Barbara Ehrenreich and the ethics of dying

Barbara Ehrenreich is “old enough to die,” she writes in her new book, Natural Causes: An Epidemic of Wellness, The Certainty of Dying, and Our Illusion of Control. With that realization, Ehrenreich abandons what she describes as “medicalized death,” the endless preventive tests, diets, and rituals designed to prevent aging, or to at least make one age well. “I will seek help for an urgent problem,” she writes, “but I am no longer interested in looking for problems that remain undetectable to me.” Instead of the “torment” of a medicalized death, or even a “medicalized life,” Ehrenreich advocates for a broader acceptance of death’s inevitability. In a series of linked essays, each of which could be expanded to its own book, Ehrenreich’s Natural Causes takes aim at the cultural practices that preach the concept of control—over both body and mind—suggesting that the inevitable is somehow unavoidable. “We are not,” she writes, “the sole authors of our destinies or of anything else.”

The refusal to accept that dying is an “achievement, not a defeat,” Ehrenreich argues, has led to a kind of pervasive cultural fiction of individual control over both the body and mind. Both are elements of another fiction at which Ehrenreich takes aim: Namely, the concept of the self, which, she argues, is little more than the religious soul rebooted for a secular age. Instead, in her characteristically blunt style, Ehrenreich deconstructs the practices that have grown to sustain these fictions, everything from wellness, mindfulness, fitness, anti-aging regimens, and diet fads.

In Ehrenreich’s hands, wellness, for example, isn’t just a trend, but a reflection of the interplay of class, power, and health (a word, she argues, that’s meaning is too class-based to be useful to wellness gurus like Gwyneth Paltrow). Wellness, she suggests, eliminates the appearance of “conflict...endemic to the human world, with all its jagged inequalities,” emphasizing instead the harmonious individual—a body and mind in complete accord. But, to what end? “To feel good, of course, which is the same as feeling powerful. Put in more mechanical terms, wellness is the means to remake oneself into an ever more perfect self-correcting machine capable of setting goals and moving toward them with smooth determination.”

Mindfulness finds similar disdain, rendered in the smart, provocative, and persuasive style that’s made Ehrenreich’s previous books (Nickled & Dimed and Bright-Sided) enduring classics. Even Ehrenreich’s own interests are subject to her critique. A self-confessed gym-rat, she explores the link between fitness and control, noting it’s logical, and sometimes ugly, consequences that can extend well beyond the gym. Conflated with morality, control over one’s body can be used to determine personal values or success. “[If you] can’t control your own body, you’re not fit, in any sense to control anyone else,” Ehrenreich writes.

Unconvinced by these practices, with their emphasis on control or the illusion that they can stave off death, Ehrenreich who has a Ph.D. in cellular immunology, offers a far more complex (if not dystopian) view of the body, centered around “intrabody conflict.” She leads us through recent research that shows that our immune systems turn on us, aiding—instead of preventing—the growth of cancer. She’s particularly interested in macrophages, a type of white blood cell that, given the opportunity, can become traitors to the very body it is supposed to protect, going over “to the other side.” The body is built for death, Ehrenreich plainly argues, it cannot be tamed by wellness or mindfulness or any other practices simply because it is a “battleground” where “cells and tissues meet in mortal combat.” Rather than toil at resistance—either by buying anti-aging products or conversion to the cult of Goop—Ehrenreich advocates “humility,” the acceptance that we “cannot control,” the body’s conflict. “And we certainly cannot forestall its inevitable outcome, which is death.”

Natural Causes is at once idiosyncratic, compelling, frustrating, provocative, and smart. Like all of her books, Ehrenreich asks hard questions that sometimes have hard answers, and sometimes no answers at all. I had the pleasure of speaking with Ehrenreich about her new book, as well as everything from wellness and Goop, to self-care, killing it in the gym, and mortality. Our conversation has been edited and condensed for clarity.

JEZEBEL: I wanted to start by asking the obligatory first question: Why this particular topic at this moment?

