Health Communism: A Reading Guide (Part Two—SURPLUS)
"Profit lives in...every locus where capitalism touches illness, disease, disability, and death."
[Image Description: Blue background with white text and printers registration marks. The white text reads “Health Communism” and is stylized like the text on the cover of the book. The word health is in serif font and the word communism is in all caps sans serif font on the next line.]
Health Communism: A Reading Guide (Part Two—SURPLUS)
It has been two years since the release of Health Communism, and since publication, we’ve received many requests inquiring about study or reading group materials to accompany the book. So I’ve slowly written a series of essays on each chapter in an attempt to fulfill that request—with the idea of offering an accessible entry point for Health Communism followed by brief discussion questions that are useful as both individual writing prompts and for group discussions. These are written with new, first time readers and also returning readers in mind, as accompaniment for a first pass or through deepened engagement for those already familiar with the work.
Over the coming weeks, I’ll be sharing a series of essays, each focused on a different chapter of the book. This week, I’ll be revisiting the first chapter, called SURPLUS. Two weeks ago we revisited the Introduction, check that out here if you haven’t had a chance to read it yet.
For practical purposes, here is some information about the discussion guide and how it was written to be used: There is a guide for each chapter, once they are all posted here on Blind Archive, I will release the full guide as a PDF. Each chapter guide contains four parts, a summary, a section breaking down a few key ideas and themes from the chapter in more depth, a concluding reflection, and, finally, a section with discussion questions / writing prompts followed by definitions of key terms from the chapter. This can be used for individual or group study, and can be read before or after reading the chapter. The discussion questions are best used after the chapter and guide has been read but can be useful to skim in advance of reading the chapter of Health Communism, because they will offer some guidance as to what ideas you might be able to get out of each chapter.
2.1 Summary, SURPLUS
The second chapter of Health Communism, “SURPLUS” builds on the concepts introduced in the Introduction, focusing on the historical and present response to populations deemed unnecessary for production. The surplus class includes disabled, chronically ill, elder, unemployed, underemployed, and incarcerated people as well as other marginalized groups pushed out of or to the edges of the mainstream economy and minors. While capitalism ostensibly discards these populations, and popular discourse frames them as burdens who make little or no meaningful contribution to society or the economy, it simultaneously has created a way to reintegrate these groups, often times creating markets around them, or by through direct exploitation of their labor at sub-minimum wage rates, despite claiming they are without the economy. This dynamic when it interacts with the popular notion of “health” as an individual phenomenon we have named “extractive abandonment.” Extractive abandonment, which iterates on Ruth Wilson Gilmore’s theory of organized abandonment, ensures that even those excluded from direct or formal labor exploitation are still instrumentalized for the reproduction of capital, sometimes with whole industries, such as healthcare, pharmaceuticals, and incarceration, formed around this central extractive dynamic.
The chapter argues that despite popular discourse, the surplus class is not merely a passive population but a distinct class in formal Marxist terms, existing in direct relation to the means of production and integral to the reproduction of capital in contemporary life. The surplus are not ever outside the system or political economy; they are central to it, serving as the foundation for industries and jobs designated for the mainstream economic sphere which are designed to extract profit and surplus labor from the managing, warehousing, surveillance, treatment, rehabilitation, policing, and studying of the surplus class. We contend that this is why left revolutionary movements must always question when they are told someone or a class of people is without the mainstream economy. And, if our movements are to successfully challenge capitalist hegemony, they must center the surplus class, not as a matter of equity, but because the liberation of the surplus class is a necessary condition for dismantling the capitalist structures and system that exploits all people, especially the working class.
To walk readers through the idea of the surplus class, we trace the historical roots of the framing “surplus population” and how it is used by Marx and Engels to construct their concept of a “general reserve army.” However, we expand the way that Marx and Engels understood the general reserve army and the surplus population to include broader and more updated social and political dynamics—afterall when Marx and Engels were writing, the very concept of disability, for example, was still coming into formal being, and many of the industries to treat, diagnose, manage, care for, or warehouse disabled people did not exist yet. In “SURPLUS” we discuss contemporary ideas that layer onto and complicate the original Marxist analysis of the general reserve army and surplus population using concepts like Ellen Samuels’ “biocertification” which describes systems and ideologies which rigidly categorize individuals based on perceived observable and measured scientific traits. We offer an example of biocertification in the modern Social Security Disability Insurance framing of disability as a certification of permanent inability to work as a way of understanding how biocertification works mechanically and as an ideology core to capitalism that sustains hierarchies of worth and exclusion.
