Consumptive Capitalism

On MAHA and Expensive Suffering -- A Guest Post by Sara Silverstein

Professor Sara Silverstein is someone to whom I listen on issues of health and history. This essay helps us to situate the present American health drama in the history of health care, and thereby to see much more clearly what we face. It draws from her forthcoming book For Your Health and Ours: An Eastern European History of Global Health. Professor Silverstein is currently at work on her next book, provisionally entitled Corporal Capitalism.

Consumptive Capitalism, by Sara Silverstein

Until very recently, tuberculosis was common, expensive, and lethal in the United States. It defined the lives and brought the deaths of many of the people who created our world. We have forgotten about all this because antibiotics, public health, and improved living conditions have largely erased the disease.

The current administration’s health policy rests on nostalgia rather than knowledge. It romanticizes a harsh past, a time when few and desperate choices were available to Americans. Because all that was available then was hope, many suffered for the profit of the wellness industry of the day. A few portraits of life with the disease can help us to imagine, and perhaps to prevent, a return to such profiteering.

In the cold central European winter of 1904, a young Polish political thinker called Kazimierz Kelles-Krauz visited a sanatorium in the Tyrol to treat his tuberculosis. He had been sick for a year and this was his second visit to the mountains. The sanatorium had a routine: resting and eating, taking the air and taking exercise. He would also try creams, compresses, and injections. He would go home after two months, still sick, only to enter another sanatorium in the summer.

Treatments in sanatoria gave him hope. But they were expensive and he and his wife struggled to afford them. His family was poor, but generally made ends meet until his illness. There was no cure for tuberculosis. The medical advice of the time was to dedicate yourself to building your general constitution. An entire industry, centered on the sanatorium, grew up around the tubercular patient’s expensive efforts to recover.

Franz Kafka also spent years chasing hope in sanatoria. At a low point in 1921, he described the sanatorium as a place where “the torture goes on for years, with pauses for effect so that it will not go too quickly, and – the unique element – the victim himself is compelled by his own will, out of his own wretched inner self, to protract the torture.” Hope was the problem. The unpredictable course of the disease, the sense that a recent improvement just might be related to the treatment, drew people in and drew people back. Kafka pursued the relentless hope that the next sanatorium would enable him to live his life with more strength and less pain. We associated the word “Kafkaesque” mainly with politics; this might be because we have forgotten about tuberculosis.

Tuberculosis, known in the past as consumption, has infected somewhere between one-quarter and one-third of all humans ever, and it possibly infected more than ninety percent of the population in industrializing countries during its peak in the nineteenth and early twentieth centuries. Not everyone who is infected develops an active disease. Whether they become sick depends partly on social and economic conditions that affect the immune system. Only about a fifth of those people who became sick recovered permanently and absolutely before the discovery of modern antibiotics. And of course tuberculosis is only one of the infectious diseases that once caused a vast portion of the population to live with chronic illness and disability.

The experiences of Kafka and Kelles-Krauz were normal. Illness was normal. And so basic historical fact casts a bitterly absurd light on Robert F. Kennedy Jr.’s “Make America Healthy Again” (MAHA) slogan. Americans, MAHA leadership tells us, live with unprecedented rates of chronic disease. This is a misrepresentation – a counting phantom that arises from longer lives, more careful recording, and omitting historical sources of chronic disease. Offering solutions that reject science and public health pushes us backwards into a past of shorter lives and more variety in lethal illness. This is perverse.

MAHA seduces with the notion that America, having been healthy once, can be healthy again. They paint a picture of a time before medical science intervened in the “natural” course of life. It is an unrealistic picture, indeed a deadly picture. It was a time when the only choice for people who contracted tuberculosis, such as Kafka and Kelles-Krauz, was to concentrate on their health by immersing themselves in nature.