BARBARA EHRENREICH: All my books, despite everything I write, are motivated by two things: anger at some kind of injustice and curiosity. I did feel a lot, I don’t know if I want to say outrage, but I couldn’t believe it when I got to a certain age and found that people my age, in an upper middle class demographic, were devoting most of their time to trying to prolong their lives. They were curating their diet. They were doing all of these preventative medical tests. They were fixed on the amount of exercise they were getting. I thought, “This is strange. What’s going on here?” That was part of it. There was also a scientific mystery here that I get into. I was interested in how cells of our own bodies turn against us no matter what we do. We have no way to control what is going on at the cellular level, unfortunately.

 J : In this book, you reject medicalization—these things we’re told that we’re supposed to do to “age well” or to extend life. One of the arguments that I thought was interesting is that this idea is selling the fiction of individual control over the body or of death. This fantasy of eternal life isn’t particularly new, but it seems more pressing at this particular moment in history.

BE : This started in the 1970s, that’s when gyms start opening up and when people start running, they start changing their diets in whatever way was fashionable at the moment. I think a big part of the impetus, which I still think is true, is that people do not feel like they have control over many things in their lives. I mean, just watch the news.

Things seem out of control, but that you can control your own body is the idea or the hope. I can’t control the kind of things that are going to come out of the White House next, but I can certainly strengthen my quadriceps. It’s a realm of control.

J : Right, but this realm of control is very fictional down to this cellular level, which you explore very elegantly in the book. I was wondering how this kind of control became so necessary to the construction of what you identify as individualism. Why is individualism so subject to this iteration of self-control?

BE :  In the 1970s, Christopher Lasch wrote a book called The Culture of Narcissism and he saw the fitness culture as part of rising narcissism. In his mind, people who had been involved politically in the 60s had now turned to this intense concern with their bodies and later their “mind-bodies.” His perfect case of that was Jerry Rubin, who went on to become a kind of fitness guru. He tried every single alternative modality. He had a business in fitness and health. That was the Lasch narrative—that it was the despair at not really being able to change anything in this society that made people turn to themselves and this narcissist construction of the perfect body and perfect mind.

J : As you just said, that’s plagued with politics. You tease out this real tension in fitness culture between discipline—like Fitbits, quotas, or reps at the gym— and an element of punishment—like, “crushing” your workout. The systems of discipline and punishment are inherently associated with cultural and political oppression. I guess I’m wondering: If fitness is a way to create a sense of individual control, then why have we allowed these systems into fitness?

BE :

There is something of the old Protestant ethic going on; there is something punitive. It fascinates me, in the gym, to see guys with a clipboard recording the number of reps and the weight and so on. This person is enacting two roles: one is the role of a manager, keeping records and getting a quota filled. The other is the role of the worker, who is supposed to perform these things. That’s a remarkable bifurcation of the self.

What I noticed just recently is that my gym started offering a new class—and this goes beyond crushing the body—to “shred” the body. I just envision ravens eating corpses on battlefields. It’s very punitive to get into this self-punishment routine. I like to feel strong and feel like I’m getting stronger—though I can’t say that I am.

Again, there’s another thing going on among the wealthy right now, which is the opposite of self-punishment. The idea of wellness—and I love that word—as a kind of self-pampering. You have written about Gwyneth Paltrow...

J : Yes, I have written about Goop and wellness.

BE :  They may do some exercise in the world of Gwyneth, but mostly you’re loving yourself. Self-love is a huge part of this; if anything sounds like narcissism to me, it’s self-love. I even found a website about self-worth. I think the self has replaced any external deity as what you take care of. In the wellness culture represented by Paltrow and others...there’s this woman Amanda Bacon in Los Angeles, have you heard of her?

J : The Moon Juice lady...

BE :  She has a heavily curated, as she puts it, “lifestyle.” And there’s Blake Lively, too, selling this curated lifestyle, whatever that means. It does mean that you have very little time to do anything except take care of yourself, rub things onto your skin, choose what food might be acceptable in your conception of what a diet might be, and on and on. I find that really fascinating. You have to spend a lot of money on yourself to prove to yourself that you love yourself.

J : This notion of wellness that you home in on is inherently classed. As wellness has really taken hold, it seems impossible to break away from this reality that in order to truly seem healthy you also need to be wealthy.

