Europe, Bentilee provides us a snapshot of class decomposition in Britain’s rustbelt regions.

This place was once home to miners, unionised workers and nodes of the labour movement. Ruth Wilson Gilmore has long insisted that our times are captured by a term from Peter Drucker’s 1990s management manuals, ‘organised abandonment,’ where companies profit like Gordon Gekko did in Wall Street, by consciously destroying lifeworlds. Britain’s rustbelt has faced a kind of disorganised abandonment. In the absence of social democratic state planning and with the breakdown of the neoliberal social contract, the dominance of global financial and rentier capital over the operations of British capitalism has debilitated the nation state’s capacity to reproduce conditions for accumulation, leaving vast swathes of the urban and bodily space of the contemporary proletarian to rot. Bentilee is the poorest place in Stoke: workers earn £10,000 less every year than those in Stoke’s richest areas. Unlike other parts of the city, Bentilee is not dominated by private home ownership. Bentilee’s history and spatial makeup are unique in many respects, but in two key ways it is indicative of a developing picture of Britain. The bulk of its working residents are employed in care, health, and ‘elementary occupations’ and they suffer a lower life expectancy and poorer health than their counterparts across the city. The work of caring for sick and broken bodies becomes more and more dominant – as Gabriel Winant’s The Next Shift has recently tracked in the American case – while those doing the work are often the same people whose sickness and exhaustion feeds the growing industry. A person’s place in the nation’s hierarchy of class power can be read increasingly through the lens of health outcomes, which tell a story about where you live and what job you do.

Marxists might imagine this is nothing new, and nothing remarkable; since at least Engels’s Condition of the Working Class in England we have been familiar with furious protest at the ways that capital accumulation attacks our health. But some updating is in order too. In Capital, Marx seems to treat the sick as a fixed category. It is a surprising step. Chapter twenty-five, Marx’s famous ‘General Law of Capital Accumulation’, narrates a cycle of attracting and repelling workers to and from the labour market amid fluctuations in capital’s needs, which produces inequalities and stratifications among proletarians through the constitution of an industrial reserve army of unemployed workers. That cycle influences how much workers earn; how much power they have; their life prospects. The different moments of the cycle shape how dependent a worker is on an employer, but also the relationship of states to workers and workers to other workers – generating divisions, forms of sectionalism and cultures of recrimination between workers who find themselves competing against one another. Marx relates the cycle to the state of the population-at-large. Refusing the Malthusian ‘law of population’, Marx thus related the health, wealth and general conditions of life of the population less to eternal and biophysical laws than to cycles of capital accumulation. These cycles exercise some determination over what Beatrice Adler-Bolton and Artie Vierkant describe as the ‘worker/surplus binary’, the social categorisation of who is and is not ‘deserving’ of dignity and life. But Marx deposited the sick as the ‘dead weight of the industrial reserve army’: one impotent cohort in a sea of pauperism.

That view seems today to jar with his insistence that we treat the character of populations as transient and subject to the laws of capital accumulation. Sometimes, capital’s impositions on populations have circular effects on accumulation. The sick and ill appear today as a substantively large fraction of the population, which ruling classes are desperate to force back into the labour market. The ills of austerity, labour degradation, neoliberalism’s psychic wounds and the spread of social pathologies have come back to haunt capital, and so it now calls for solutions through the regulation of our health. In Britain today, it is possible to diagnose a new capitalist biopolitics, a central feature of Keir Starmer’s project in governmentality. Intensifying rhythms of capitalist exploitation and domination have not only weakened proletarian power and the ability to organise; they have also inhibited accumulation by pushing workers into the reserve army when capital needs them at work. That coexistence of weakened workers and anxious employers has been a long time in the making. Part of the wider productivity puzzle, and playing a role too in panics about low-wage migration, the nightmare of the sick proletarian looms larger after Covid-19. Tracing the emergence of that angst is one way of telling the story of Britain’s changing regimes of accumulation since 1945, casting fresh light on the structures of feeling we face now and their political possibilities. The wider question posed here is the one long raised by culturally inflected Marxisms: what kinds of people are the working class really, and how do they get made and unmade as political subjects?