2.2 Deeper Discussion of Key Ideas and Themes, SURPLUS
A) Capital’s Need for Abandonment
In the first chapter of Health Communism, “SURPLUS,” we take up the concept of the surplus populations—those whose lives have been deemed unnecessary or burdensome by the capitalist state, understood as outside of any class relations—and argue that they are in fact a distinct and important class central to how capitalism functions. This chapter begins with a historical materialist analysis, using the writings of Engles and Marx to ground our understanding of surplus populations not as an unfortunate side-effect of capitalism as they conceived of it, but as central to its functioning.
In the industrial era, Marx and Engels identified the surplus population as a “general reserve army,” and named this reserve army as an essential component for disciplining labor and ensuring that wages remained low. The surplus were those who, at at given moment, could be brought into the labor force when capital needed them, and discarded when it did not.
To Marx and Engels, the surplus population and “general reserve army” consisted mainly of the unemployed, who were held in a state of languished suspension so as to be available to be drawn upon in times of economic expansion or during labor shortages to enter the labor force when needed, and often kept in a state of precarity. This reserve army serves a dual purpose: it provides a pool of labor that can be tapped into when capital needs it, and the precarious conditions of the reserve army exert downward pressure on wages and working conditions for the employed, as workers are made to compete with those who are categorically made to be desperate for jobs. By maintaining this surplus population, capitalism ensures a flexible labor force that can adapt to changing economic demands, while simultaneously reinforcing the power dynamics that sustain exploitation in the context of labor.
But the definition of the surplus population that Marx and Engles used was limited, and we expand it well beyond the unemployed. As we show in this chapter the surplus population, which we argue is not just a population adjacent to the working class, but a class in and of itself, includes anyone deemed unfit for captial’s needs—whether due to illness, disability, racialization, incarceration, citizenship, gender, or any other socially or politically constructed category of exclusion. These populations are not abandoned because they have no value; rather, their abandonment is itself both a mechanism for disciplining labor and a profitable mechanism for capital.
This is the process we call extractive abandonment, a system where those who are deemed excess to the labor market are warehoused, managed, or extracted from in ways that continue to generate profit for capital regardless of that individual’s productive relation to the market. Nursing homes, prisons, psychiatric hospitals, and long-term care facilities are all sites where surplus populations are subjected to extractive abandonment; but not the exclusive domains in which this concept is applied or encountered. These populations, rather than being extra or outside of capital’s sphere of influence, are fundamental to the means of production—therefore they are not simply a population but an independant and separate class.
B) Why is the Surplus Class a Class, Not Merely a ‘Population’?
To be a class means sharing not only economic conditions but also social relations and political interests that arise from one’s position within the broader system of production. Unlike traditional working class identities, which are often defined by their roles and value in the labor market, the surplus population has historically been overlooked as a distinct class because dominant narratives focus on the productive worker as the primary subject of political and economic struggle. This neglect stems from the capitalist framework that prioritized productivity and often vilifies those deemed unproductive, leading to a failure to recognize the surplus populations’ potential for solidarity, class formation, and collective action in challenging systemic exploitation.
In formal Marxist terms, a class is defined by its relationship to the means of production, specifically in terms of ownership and labor. The surplus population constitutes a distinct class not through its direct engagement with the means of production but through its relational position within the capitalist system. While the working class is defined by its direct labor power—selling its labor to generate value— the surplus population exists in a precarious state, often excluded from the formal labor market but still fundamentally linked in every way to the capitalist mode of production. This class is produced by the contradictions of capitalism, where economic fluctuations create a reserve army of labor that can be drawn upon in times of need, allowing capitalists to maintain control over wages and working conditions.
The surplus population has a very complex relationship with the means of production: they often embody the consequences of capitalist exploitation and accumulation, serving as a buffer that maintains the discipline of the working class. Their existence (and the denial of their class formation in favor of a depiction of the surplus as merely a ‘population’) highlights the limits of capitalist production. The surplus class while considered to be non-working, is far from it and often is subjected to various forms of economic exploitation—such as low wage or sub-minimum wage labor, informal work, or coercive state mechanisms—which ultimately reinforces the capitalist structure, even as the surplus remains marginalized and invisibilized within it.
The surplus class is not an afterthought or addendum to the working class, but the key to understanding how health operates under capital. Health is not neutral; it is deeply stratified by class, race, and ability, shaped by the demands of the capitalist state. Capital needs healthy workers, but it also needs a surplus class to justify its violent regimes of exclusion, abandonment, and extraction. The surplus class is key to the care economy, which is the largest growing sector in modern capitalism, because they represent a primary source of labor for the sector and a significant group that the sector is designed to manage. While they do not have traditional property and wages like the working class, their health itself and care needs produce a similar relation to the means of production as the working class’s labor power.