BE :  I think there’s some truth to that in reality too, not just the realm of wellness. There’s a big difference in mortality between rich and poor, between even rich white men and poor white men. That probably has to do with better nutrition and less stress. The working class person today may have no job, may have three jobs, may have jobs in many cases where they’re just on-call with no regular schedule. When you’re on call, you can’t plan anything like child care. It’s extremely stressful, and one way of handling stress, which is deeply disapproved of by the social class I more or less inhabit, is smoking. Weirdly enough that becomes a form of self-nurturance for people who can’t take afford to take a holiday in the Bahamas or wherever.

J : I wanted to go back to self-love for a moment. In a lot of women’s publications, the concept of self-care has really taken hold—and I mean self-care as cosmetics or skincare aimed at white women, to be clear. It’s often presented as this really radical feminist action, just as Goop presents itself as a feminist site. How does this idea of self-love or self-care as radical political action work when there is so much class divide? Most people can’t participate because of its high cost.

BE :  When this kind of self-care is discussed as a brave political activity, someone always quotes Audre Lorde, and usually out of context [Editor’s note: For context of the Lorde quote, read Shanesha Brooks-Tatum’s insightful discussion of health, race, and gender.]

I think that a movement should be developing mutual care; a social movement itself should not be about self-care. It’s right to say, and I say it to a lot of people: Don’t burn out. This is a long struggle. Just do what you can but be sure to get enough sleep, enough to eat, and have some fun now and then. But I think that these are thing also that we can do in a more solidaristic way than just say “Oh, go home and do some self-care.” We could talk to each other, we could have more parties and celebrations, we could do more dancing. I know this sounds a little crazy, but I think that it’s something that’s very much missing in our lives.

J: I’ve noticed that as women’s publications have embraced self-care, they’ve replaced their health sections with wellness sections instead…

BE : Oh yes, health had to go. Health is lower-class.

J :  Yeah, definitely. In the book, you note that health, or the absence of disease, is no longer enough, you also have to be well. Why do you think it is that this incredibly classed concept has such currency, especially in women’s publications?

BE :  Wellness edged out health because health had this unpleasant meaning of the absence of disease and we don’t even want to mention disease. Wellness is the upper-class version. We have such a class divide in our society that we can’t have one word that covers even a sort of biological or mental condition of both the upper and lower classes. Wellness had to be carved out as something new, something boutiquey, special, and expensive.

Now, wellness has another meaning if you’re a worker, blue- or white-collar; your employer might institute a “wellness program.” All that means is that they want to do surveillance. They had the idea that they could cut their expenses on health insurance if they can monitor the health of employees. It’s mostly about getting their weight down, frankly. Sometimes blood pressure is involved. One of the ironies here is that studies have not found any effect on health insurance expenditures for companies that do this. But anyway, for the lower classes, wellness is a really scary word because if you don’t participate in a company wellness program, you can be fined. 

J:  There seems to be this real tension built into wellness. On one hand, wellness for the wealthy places a real emphasis on the individual but, on the other, for the middle and working classes, it can be corporate surveillance that seems to strip them of this very concept of individuality. Is individuality itself a commodity that can only be purchased by the wealthy? 

BE : That’s a hard question. Certainly, when you get to the level of self-branding, you are probably not talking about somebody who does lawn maintenance. That idea of branding and creating a unique you that can then be displayed in the world….I think it’s kind of fascinating. What do you think?

J :  I agree that it’s interesting, that transformation of the self into a brand and thus a product to be consumed….

BE :  Yeah, with your own style and everything. I don’t understand the kind of split in one’s consciousness this requires. To say, “Okay, I, Barbara, am going to polish and hone my brand today.” It’s sort of like another Barbara I’m putting out in the world. I can’t do that to myself. Can you think that way?

J : No, but to be honest, the longer I am online, the more alien social media platforms that help you cultivate that idea of the brand seem to me. I found the idea of the body as a “tiny collection of selves” to be really compelling. You argue for this kind of paradigm shift that constructs the body as a site of conflict down to this cellular level. I’m wondering, what would our concept of the body be—or even our concept of the individual—if we thought of ourselves as permanently in conflict? Would these concepts even have any currency?

BE :  The wellness, holistic style paradigm has been of a body where, there may be different parts, but everything is in harmony. If it’s not in harmony, you can adjust that with mindfulness or yoga or whatever. That’s not how the body works: There is a huge amount of conflict between the cells, and some of this gets pretty dramatic as you get older and you get more and more inflammatory-related problems, which are really immune cells turning against your own body.

