“Not All Suffering Is Illness; Some Suffering Is Political”:
The Ambit of Radical Care

BaijayantaMukhopadhyay.
         2016. A Labour of Liberation. Regina, SK, Canada: Changing Suns Press. 68 pages.

A Labour of Liberation, published by the new Changing Suns Press, is a slim, significant book that takes seriously health care as labor — raced, gendered, classed labor — while holding up the specificity of what that labor is: care. Baijayanta Mukhopadhyay is uniquely positioned to write this book: a physician working among indigenous communities and in settler resource-economy towns in northern Quebec and Ontario; trained in sociology; active in the People's Health Movement; an immigrant attuned to medicine's role in colonialism and in post-colonial state-building. However, a biography of this sort does not convey the quality of writing — the economy, grace, rage and yes, care — that makes A Labour of Liberation a compelling and accessible read.

In 13 short chapters, ranging from two to seven pages, Mukhopadhyay considers aspects of medical care that constrain its potential as liberationary practice. For, as he has stated in an interview,11. I strongly recommend this two-part interview to those desiring more of Mukhopadhyay's voice: http://rankandfile.ca/2016/07/21/the-labour-of-liberation-an-interview-with-author-baijayanta-mukhopadhyay-part-1/ [1.] View all notes “You really have to step out of the mundane for liberation, whilst the practice of a physician is the epitome of the relentless grind of everyday life.” Some of these everyday constraints — overwork, alienation, specialization, commodification, neglect, coercion as well as empathy — have long been legible through the lens of political economy. But Mukhopadhyay always stays close to the labor that is particular and peculiar to medical care (and often escapes political economic analyses): diagnosis, cure, easing suffering, saving life, preparing for death.

Each of these acts requires a decision, and it is in the deciding, its hierarchies of responsibility, exclusion and control, that Mukhopadhyay locates one kernel of the political struggle. Who decides such things? Which histories of capital, race and gender have made this so? The other kernel of political struggle is care's technicity. As health becomes “an inscrutably technical field,” it comes to resemble other fields of instrumentalized rationality, in which technical fixes are used to address political economic factors, in this case, those that cause ill health. The bibliographies in each chapter bring forward an invigorating diversity of critique and imagination: from Steve Epstein's sociology of HIV social movements to newspaper articles on medical worker strikes around the world; from journal articles on placebo and evidence-based medicine to critiques of colonialism in India and settler colonialism in Canada.

The book begins with the story of black nurses organizing at a hospital in Jim Crow Charleston, firmly situating health institutions and care work as zones of antiracist struggle. Mukhopadhyay locates himself within these sites, asking, “How solidly have the institutions in which I invest so much of my energy been built upon the presumption of hateful hierarchies?” This mode of questioning resonates throughout the book, compelling the reader to wrestle, alongside Mukhopadhyay, with exclusions that should preoccupy anyone in, or training for, positions of professional privilege. In a chapter called “The advice of old women,” Mukhopadhyay begins with the story of his mother in India, who, after cataract surgery, was torn between the advice of her ophthalmologist and the advice of her mother, two distinct authorities, “both grounded in very particular empiricisms of care.” In India, as elsewhere, “wariness of women” and of lay healers translates into exclusion from official care. On the other hand, “traditional” medicine may be coopted by the state, as is the case with Ayurveda, a humoral system of medicine that has been institutionalized in India. This is one of many stories in the book that illustrates how medicine reflects and configures social hierarchies, whether of gender, race or knowledge.
Always entangled with the politics of who is the politics of what: Just as certain carers are valued over others, so, too, are certain care practices. For Mukhopadhyay, state and capitalist logics skew resources toward care that can be counted — “[c]aring mechanisms which are not commodified escape our accounting” — yet much meaningful care is not profitable or even quantifiable. Medicine has long valued intervention, and as interventions are increasingly technologized, the labor of those who make decisions about and based on technological interventions is privileged. A Labour of Liberation is grounded in the perspective of the physician, but Mukhopadhyay is mindful of cleaners, nurses, cooks as well as indigenous healers and family members of patients.

“Everyone becomes a health worker at some point in their lives,” Mukhopadhyay writes, hinting at a radically inclusive vision of care as one point from which to grow a liberation project. Striving for justice means that carers must “unlearn the instinct to intervene,” that care labor within institutions should be revalued and health work beyond institutions be recognized as care.