Kelles-Krauz spent two years in and out of sanatoria in the mountains and forests of Tyrol and then Galicia, in what is now western Ukraine. He missed his young daughter and hoped to build up his health enough to spend more time with her – and to continue his work for social and political change. But he knew that his tuberculosis would likely kill him. He died from the disease in the summer of 1905.

The greatest modern Ukrainian writer, Lesya Ukrainka, was a contemporary of Kafka and Kelles-Krauz. A poet, dramatist, and chronicler of dreams of freedom, she contracted tuberculosis of the bone as a child. Tuberculosis most frequently affects the lungs but it can infect other parts of the body. It attacked Kafka’s larynx, eventually making it extremely painful for him to swallow and causing him to starve to death in 1924. This was a natural course of life before vaccines and antibiotics. It happened quite often.

Lesya Ukrainka lived in pain. She underwent surgery to amputate affected fingers as a child, then concealed the stumps from photographers for the rest of her life. She traveled to sanatoria in Ukraine, Europe, Egypt, and the Caucasus. The limits of her body made her wry, determined, and empathetic. She loved nature, despite everything, as a glimpse through a window or breath of sea air. “In all the forest there is nothing mute,” she wrote in 1911. The rustling of the forest echoed the fluttering of hope and elusive health.

With no cure for tuberculosis, a growing industry offered uncertain treatments and promoted lifestyle changes. By the late nineteenth century, health resorts (sanatoria) capitalized on the disease known as consumption. The industry began in the 1850s with the work of a German doctor in a town that is part of present-day Poland. His sanatorium was the model for the first in the United States, at Saranac Lake in the Adirondacks. Soon, sanatoria could be found on the Danish shores of the North Sea, in the rolling hills of the English countryside, in the forests of Germany, and in mountains from the Urals to the Rockies.

The sanatorium was something like a cross between a hospital and a hotel. There was medical staff and medical interventions could occur. Surgically collapsing a lung was one of the more common drastic treatments. But many people went to the sanatorium for its natural lifestyle and reassuring routines.

Yet somehow “nature” was very expensive. There were public sanatoria, but they never had enough beds. Kelles-Krauz struggled to pay. Kafka wasn’t able to secure the travel documents to go to his desired sanatorium in Davos, high in the Swiss Alps. A sanatorium was far beyond the means of Gavrilo Princip, a young student and revolutionary who was sick with tuberculosis when he assassinated Archduke Franz Ferdinand in 1914. Had he been treated, would he have become a revolutionary? Would he have fired that shot?

The great German writer Thomas Mann wrote a novel that turned that Davos sanatorium and its patients into a commentary on a decaying European society. Mann knew the Davos tuberculosis industry through visits to his consumptive wife. In The Magic Mountain, he recorded the sanatorium’s wellness rituals and calculated the costs. There were blankets and clothing necessary for resting in the fresh air and taking the prescribed exercise, there was the thermometer that would allow you to measure your own temperature, there were special foods, and recommended creams and injections. The ethos was that you would spend money if you cared about your own health.

Davos, Switzerland: the path

We are familiar with the money to be made from a jittery hope for health. In our time, about a hundred years later, the wellness industry in the United States reached more than $2 trillion. It repeats the recommendations of the consumption sanatorium, including nutrition and special diets, exercise, clean air, personal hygiene, and skin care. You can even travel to a luxury health retreat in Austria that promises to introduce you to the lifestyle for a healthier you – following in the footsteps of Kelles-Krauz, Kafka, and Ukrainka but treating a taste for sugar rather than a tuberculosis infection.

Some of the media techniques are new, although the psychological appeal is the same. Worry about being ill, and spend money to show that you care. Wearables and apps advise routines for eating and exercise and maximizing the value of sleep. Dietary supplements alone account for a $69 billion market. Subscription services guide you through weight loss or a nutritious diet. Influencers promote their favorite wellness products and routines. The wellness industry makes a virtue of investing financially in your health, suggesting that the virtue of prevention is only accessible to people who can afford it. And surely you can afford to spend more on yourself?