So, what am I then? I am this site of a lot of cellular activity, some of which is very helpful to my conscious mental self, and some of which is very destructive to the body as a whole and how I feel.

I don’t know where we go from here. I think the idea of the self has to be really reexamined. I’m not a Buddhist—Buddhists would have a good rap on this that I should learn—but the self was an invention that’s only about 400 years old. This is a new idea. This notion of the individual self, as opposed to other individual selves, is a recent one. We have to get beyond it.

J : You also seem very wary of the concept of the self and argue that, in many ways, it’s just the religious soul modernized.

BE : Historically, the soul, which was also at one point an invention, the term became secularized as the self. It is a major concern of, say, psychotherapy. When you go to a therapist, you don’t talk about how the world needs to change or systems of oppression, you talk about minute feelings about these things instead. It’s all self, self, self.

J : You brought the idea of mutual care instead of self-care earlier, do you think that we’d be better prepared, or at least more accepting of mortality, if we were invested in these communal bonds?

BE : Absolutely. I face my personal death with equanimity in no small part because I have been a participant in the feminist movement and whatever else we social justice warriors do. I know that I am part of a very long tradition of people who have fought for the same things over the centuries. I’ve made my tiny contribution, maybe I can make a little bit more and then others come along. I’ve been so busy in the last few years passing the torch. That’s what I do in my work life now, more and more.

I work with an organization called the Economic Hardship Reporting Project, which raises money to support financially challenged journalists, mostly poor, women, people of color. What I see myself doing, rather selfishly, is reproducing myself. I’m not going to be able to do this work—you do it. That includes you, too. I think you’re probably a lot younger than I am, right?

J : A little, yes.

BE : So, I’m passing a torch. The work will go on. In a physical and abstract way, the duty of the world will go on. Maybe other people will see it and enjoy. The world seems alive with beauty to me and that doesn’t go when I go.

                            Economic Hardshop Reporting Project, photo Joseph Rodriguez

Barbara Ehrenreich Isn't Afraid to Die. By Stassa Edwards. Jezebel ,  May 1, 2018. 

There’s no surer sign that life has become too comfortable for the rich than when they try to buy immortality. The first Chinese emperor enlisted scholars in his search for the elixir of eternal life and, after none was discovered, had them buried alive, figuring that if any of them was a true alchemist, he would return from the dead to share his secrets. (None ever did, but the emperor’s penchant for drinking mercury—which he believed also had life-giving properties—probably didn’t end up helping him live a long life.)

Leonard “Live Forever” Jones, a 19th-century US presidential candidate who accrued his fortune the American way—through speculation—believed that death could be overcome through prayer and fasting. Embarrassingly for his supporters, Jones died after refusing treatment for pneumonia on the grounds that illness was a moral, not a physical, concern. Later in the century, Gilded Age tycoons deified themselves through portrait-sitting, palace-building, and philanthropy, hoping this might at least sustain their image after their death, though it was then up to their heirs to maintain the memorials and the union-breaking that built them.

These acts of hubris pale in comparison, however, with the determination of today’s global elites to modify their bodies and transcend mortality. Ray Kurzweil, the computer scientist and spiritual docent to Silicon Valley, has predicted that by 2045, it will be possible to download a human brain to a computer. To make it to that year, Kurzweil drinks alkaline water, takes 100 pills a day, and spends one day a week at a clinic having supplements delivered directly to his bloodstream to preserve his flesh for the time when humankind will finally merge with machines. It may sound like a 9-year-old’s vision of the future, but Kurzweil isn’t a kid or a cultist; he’s a best-selling author who has been honored by multiple universities and three American presidents.

In Natural Causes, Barbara Ehrenreich explores the stories told by death-defying elites to make her own biological and political point: “no matter how much effort we expend, not everything is potentially within our control, not even our own bodies and minds.” In death, we will once again be equals—and so an egalitarian politics also means accepting this outcome.