Disassembling the Proletariat

A world ago, postwar social democracy bred several distinctive class subjects with frighteningly radical potential. The white male Fordist car worker gradually became one of the most rebellious forces of the postwar settlement and challenged wage suppression, speed-ups and employer autocracy. The South Yorkshire miner revived age-old traditions of industrial militancy and fought against the repeated and growing effort to crush proletarian lifeworlds constructed around the mines. The part-time female clothesmaker challenged her subordination as the domestic servant in the male breadwinner single-earner family model just as she also increasingly turned to uprooting forms of industrialised housework on the factory floor. The black foundry worker struggled against racist employers and exclusionary trade union bureaucracies in equal measure, while questioning conditions of segregation, wage inequality and growing obsolescence.

This assemblage of class agents was not simply invested in fighting for better conditions or higher wages. These workers fought for greater control over the shopfloor. They brought down governments, defended old proletarian lifeworlds from ruin and struggled for the right to be free as women, as black people and as human beings. Their confidence was overdetermined by numerous conditions of possibility coalescing in the mid-century. One line of domestic economic determination in that story was captured by Michał Kalecki’s 1943 warning about the ‘political aspects of full employment’. With the threat of the sack lacking its usual impact in the absence of mass dole queues, workers exercised a degree of power unseen outside periods of revolutionary instability.

By implication, the social democratic state administered a tense balancing act. Its ability to guarantee capitalist profitability, control worker populations and ensure the employers’ right to manage was constantly challenged and jeopardised by the class subjects it bred. Exploiting this crisis in social democratic governance, Thatcherism developed a conservative critique of redistribution, trade union power and the uneven cultural awakenings of the postwar years: all in the service of disassembling these radicalising subjects. The project did not present itself to voters fully formed. The 1979 Conservative manifesto committed to revitalising Britain’s industrial economy, but that was superseded by an overarching and longer-term ambition to combat inflation and disempower proletarians. Thatcher offered early pay rises to the steelworkers, but her regime then largely refused the social democratic temptation to buy out manufacturing capital and grant wage increases. Her alternative was to build a political, economic and legal architecture capable of existentially curtailing and disheveling working class organisation and power.

When unemployment hit one million in the early 1970s, that number was seen as a fundamental challenge to Edward Heath’s struggling Conservative government. Less than a decade later, and against intense opposition, Thatcher was able to present three million unemployed people as a necessary evil to control the intimately connected ills of inflation and worker power. Her monetarism was the straw that broke the camel’s back for the world of the white male Fordist factory worker, long under pressure from the growth of services, the decline of industry and the insurgent claims of women to bodily and social autonomy.

Shortly after Thatcher’s landslide re-election in 1983, Beatrix Campbell trod Orwell’s steps again to publish Wigan Pier Revisited. She recounted the thoughts of a male trade unionist on what he called, ‘front door socialism.’ His life, he said, was ‘politics first, family second.’ His politics of militant confrontation with power began when he ‘shut the front door’ and ended when he ‘came home’, relying upon his wife as an ‘emotional sponge’ throughout. The combination of manufacturing overcapacity, energy transition and class warfare spawned mass unemployment and deindustrialisation as many older manual workers became long-term social security claimants, especially in those regions hit most heavily by the decline of coal and manufacturing. Additionally, the long-term consequences of industrial injury resulted in the number of people on invalidity and sickness benefit doubling between 1980 and 1993 to two million people. The world of ‘front door socialism’ had been overturned, in the words of Linda McDowell, by ‘redundant masculinities’.

The introduction of means-tested benefits was crucial to the decline of these class agents. They became a staple of Thatcherite statecraft, supplementing monetarism and anti-trade union legal reform in the quest to reduce workers’ bargaining power. Jim Tomlinson’s contribution in A Neoliberal Age? rightly stresses how, as Chancellor of the Exchequer, Nigel Lawson concentrated on ‘the rediscovery of the enterprise culture’ through the removal of any ‘rigidities and distortions’ in the labour market. Lawson was especially eager to reproduce American patterns by growing part-time and casual jobs in an expanding service-sector. In practice, that meant in-work benefits were a critical component of Thatcherism’s attempt to transform the workforce, topping up the pay of low-wage workers in a state subsidy to employers. The spread of low-paying jobs in education, health, social care and services was accompanied by a substantive rise in state spending on welfare.