As an anthropologist of medicine, I see fruitful connections between A Labour of Liberation and Joe Dumit's work on pharmaceuticalization [2.] Joseph Dumit, Drugs for Life: How Pharmaceutical Companies Define our Health (Durham: Duke University Press, 2012). View all notes Angela Garcia's on addiction care between kin, clinic and prison [3.] Angela Garcia, The Pastoral Clinic. Addiction and Dispossession along the Rio Grande (Berkeley: University of California Press, 2010). View all notes Annemarie Mol's on the logic of care [4.] Annemarie Mol, The Logic of Care: Health and the Problem of Patient Choice (New York: Routledge, 2008). View all notes and Alondra Nelson's on Black Panther free clinics [5.] Alondra Nelson, Body and Soul: The Black Panther Party and the Fight against Medical Discrimination (Minneapolis: University of Minnesota Press, 2013). View all notes to name just a few. As a former lay health worker, the book took me back to the Berkeley Free Clinic and NEED (Needle Exchange Emergency Distribution), where we tried to cultivate lay expertise, anticapitalist medicine and health care as social justice work. In the late 1990s and early 2000s, these sites were the basement of a church and a mobile van bringing drug supplies to the street. Hippy political art, humming fluorescent lights and the sharp smell of alcohol wipes and bleach were the backdrop for interminable late-night debates and, during clinic hours, for the bodies in waiting — slumped, twitching, raging, hopeful, fearful, but most of all, suffering.
With these images in mind, Mukhopadhyay's lines ring true:

How do I make the structures of the clinical encounter — so enmeshed by a system that pushes me to limit healing to a biochemical intervention — into a political encounter, that steps away from the laboratory tests and the diagnostic imaging for an individual to also identify the social, economic and political processes that lead a person to suffering?

One of the important puzzles of A Labour of Liberation is how the individualized nature of most medical encounters is both a limit on and potential for care as transformative practice, for patients and for health workers alike. Mukhopadhyay's vision of care is one in which he shares his knowledge of the body “with people who share their contexts and histories, so that we can make decisions together.” This is a vision of collaborative medical decision making, involving equity and autonomy for all parties, even if the forms of knowledge and responsibility are not the same.

Mukhopadhyay recognizes that people often “want to delegate dealing with the decrepit, decaying body” to someone else, to the doctor or clinic. This deferral must be accepted as a component of patient autonomy. Yet Mukhopadhyay's aim, which resonates with that of the Black Panther clinics (and the Berkeley Free Clinic), is to reach redundancy: The liberatory goal is to work oneself out of a job by achieving a situation where there is less sickness, where knowledge of the body and disease is dispersed outside of institutions, and where communities have autonomy to control the organization and practice of medical care.

This is a book for many audiences: college undergraduates, particularly in social and health sciences, and health workers of all kinds — in community, finance, policy, government, or for-profit medicine (as if!). It is also a book for teachers, writers and researchers who must continually reckon with how “the professional privilege that comes with state recognition can devalue and drive underground long traditions of care that have existed outside formal settings.” It certainly broadened the thinking on caring and carers for this reviewer.

Notes
1. I strongly recommend this two-part interview to those desiring more of Mukhopadhyay's voice: http://rankandfile.ca/2016/07/21/the-labour-of-liberation-an-interview-with-author-baijayanta-mukhopadhyay-part-1/.
2. Joseph Dumit, Drugs for Life: How Pharmaceutical Companies Define our Health (Durham: Duke University Press, 2012).
3. Angela Garcia, The Pastoral Clinic. Addiction and Dispossession along the Rio Grande (Berkeley: University of California Press, 2010).
4. Annemarie Mol, The Logic of Care: Health and the Problem of Patient Choice (New York: Routledge, 2008).
5. Alondra Nelson, Body and Soul: The Black Panther Party and the Fight against Medical Discrimination (Minneapolis: University of Minnesota Press, 2013).
  
Jenna Grant

Jenna Grant is Assistant Professor of Anthropology at the University of Washington, where she teaches anthropology of medicine, technology, visuality and Southeast Asia. Jenna is currently working on a book manuscript titled Seeing clearly: Medical imaging and its uncertainties in Phnom Penh. The book explores histories and contemporary practices of medical imaging in Cambodia's capital.

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