The care economy—comprising health services, elderly care, disability care, and social work—relies heavily on low-wage, often precarious labor, much of which is performed by workers who are themselves drawn from the surplus class, including women, migrants, disabled people, and racialized communities. These workers are frequently underpaid and marginalized, reflecting their surplus status in the broader economy, yet they are essential to not only the functioning of the care sector but to the maintenance of the labor force and therefore the functioning of capitalism itself.
Simultaneously the surplus class is a target of care. Disabled, elderly, chronically ill, and other populations deemed unproductive by capitalism are positioned as passive recipients of care services often managed through state or privatized institutions. This care is not essential to their well-being, but to regulate and contain them as “burdens” on the capitalist system, ensuring their existence does not disrupt the economy. Thus, the surplus class finds its relationality to the means of production both as providers of care and as the population that constitutes the raw material that this growing sector seeks to manage and profit from.
C) Organized Abandonment and Centering the Surplus Class
The vulnerability of the surplus class is not inherent; it is produced by capitalism. We draw on Ruth Wilson Gilmore’s concept of “organized abandonment” to demonstrate how these populations are deliberately and systematically marginalized by the state for its own gains. Under capitalism, vulnerability is not just about exclusion but about the active production of precarity. Gilmore shows that the capitalist state, through austerity, divestment, and the withdrawal of resources, creates conditions in which entire populations are exposed to premature death. This is a deliberate strategy, one that both controls the surplus population and creates avenues for profit for others from their abandonment.
In SURPLUS, we expand on Gilmore’s analysis to show how health too, is central to the certification of who belongs in the surplus class. It is not enough for capital to merely declare that certain populations are surplus; it also must create social and legal categories—like disabled, sick, criminal—that justify their abandonment. Health, in this context, become another weapon in the capitalist arsenal. The ill and disabled are not simply left to die; they are subjected to regimes of care that are more about managing their unproductivity, or the ‘burdens’ they may pose which could limit the labor power of others, than about ensuring or fostering well-being. This management is always in service of capital’s need for control, surveillance, and extraction.
We further complicate this analysis by refusing the traditional leftist notion that only the working class can be the subject of revolutionary politics. In this chapter we argue that centering the surplus class in our political projects is actually essential for any revolutionary movement. These are the people that capital has deemed unworthy, and yet they are a key source of profit, while also being the ones most vulnerable to its violence. By centering the surplus class, we shift the terrain of struggle from the worker to all those whose lives are marked as less-than by the capitalist state.
Centering the surplus class within revolutionary politics is essential, as it broadens the struggle to encompass all those oppressed by capitalism, not just those labeled as ‘workers.’ When the surplus class is prioritized, it challenges existing hierarchies within labor-centered movements that often overlook or marginalize the experiences of disabled, sick, incarcerated, unhoused, or elderly people, or anyone deemed ‘unproductive’ in any way. By recognizing the intrinsic value of the surplus class as revolutionary subjects, we can better organize against structures, values, policies, laws, and systems that oppress the working class. In challenging the ideologies that categorize individuals as worthy or unworthy of care, support, shelter, and well-being based on their productivity, we can also dismantle the threats which capitalism uses against the working class.
D) Reimagining Health
Health Communism demands that we reorient our political projects away from the worker and toward those who are most marginalized by the capitalist state. In doing so, we refuse the capitalist notion that certain lives are more valuable than others. Health communism is not about creating a more equitable distribution of resources within the existing system; it is about dismantling the system that creates the surplus class in the first place. By centering the surplus, we create a politics that is not just about survival but about the possibility of flourishing outside of capitalist constraints.
This shift in focus can not only foster solidarity among those facing systemic violence whose struggles are not currently unified, but it can also expose working class movements to the power of interconnectedness in struggles against oppression. In contrast, centering only those in the working class does not inherently uplift the surplus class, and it often risks perpetuating existing power dynamics that prioritize the needs and experiences of ‘productive’ workers while sidelining those deemed surplus.
The traditional labor movement has historically focused on securing benefits, rights, and protections for workers, frequently at the expense of those unable to participate in wage labor. This can create a hierarchy in left moments, where the needs and voices of the surplus class are not just overshadowed or ignored, but treated as if they are taking away from working class movements. Such an approach not only fails to address the specific challenges that capitalism throws at the working class which lead to the conditions they struggle against, it also reinforces the capitalist logic that you are only worth something while you’re productive—and most workers, if they are lucky, will at some point pass into the surplus class themselves via old age or disability.