In short: while Thatcher reformed the welfare state and the social wage to contravene proletarian power, she massively increased expenditure on welfare to cope both with rising unemployment and with deliberately aided changes in the structure of employment. Thatcher’s government did not simply witness Joshua Clover’s ‘affirmation trap’ – where, to survive, proletarians must abandon the questioning of their position as workers and affirm their place as labourers dependent on a boss. She sprung the trap too. The comfortable left adage about the enduring destructive power of that moment, reproduced in David Edgerton’s story of Thatcherism as a ‘rulers’ revolt’ can sometimes overstate the agency of the Tory Right in a global transformation, but it has its kernel of truth. In the policing of growing surplus populations through workfare and means-tested benefits, our contemporary moment is inseparable from Thatcher’s mission to drastically weaken proletarian power. The spread of moral panics over ‘mugging’ amid black deindustrialisation, so aptly recorded by Stuart Hall and his co-authors in Policing the Crisis, marked an attempt to articulate racialised readings of the crisis of postwar social democracy. Thatcher attentively reproduced many a theme from the pioneering monetarist and racist Enoch Powell, racialising the experience of inner-city industrial decline as a problem of disobedient foreign cultures. The Iron Lady would be proud of how these stories continue to be taken up by her heirs.

Thatcher’s Heirs

When New Labour took office in 1997, they inherited an official unemployment rate of 6.8 per cent, or just under two million. According to a comprehensive study by Christina Beatty, Stephen Fothergill, Tony Gore and Alison Herrington, real unemployment – measured to factor in the excess early retired, the excess permanently sick and those on government schemes – was almost four million. Facing that challenge, Tony Blair argued that reducing the dole queue would ‘be easier’ if the labour market was ‘working properly’. What was needed, in the view of New Labour ideologues, was the creation of a ‘low-wage sector’ predicated on low-skill jobs readily accessible to those on welfare.

Although New Labour stalled the spiralling immiseration commenced by Thatcher’s war on workers, their minimum wage regulations and introduction of tax credits did not reverse the trend. Instead, their commitment to subsiding low-wage employment through tax credits, workfare, obligatory training programmes, and their New Deal for Young People were all central aspects of a policy programme that sought to provide a steady supply of precarious, low-paid workers to the service sector. According to Bernhard Rieger, New Labour’s rejigging of the welfare system involved a move towards a welfare state best characterised as a ‘new Speenhamland’ system. The original Speenhamland system, the backdrop to Karl Polanyi’s Great Transformation, saw the payment of wages below survival levels subsidised through the Poor Laws rate system. If that sounds like a very non-neoliberal moral economy, it was in fact recreated under neoliberalism in an effort to subsidise employers, weaken worker power and stymie the problem of poverty.

Accompanying this new welfare system, a ramped up moral panic targeted ‘benefit scroungers’ while Blair railed against a ‘sick note culture’. As Secretary of State for Work and Pensions, Alastair Darling condemned a ‘something for nothing culture’. New Labour increased spending on welfare for deeply classed, non-redistributive purposes with one hand, and held up a megaphone decrying benefit claimants with the other. Blair’s party introduced Anti-Social Behaviour Orders to police unemployed urban youth and attacked single mothers through a lens indebted to the war on ‘welfare queens’ prosecuted by the American ruling class, stressing the need for young single mothers to restrain themselves from having more children. Helen Charman’s Mother State captures the reactionary mood at the time, wherein single mothers ‘were accused of … producing a child to extract support from the surrogate paternal state.’ In this reading, a campaign of demonisation, orchestrated on both benches of the Commons, took Britain’s relatively high teenage pregnancy rate and mobilised it against a section of the population deemed a sponge on welfare and a hurdle to cultivating a slick labour market. Blair’s emphasis on ‘strong families’ as units of production, the New Deal for Lone Parents and sex education in schools were all staples in the cultivation of a reactionary environment geared towards the proliferation of amenable, obedient forms of particularly feminised wage labour.

