The Cartesian binary describes the body in mechanical terms. Sontag references the oft-employed metaphor of the body “as a factory, an image of the body’s functioning under the sign of health.” In this conception, the chronically sick body, unable or unwilling to function as a factory, is in revolt. The James family frequently used economic metaphors in which one family member’s health came at the “cost” of another’s illness. Henry wrote of “a theory that this degenerescence of mine is the result of Alice and Willy getting better and locating some of their diseases on me.” Did he really believe that one sibling’s health could cause the others’ pain? Such economic metaphors are some of the easiest to grasp toward when trying to explain to a healthy person how the basic expenditures of energy for everyday life seem to “cost” me more.

When I began the symptom diary that turned into writing projects that turned into this book, I worried about brain damage, memory loss, loss of my words. I wasn’t sure which parts of me could be lost—to damage, to the dulling effects of lifesaving (or -prolonging) medications. Orienting myself toward whatever gave me the disease seemed a dead end, compared with trying to document the disease’s impact on my relationship to the rest of the world or to investigate what, exactly, it may have taken from me.

While I have lived through a fairly constant tide of physical impairment, I have only recently become acclimated to referring to myself as “disabled.” Disability is constructed against a capitalist ideal of ability. Unsurprisingly, my coming around to the term was not the result of revelation or self-understanding, but of having to navigate both the astounding lack of medical resources available for people who must work through chronic illness and workplaces not built with sick people in mind. I chose academic labor because it would allow me to structure more of my time than a nine-to-five and because I am not consistently capable of working forty-hour weeks sitting in a chair at an office. In academia, some of my work can be done from bed. (The Covid-19 pandemic quickly revealed that much more of it can be done from bed than our employers like to pretend is the case.) Each academic job application gives the federal ADA disclaimer, something along the lines of Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternative format, using a sign language interpreter, or using specialized equipment.

The perceived risk of disclosing a disability is contextual: chronic illness and its corresponding brain fog and cognitive decline are likely to be interpreted as a candidate’s being unqualified. There are no alternative document formats or specialized equipment that will make working through pain and exhaustion more bearable. True accommodation would mean universal health care, a living wage that covers housing and nutritious food, debt forgiveness, sufficient time to rest, sick people being supported without fear of losing their jobs, and the abolition of all wellness webinars. As disabled poet Liz Bowen, in the previously mentioned cluster of essays I edited, wrote of her experience working through life-threatening illness to meet the demands of the academic job market, “We can theorize all we want about the breakdown of the mind-body divide, but if our labor practices don’t allow for rest and healing, the critical thinking we are tasked with teaching others is a corrupt and empty enterprise.”

A medical model of disability considers a person to be disabled by an impairing characteristic; a social model of disability defines the disabled not necessarily by something they lack but by society’s lack of accounting for them. American disability activist Marta Russell moved beyond these two models and toward a Marxist materialist analysis of disability, considering what the systems of production extracted from the disabled. Quoting Russell, Beatrice Adler-Bolton and Artie Vierkant write in Health Communism:

Under the money model of disability, “the disabled human being is a commodity around which social policies are created or rejected based on their market value.” Russell argued that this constituted much more than simply profiting from the provision of medical care to the disabled. For Russell, the money model is presented as a corporate “solution” to the problem of disablement, predicated on the primary assumption that “Disabled people are ‘worth’ more to the Gross Domestic Product when we occupy a ‘bed’ instead of a home . . . The ‘final solution’—corporate dominion over disability policy—measures a person’s ‘worth’ by its dollar value to the economy.” The money model of disability identifies what is in essence a “cure” for the existence of unproductive bodies under capitalism.

Everyone is either sick or will become so. The brutality that health-as-capital commits forces us to “cease to be soldiers in the army of the upright,” as Virginia Woolf put it—we “become deserters.” The old adage that socialism never took root in America because the poor see themselves not as an exploited proletariat but as temporarily embarrassed millionaires seems to apply to health, too: only a people delusional that they will always be healthy and available for work could believe our capitalist arrangement of society to be anything but tyrannical, hateful, and targetedly cruel to the ill. As Russell puts it, “people with disabilities function as canaries in the coal mine” for what healthy workers can expect with the progression of capitalism. Yet, it is easy to erase the sites where illness occurs outside the workplace (hospitals, clinics, asylums, and the home) as those of political struggle. Foucault analyzed the conversion of leper management into plague management: lepers had been treated with exclusion from social life outside the community, while early modern plague management brought a more disciplinary approach, relegating bodies to confinement in homes. Where we put the sick determines what political action might look like and what we mean when we talk about “visibility.”

The Socialist Patients’ Collective (SPK), a West German organization of patients and doctor allies founded in 1970, thought illness was both the condition and the result of capitalism, the group’s ethos summated in the slogan “Turn illness into a weapon.” By reframing illness as a contradiction created by capitalism—and health as a “biological fascist fantasy”—the SPK held the conditions that the sick must live under accountable for their suffering, as opposed to treating suffering as an inevitability of biology. Their project of unifying and mobilizing the “sick proletariat” has been largely lost to history. The most comprehensive history of the group published in English can be found in Adler-Bolton and Vierkant’s Health Communism. They write, “Unlike other self-organized patient groups and their counterparts in the anti-psychiatry movement, SPK uniquely combined Marxist political theory, social science analysis, and what they termed ‘therapeutic praxis’ to create an improvised, in-patient community with the express collectivist goal of researching the connections between capitalism, madness, eugenics, and the individuation of illness under political economies of work and care.” As I began writing this book in graduate school, lines from the group’s manifesto littered my desk:

Subjectively the sick person is compelled through his or her suffering to make his existence, his life, the object of his consciousness.

Illness is inseparably bound up with psychological stress, with the need for change, with the need for production.

The success of the “treatment” gets reified in the reproduction of the sick person’s employability, of their ability to function in the anti-human, illness-engendering social production process of capital, in their “rehabilitation.”

Anyone can become acutely ill, all are potential patients.