Health Communism argues that it is imperative for worker led movements to not just integrate the experiences, needs, and demands of the surplus class, but to welcome the surplus as leaders of the struggle. The liberation of the surplus class is not just inseparable from the liberation of the working class; it is a necessary condition for the working class to achieve its own liberation.
The workers’ struggle cannot be fully realized without dismantling the systems of exploitation and abandonment that specifically target the surplus populations. Capitalism’s ability to control and discipline the working class is only possible because of the oppression of the surplus class, whose precarity and vulnerability serves as a constant reminder of the consequences of non-productivity. By placing the surplus class at the forefront, movements can challenge the entire framework of capitalism’s exploitation, pushing beyond reforms that merely serve workers and toward a revolutionary restructuring of society that actually can deliver care and solidarity for all.
This approach forces us to confront the ways in which capitalist logics of worth and productivity are embedded even within worker struggles, often reinforcing the idea that it is necessary to leave the surplus class behind. When the surplus class leads, however, it forces the movement to grapple with the deeper structural violence inherent in capitalism—not just the exploitation of labor, but the commodification of life itself. Only by prioritizing the most marginalized can we even dream to create a movement capable of confronting the full scope of capitalist oppression, let alone build a world where liberation and care are universal, not contingent on one’s ability to work.
2.3 Reflection, SURPLUS — The Stakes of Surplus Populations as a Class
As we reflect on the two years since the release of Health Communism, it is clear that the arguments we made in SURPLUS are more urgent than ever. The pandemic, the ongoing crises of care, and the deepening austerity measures on the rise worldwide all point to the ways in which the surplus populations are being subjected to increasing levels of violence and abandonment. Since the end of state supports for Covid care, treatment, testing, and vaccines in May of 2023, the U.S. has only intensified its reliance on extractive abandonment, finding new ways to profit from those it deems unworthy of care.
But these conditions also make the possibility and the vision of health communism more pressing. By centering the surplus class, we open up new terrains of struggle—ones that refuse the narrow definitions of health, care, and productivity that capitalism imposes. Two years after its release, Health Communism remains a tool for imagining and building a world in which no one is disposable. As we write at the end of SURPLUS:
Profit lives in the interstitial spaces between bodies, in the counting of bodies, in the measuring of bodies, in the creation and destruction of bodies, in every locus where capitalism touches illness, disease, disability, and death. This relation in and of itself, is not intent to harm; instead, it is the capacity to levy harm at the population level, as driven by clearly defined, socially constructed parameters of race, ability, health, and class. Public money guarantees a fixed amount per body, leaving public and private entities…to find or create the opportunity for growth and revenue. This totality of motivations and relations, defining the intersection and incorporation of health with capital, is what we have elected to call extractive abandonment. In a political economy built on systems of extractive abandonment, the state exists to facilitate a capacity for profit, balanced always against the amount of extractable capital or health of the individual subject.
We argue that, at the intersection of these forces, there exists a core relation of health to capitalism called extractive abandonment—that is, the means by which the state constructs “health” culturally, politically, and institutionally. And in the process of constructing, destroying, and reconstructing health, the state itself is made.
In the coming weeks, there will be essays on each of the chapters of Health Communism: Introduction, SURPLUS (this guide), WASTE, LABOR, MADNESS, PHARMACOLOGY, BORDER, CARE, CURE, and HOST. We put this together over the last two years to humbly offer some accessible entry points into the book for new readers, facilitate group discussions, and provide those returning to the text with new ways to engage with its lessons.
2.4 Further Study — Discussion Questions and Key Terms, SURPLUS
Discussion Questions for SURPLUS:
How does Health Communism redefine surplus populations? Why do the authors argue that centering surplus populations is necessary for revolutionary movements, and how does this differ from traditional worker-focused politics?
The chapter further elaborates on the concept of extractive abandonment. How does capitalism profit from surplus populations even as it abandons them? What are some real world examples of this process at work today that you have encountered in your own life, or in the life of a comrade, kin, or loved one?
In what ways does the capitalist state justify the abandonment of the surplus class through the construction of categories like illness, disability, and poverty? How does the measurement of individual health become a tool of control in this process?
Why does the chapter argue that centering the surplus class is essential for revolutionary politics? How does this shift our understanding of who should be at the center of left political struggles?
How can we imagine systems, institutions, research or educational models of health communism that center the needs and expertise of not just the working class but also the surplus class? What are the political implications of rejecting the capitalist notion that care must be earned?
Why do you think some people believe that the needs of the surplus class and working class are contradictory? How would you explain that they aren’t to someone who is captured by the zero-sum ideology that to support the surplus class requires subjection of the working class?