At 76, Ehrenreich tells us, she is old enough to die, and over the past few years she’s given up preventive screening for breast cancer, scaled back her punishing exercise regime, and chosen to spend her time doing the things that bring her joy, like hanging out with her grandchildren. For Ehrenreich, this embrace of death is not merely a matter of biology but also of politics and ethics: “You can think of death bitterly or with resignation, as a tragic interruption of your life, and take every possible measure to postpone it,” she writes. “Or, more realistically, you can think of life as an interruption of an eternity of personal nonexistence, and seize it as a brief opportunity to observe and interact with the living, ever-surprising world around us.” Accepting death, for Ehrenreich, means being able to live more fully.

Over her long career as a journalist and activist, Ehrenreich has primarily made her name writing works of social history and cultural and political critique. Her first work, Witches, Midwives & Nurses: A History of Women Healers, written with Deirdre English soon after Ehrenreich received her PhD in biology, was composed in “a blaze of anger and indignation” at the exclusion of women as decision-makers in their own health care and the low status of the nursing profession. In 1983, at the height of the conservative backlash against feminism, Ehrenreich published The Hearts of Men, an examination of how cultural conceptions of masculinity entrap both men and women in resentment and dependence while preventing any economic reckoning with the generalized assault on the working class. The book sought to locate the appeal of figures like Phyllis Schlafly and the antifeminist movement. It was also a brilliant defense of feminism and socialism: “By simply asserting women’s right to enter the labor market on an equal footing with men,” Ehrenreich observed, “feminism undercut the dependent housewife’s already tenuous ‘right’ to be supported.”

Ehrenreich followed up these early works with her seminal Nickel and Dimed, for which she spent three months struggling to survive on the wages earned while working in retail and as a maid, house cleaner, and waitress. A firsthand account of low-paid service work, Nickel and Dimed was made all the more powerful by the author’s awareness that no matter how many shit stains she scrubbed away, she couldn’t possibly convey what it really meant to “experience poverty” in America. Published just before the financial downturn of 2001, the book sold over a million copies.

Ehrenreich has always had a deeply personal aspect to her writing, but it was only with 2009’s Bright-Sided that she put her own life at the center. In it, she used her breast-cancer diagnosis as the occasion for a striking critique of the positive thinking that runs through health-care treatment in America. Puncturing the insistence that people with cancer are more likely to survive if they think optimistically about recovery, Ehrenreich also explored the big business around prescribed optimism, from Dale Carnegie to the snake-oil salesman who “recommended positive thinking as a cure…for the entire economic mess” of the Great Recession.

Like Bright-Sided, Natural Causes was inspired by a particular moment in Ehrenreich’s life: her acceptance of her own mortality. But that moment gives way to a broader inquiry into the biological, social, and political implications of the American denial of death. In fact, one reason the book is so compelling is that Ehrenreich moves fluidly back and forth between discussing our physical limitations, our social and political limitations, and the relationship between the two.

Ehrenreich begins with microscopic observations of cell behavior to paint a detailed yet accessible picture of the body in conflict with itself. Macrophages, she tells us, are the “blue collar workers” of the body, cells that dispose of dead and injured cells and eat microbes that have made their way past the barrier of the skin—so it’s easy to see them as the good guys, “the vanguard of bodily defense,” as Ehrenreich puts it. But more recently, scientists have discovered a sinister role played by these cells, at least “from the point of view of the organism”: They can serve as “cheerleaders on the side of death,” accumulating at the site of cancerous tumors and encouraging their growth.

Macrophages—and the cancers and autoimmune disorders these cells promote—increasingly seem to be not just an error or mutation, but something happening within the natural responses of the body. For Ehrenreich, this opens up a much more philosophical question about the very nature of human autonomy and control: “If cells are alive and can seemingly act in their own interests against other parts of the body or even against the entire organism, then we may need to see ourselves less as smoothly running ‘wholes’ that can be controlled by conscious human intervention, and more as confederations, or at least temporary alliances, of microscopic creatures.” Just as our efforts to control our individual bodies are doomed, Ehrenreich argues, so are our efforts as individuals to uplift ourselves. The interdependence and chaos created by the body also lead to the same conclusions as the interdependence and chaos created by modern life: We can’t just go it on our own.

                                                 Illustration by Joe Ciardiello.