This traditionalist assault culminated in a young employed mother on in-work benefits, Shanene Thorpe, being invited onto BBC Newsnight in 2012. She was monstered by Allegra Stratton, with questions including, ‘Don’t you think you should still be at home with your mum?’, ‘Do you want any more children?’ and worst of all, ‘Do you think you should have had your daughter?’ Stratton later worked as Director of Strategic Communications for the Treasury under Rishi Sunak, and would go on to appear as the laughing face of Boris Johnson’s partygate: proving herself a libertine when it comes to the powerful skirting social duties to protect the health of others.

By the time of Thorpe’s public humiliation, the assault on welfare claimants had reached its peak under the Conservative-Liberal Democrat coalition. David Cameron’s government combined austerity for public services with further anti-trade union legislation, the rise of zero-hours contracts and the merging of different benefits into Universal Credit in a digitised, reduced monthly form geared more heavily towards incentivising the unemployed into shit, precarious work. The government placed further conditions on all benefits, most notably through changes to disability benefits and the so-called bedroom tax. According to the Labour Force Survey, the number of people on employment contracts with no weekly minimum hours increased from less than 200,000 in 2010 to over 900,000 in 2017. The inauguration of a grossly authoritarian benefits system alongside the growth of bogus self-employment expanded Marx’s ‘stagnant’ surplus population – that cohort of proletarians subject to a permanent state of temporary employment – while weakening the power of workers above them in the labour market hierarchy.

Despite the punitive, austerian environment created by Cameron’s Tories, the paradoxical situation of increased welfare spending and deepening public resentment towards welfare claimants grew throughout the course of the early 2010s. Spending on welfare has dramatically increased since 1979, and 7 per cent of this rise took place in the short years of that cost-cutting Conservative-led administration. Today, around half of the Department for Work and Pensions (DWP) budget is spent on pensioners, signalling the state’s faltering and sticking plaster response to ageing, while 11 per cent is spent on disability benefits. Contrary to the image crafted by politicians and ideologues, when welfare spending is not being invested to cope with substantive demographic changes in the population, it is being mobilised to supplement capitalist power.

‘Don’t medicalise these issues…’

This relationship between capital accumulation and demographic transition moulds the priorities of Keir Starmer’s Labour Party. Committed to keeping capital’s pockets full, dogmatically in hoc to the enduring ‘Treasury view’ that has preached fiscal restraint for at least a century, but absolutely obsessed with ramping up economic growth, Labour’s front bench have become invested in the bodily capacities of British workers. In a state of affairs that preceded the Covid-19 pandemic but was exacerbated by it, the economically inactive outnumber the officially unemployed by six to one. 3.7 million workers have declared they have work-limiting health conditions. People aged sixteen to thirty-four years old are now as likely to report a work-limiting health condition as someone aged forty-five to fifty-four in the data ten years ago. Much of this increase is a product of mental ill-health. Even more profoundly, demographic ageing has contributed to 63 per cent of the actual rise in economic inactivity between 2019 and 2021. Of the 3.5 million fifty-to-sixty-nine-year-olds inactive in 2022, 45 per cent reported ill health as the main cause of their inactivity. 900,000 sixteen-to-twenty-four-year-olds are currently neither in work, education or training. The annual welfare budget currently sits at £266.1 billion, with the Institute for Fiscal Studies reporting that spending on disability and incapacity benefits for working-age individuals is likely to increase by a further 15.4 billion by 2028-29.

These figures are lit up in the Pathways to Work Commission Report published by Barnsley Council, praised and launched in Barnsley in July 2024 by Liz Kendall, the new Secretary of State at the DWP under Starmer. The choice of location is no coincidence. Britain’s northern and rustbelt towns have been described with a slew of anxious monikers over the last two decades, from ‘chavs’ to ‘left-behind’ to the vaunted ‘red wall’. Today these deindustrialised areas provide the nucleus for worries about a workforce that is calling in sick rather than turning up to work. This is only the latest rendition of hand-wringing about the effects of two longue durée processes: Britain’s relative decline within world capitalism; and the move from a Fordist Keynesian geography to neoliberal uneven development. Together, these two shifts have moved places like Barnsley from an important global manufacturing town of the industrial revolution to a national periphery amid financialised growth emanating from the City of London. Worries about sick proletarians communicate that longstanding angst. The angst is national, even transnational amid the fading of American unipolarity – that is, this discourse speaks to a panic about decay, after a decade of stagnant living standards amid higher GDP growth rates outside the global North – and it is especially concentrated in places like Barnsley. Compellingly this discourse connects longstanding language around ‘the economy’ as a dying patient (‘the sick man of Europe’ in sloppy diagnoses of Britain’s 1970s woes) to an image of its workers as sickly, feeble and fading: and in need of a big stick. The first key trick of the discourse is to imagine that the problem is rooted in individuals’ failings.