Key Words, Ideas, and Terms, SURPLUS:
Surplus Class: People who capitalism deems unnecessary for production, including but not limited to disabled, elderly, unemployed, and incarcerated people. Despite being described as either non-consequential to production or as a burden, the surplus remain integral to the political economy through their direct relationship to the means of production, not through the exploitation of their labor power or extraction of surplus profit from their toils but by being turned into the raw material around which jobs, industries, and whole markets are made.
Extractive abandonment: The way capitalism constructs and manages health at the population level, functioning as both an economic and social strategy of control. It refers to the simultaneous exploitation and neglect of populations deemed surplus or marginal. Under a political economy designed around extractive abandonment, health/social policies and institutions are structured to extract profit, create jobs and markets, and reclaim those deemed not fit for membership in the mainstream body politic who is subject to traditional surplus labor extraction. Extractive abandonment turns bodies into raw materials, treating individuals and whole populations not as people but as economic units in the process of production, like steel, coal, or textiles. The state also justifies and legitimizes its power through health and social policies that claim to optimize populations, leveraging biocertification and other statistical, scientific, or pseudoscientific mechanisms to categorize, commodify, and regulate bodies. Extractive abandonment is a cornerstone of health capitalism, ensuring profit generation but also the need for and means of growth for industries like healthcare, incarceration/policing, elder care, etc., while perpetuating systemic neglect, inequality, and harm.
Organized Abandonment: A concept from Ruth Wilson Gilmore describing how the state systematically withdraws resources from marginalized populations, creating conditions of precarity and abandonment for some to directly benefit others. Organized abandonment refers to the deliberate withdrawal of resources and support by the state from specific populations, typically those deemed surplus or marginal, to sustain capitalist systems. This process is not just an act of neglect but a calculated capacity through which the state builds power and restructures itself. By sorting and separating surplus populations—marking some for exploitation and others for slow death—the state leverages policies of austerity, criminalization, and neglect to maintain control over labor, health, and social resources. This strategy is intertwined with racial capitalism and the social determinants of health, ensuring that abandonment is profitable by creating industries and revenue streams based on the management, warehousing, and surveillance of these populations.
Biocertification: The bureaucratic process of categorizing individuals based on perceived observable scientific metrics that are then used as stand ins for a measurement of perceived health, productivity, value, dangerousness, disability, or worth. Biocertification shows up everywhere from state benefits systems like Social Security Disability Insurance (SSDI) to abstract processes that have been incorporated into formal population management schemas like fingerprint analysis in policing/incarceration and Body Mass Index (BMI) in healthcare. Biocertification is used to sort individuals, lay blame, and determine access to resources, and the results of biocertification are treated as “more true” or “more reliable” than what the biocertified person has to say about themselves or their own experiences, which is why this is a key part of the fantasy that scientific measurements and metrics are non-biased or value neutral even when explicitly designed to, for example, determine access to resources by defining human worth through a measure of raw economic output (SSDI).
Warehousing: The containment of surplus populations in institutions such as prisons, nursing homes, and psychiatric hospitals, where they are managed, controlled, and often exploited for profit without addressing their needs.
Social death: The condition of being excluded from social and economic participation, experienced by the surplus class who are stripped of societal value and treated as expendable, undesirable, “post-human,” or undeserving of agency. This is a process where individuals or groups are rendered invisible or denied full participation in society. It is not a literal death but a form of exclusion from the social contract.
General Reserve Army: A Marxist concept describing the unemployed labor force and how the conditions of their lives are used to discipline those who are currently laboring, often resulting in the necessary labor discipline to keep wages down, reduce worker demands, and illustrate the cost of non-compliance with norms of productivity. Expanded in Health Communism to include surplus populations that capitalism both exploits and excludes, e.g. the surplus class.
Population management: Strategies employed by the state to regulate and control surplus populations through law, policy, institutionalization, surveillance, and commodified systems of care. These mechanisms serve both to manage the surplus class by limiting their access to resources and to create conditions of exploitation where surplus populations are used for profit generation, through industries like healthcare, prison systems, and elder care. Population management is central to extractive abandonment, as it dictates the terms of survival for those deemed unnecessary to the capitalist economy.
Structural violence: Structural violence refers to the systemic harm inflicted on marginalized populations through the political, economic, and social structures that reproduce inequality and exploitation. This form of violence is not always visible in direct physical harm but is embedded in the policies, institutions, and ideologies that uphold capitalist systems. It shapes the material conditions of health by ensuring that surplus populations—those deemed unnecessary or unproductive—are subjected to deprivation, poor healthcare, and social neglect. In this context, structural violence is a tool of capitalist governance, creating conditions where surplus populations are exploited for profit, while their well-being is systematically ignored or undermined.