To be sure, nothing is more important than health, and Americans can certainly use more exercise and nutritious food. The wellness industry provides resources that are useful for many people. But the profit motive tends to promote anxiety about health rather than the thing itself, creating more demand rather than delivering satisfying solutions. It does nothing about problems of access – precisely the opposite.

At the extreme, following this logic, a wellness industry seeking profit would naturally undermine the government’s responsibility for safeguarding the health of the entire population. It would sabotage efforts to reimagine equal and inexpensive access to healthcare in the United States, and reject the possibility for future advances in medical science.

MAHA leadership builds its community and sows distrust in medical science by pointing to the pharmaceutical industry’s profit motive. They warn the profit motive makes everyone involved in pharmaceuticals unscrupulous, pumping your body full of unproven vaccines that are unnecessary since you are not even sick yet. Their answer is to build up your constitution to prevent illness or to address chronic conditions.

The wellness industry is receiving a boost from RFK Jr. and MAHA. They advocate a return to nature and the natural and portray the wellness industry’s consumerism as a way for people to take control of their own bodies, breaking free from the medical industry. The imperative to be responsible for your own body places an imperative on you to buy ever more. Embrace consumption – build your health by buying.

Tuberculosis killed Lesya Ukrainka in 1913, thirty years before the discovery of the first antibiotic that would contribute to curing tuberculosis. Antibiotics were a revolution in how people lived their lives. Davos emptied, leaving its remote but expensive hotels and shops open for the world’s business and political elite. Today, pharmaceutical company executives travel to Davos each January for the World Economic Forum. To be sure, they too are motivated by profit. But unlike sanatoria, antibiotics do cure tuberculosis.

MAHA, were it a serious movement, would criticize capitalism, or at least the bloated “health sector” of the American economy. And that would be the right target. But MAHA is not a social movement but a capitalist faction, or an ad campaign, seeking to divert profits from one set of businesses to another. MAHA leadership criticizes the pharmaceutical industry’s profit motives in order to promote the wellness industry, which of course also operates according to the profit motive.

By directing its energies against a competitor, MAHA worsens the problem. By dodging the basic issue – that instead of a strong public health system we have commercial medicine – it only strengthens and consolidates the status quo it claims to be critiquing. Then, to make matters worse, it undermines belief in practices that do in fact work, in the present flawed system, to prevent suffering and save lives. And so it creates a situation in which reform is less likely and epidemics are more so.

The MAHA attack on government can disable the only institutions that can implement certain kinds of health policies, and thereby open new sectors of an infectious economy. Antibiotics and vaccines save lives, but only with the support of public education about the body and campaigns for public health. If these are dismantled, bodies suffer, and anxious minds spend money.

MAHA exploits fear and hope in a disheartening echo of the consumption sanatoria industry. But the profiteering of today is far more mendacious than that of the past. A century ago, the tragedy was that only hope was available. Today, forces are at work to artificially recreate that situation, entirely unnecessarily, with profit for the few as an obvious motive.

Tuberculosis is curable, but it remains widespread in parts of the world where the price of pharmaceuticals outstrips the value global capitalism places on life. It is still the leading cause of death by a single infectious disease globally. A serious critique of the pharmaceutical industry would also look beyond the United States, even to where there is no opportunity to divert profits.

Tuberculosis will not be the first epidemic to return to the U.S. Other diseases are much closer. Measles can affect long-term health as well as kill quickly, and we are on the verge of losing our measles elimination status. MAHA depends on the “again,” the fantasy of a better past. But it also depends on the “America,” the notion that we are in some way exceptional. But we are as vulnerable as everyone else without investment in medical science and public health. Valuing profit above life undermines our progress, and doing so under misleading appeals to myth only makes matters worse. The wellness industry will not have a solution for the future’s disease landscape. But health industries will have a vast new market.