In light of this, the DWP has committed to making annual cuts to sickness benefit worth £1.3 billion while retaining the Conservatives’ Work Capability Assessment, which narrows eligibility for incapacity benefits and subjects 450,000 people to benefit cuts. Keir Starmer recently confirmed to rightwing rag, The Sun, that he did indeed have ‘the balls’ to cut disability benefits even further, signalling that the regime’s austerian impulse is not afraid to draw upon Thatcherite framings of a ‘culture of dependency’ in order to punish the poor and disabled. DWP chief Liz Kendall and special advisor Alan Milburn have set upon a plan to confront the problem of long-term sickness amongst the working population. Milburn has been adamant that the long-term sick should be forced to search for work. In an interview on The Rest Is Money podcast, Milburn asked that we ‘don’t medicalise these issues … there’s a risk that it becomes an excuse culture … You don’t need a psychiatrist, maybe a talking therapy or group therapy will help’. Concretising this logic, Kendall has declared that job coaches will visit ‘seriously ill’ patients on mental health wards in an effort to force them back to work, with employment advisors deployed to hospital wards to give CV and interview advice. Labour has announced free health checks in workplaces (fittingly named after the Ministry of Transport’s obligatory vehicle inspections), toyed with the idea of banning high-caffeine energy drinks and disposable vapes, prohibited vape and junk food advertising to under-sixteens, and given councils powers to block new fast food outlets near schools. Health Secretary Wes Streeting has also declared that unemployed people will be given weight-loss jabs to get them back into work, claiming that ‘widening waistbands are a burden on Britain’. Streeting has attracted a £280 million investment from Lilly, the world’s largest pharmaceutical company, to develop new treatments to confront obesity and worklessness. A new Labour Market Advisory Board, launched by the government in September 2024, has the sole task of addressing ‘the greatest employment challenge for a generation’ – long-term sickness – to boost employment as the government prepares their ‘Get Britain Working’ White Paper to involve Kendall and Streeting. The joint participation of those two departments is meant to send a message; the goal is a healthier population because the goal is a more hardworking population.

All this is to identify a capitalist biopolitics. The ruling class is clearly concerned that capital accumulation is encountering limits that need to be removed, and those limits are constituted in our fungible bodies and brains. Across large parts of the world, ageing, sicker and shrinking populations are becoming the norm, constraining productivity and inhibiting economic growth. In this context, the principles of maximum economy come to the fore, creating room for greater coercion on the part of states and more disciplinarian attitudes to the growth of sick proletarians who produce tighter labour markets, the potential for increased bargaining power by those in work and higher welfare bills. This renewed attention to the proletarian body, reorganising the line between the worker and the surplus population, signals a new course of capitalist governmentality, viewing the physical state of workers as key to reviving British capitalism’s fortunes.

Repair and revolution

There are opportunities in the ether. Starmer’s purge of Corbynism appeared in Opposition as an attempt to crush radicalism in the Labour Party. In office, it is also a project to undermine the policy radicalism that Corbynism was able to mobilise. According to the British Social Attitudes Survey, positive views of welfare have increased over the last ten years, with rising support for welfare spending and growing dissent from images of the undeserving poor. Similarly, the proportion of people who thought falsely claiming benefits was never justified fell from 85 per cent in 2011 to 67 per cent in 2023. With 38 per cent of Universal Credit claimants in low-paying work, it is no wonder that, according to the Office for National Statistics, street theft has risen by 40 per cent and shoplifting increased by 30 per cent over the last year. EP Thompson’s notion of a ‘moral economy’ – which he used to describe the clash between trade liberalisation, price rises, and a consequent explosion of popular revulsion, food riots and theft in the eighteenth century – is today reappearing not in the softened form of a social contract managed by the state, but once again in its insurgent original shape from below. And we are shifting somewhat away from the cultural resentments of peak neoliberalism. There are grounds, which Starmerism underestimates and undermines, for generalising a politics of health quite different from capitalist biopolitics. Its twin lynchpins, in opposition to the twin terms of Starmer’s governmentality, would be to take sickness as real and socially caused, requiring care rather than punishment, and secondly to see sickness as a problem for our flourishing rather than for our usefulness to capital.

At the mere age of thirty-two, my body, marked by the intrusions of class power, is painfully catching up with me. Many of us suffer from forms of ‘ordinary unhappiness’. Some of us suffer much worse. On my own estate, just an hour’s walk away from Bentilee, you can see the melting pot of shit, precaritised jobs; appalling housing conditions; the ghosts of neoliberalism’s wars in the form of drug addiction; and stark images of disorganised abandonment caught in the bonfires lit at night to warm the homeless and poor. The past two decades of social struggle in Britain have often been concerned with defending what remains of the National Health Service and the broader welfare state. The politics of managed decline, privatisation and welfare authoritarianism have become sites of reactive campaigning which have sought to return the nation’s health and social safety net to a long-abandoned past. Yet, if we are to escape this defensive and losing cycle, we must begin to put some flesh on the bones of what Artie Vierkant and Beatrice Adler-Bolton captivatingly term Health Communism.

In 1988, reckoning with the labour movement’s isolation, Stuart Hall insisted that the Left learn from its enemies. Cognisant of a new realm of social identities and cultures forged throughout Thatcherite post-Fordism, Hall suggested that the labour movement should trade its ‘negative’ politics of ‘contestation’ over policy detail for an overarching account of the good society, fitted to contemporary structures of feeling, which could then more confidently ground a more radical set of policy demands. Thatcher framed the future of the NHS through enterprising principles and the ‘politics of choice.’ Hall argued that the Left should take up that fight and articulate its own vision of health, ‘dramatising the NHS crisis in concepts Thatcherism has not managed to appropriate: democratisation, rights and the expansion of social citizenship’. Today, we must rise to this task and refuse the consolation that the coalitions of the past will suffice. The future of communist politics demands that we articulate a vision of health and welfare futurity constructed through a diverse array of social agents – nurses, GPs, the physically sick, the mentally ill, welfare claimants and taxpayers – who can actually see their needs and hopes communicated in the construction of a majoritarian vision.

This view of communist freedom should combine Frantz Fanon’s psychoanalytic and political case (as David Marriott has put it) for ‘repair within revolution’ with Alberto Toscano’s ruminations on ‘dual biopower’, wherein subaltern populations stitch together a collective project reappropriating control over their bodies from the state and capitalists. Marshalling Fanon’s clinical practices and the Black Panther Party’s free breakfasts and health clinics could perhaps provide us with the organisational and ideological inspiration to cultivate an insurgent moral economy from below. A social order whose pollution attacks our lungs, a working day whose rhythms exhaust our capacity to be fully present with loved ones after it’s over, and the sense of self-loathing and wasteful existence deliberately propagated in humiliating Work Capability Assessments all make us less than we might be. In struggling to be fuller versions of ourselves, drawing the connections between our health and the health of the planet and its ecosystems too, we might find that a horizon of repair is (as David Scott points out in writing on reparations for slavery and colonialism) less invested in teleological stories of progress than past left vocabularies. The push for repair could combine a supreme norm of care (which is different from growth) with daily practices that instantiate and prefigure that norm, enacted by radicals in a mode that involves and empowers the sickly of the earth. But there are limits to such a community approach, where it works from below and leaves the grand heights up above (including most of the state) outside its reach. Building towards the democratic control of health and welfare, free at the point of use, shorn from the market, statism and means-testing, and in service of a liberated and healthy future for everyone, will almost certainly require a party.

Jonas Marvin is a writer and researcher, currently working on a book, provisionally titled Disorganised Abandonment, forthcoming in the Salvage Editions series with Verso. He also blogs at Marx’s Dream Journal.