For Ehrenreich, this is demonstrated by the very nature of health. It’s only because of the collective medical advances of the past century or so that people living in a postindustrial world can conceive of “wellness” as a natural state and nature as harmonious or wise. Sure, herbal remedies, breastfeeding, and at-home childbirth are “natural,” but so are famine, epidemics, and high infant- and maternal-mortality rates. (The first-century philosopher Epictetus instructed parents, “When you kiss your child, say to yourself, it may be dead in the morning.”) Today, with good reason, we expect children in postindustrial societies to survive their parents, and we have the dedication of rigorously trained doctors and devoted scientists to thank for that. But this doesn’t mean that nature itself is on our side or that medicine and science will be able to save us. From this recognition, Ehrenreich begins to weave together an ethics rooted in not just accepting but embracing the realization that humans are united in suffering, that we will all experience the ravaging effects of nature and time, and that rather than try to run from that knowledge by controlling our minds and punishing our bodies, we must address it together, as a society.

At a time when American life expectancy is falling because of lack of access to health care—and when the abject failure of private insurers and health-care companies to provide the most basic care to their customers without bankrupting them has made “Medicare for All” a popular rallying cry in one of the most libertarian countries on earth—an indictment of the health-care and wellness industries may seem like a curious undertaking for a self-proclaimed socialist. But Ehrenreich’s message is not that we should do away with health care; it is that we should think more critically as a society about how, when, and why we use it. Screenings and lab tests can be lucrative for doctors, but seeing the patient as a chart of numbers can lead to serious mistakes and oversights. Doctors for whom the perfect patient is a silent patient miss out on hearing symptoms—or a lack thereof—that should influence their diagnoses. But it “isn’t easy to protest from the lithotomy position,” Ehrenreich notes sardonically, referring to the position that women are placed in during childbirth.

Ehrenreich also insists that viewing health care differently will allow us to see the ways in which the inequalities produced by class, race, and gender are much more central in determining one’s health than individual choices and screenings. It is not the specific choices of a poor person that lead to diabetes, cancer, obesity, and so on, but rather those inequalities produced by capitalism. While physician and Rockefeller Foundation president John Knowles may have pronounced in 1977 that most illnesses can be chalked up to a person’s bad habits, and thus the “idea of a ‘right’ to health should be replaced by the idea of an individual moral obligation to preserve one’s own health,” Ehrenreich wants to remind us that it’s almost always not just one’s own choices, but also the randomness of nature and the inequalities produced by human societies, that have the power to destroy us.

These days, Knowles’s view of health is everywhere. It is a common line of reasoning found in the health-care and related industries, which are eager to “empower” consumers through the use of apps, personal devices to monitor everything from steps to sleep to heart-rate stats, and discounts offered by insurers for annual exams (the utility of which, like preventive screening, is now the subject of scientific scrutiny). But it’s a line of reasoning that is also often used to justify opposition to the creation of a national health-care system.

This view of individual accountability has migrated from the health-care industry into the workplace, Ehrenreich argues. Mindfulness, for example, has become a religion in boardrooms—“Buddhism sliced up, commodified, and drained of all reference to the transcendent.” Individuals are supposed to build control over their emotions through practice, just as we aim to control our bodies through exercise. Mindfulness promoters draw on the concept of “neuroplasticity” to sell training programs with a thin veneer of science to the business world; but there is no evidence that meditation offers benefits beyond those we get from other forms of relaxation—say, a mandatory five weeks of vacation time a year, as is the case in Scandinavian countries. The problem, again, is not the practice itself, but how it’s expected to transform us into “an ever more perfect self-correcting machine capable of setting goals and moving toward them with smooth determination.” As Ehrenreich observes, “the word ‘enlightenment’ never arises in the mindfulness lexicon.”

Indeed, for Ehrenreich, mindfulness is as dangerous as the myths found in medicine about the power of individual choice. Just as medicine offers a reassuring illusion that we have more control over our life spans than we actually do, the mindfulness industry actively and insidiously serves to depoliticize the realm of work and other spheres of social life: It tells us that our mental as well as physical health is up to us, and discourages us from seeking collective solutions. What Ehrenreich instead proposes is confronting the chaos of the body, embracing the uncertainty of life and the limits of fitness and medicine, and finding comfort in our collective humanity.

There are some shortcomings to Ehrenreich’s argument, however. It’s fine for a retired woman who’s financially secure and doesn’t have any dependents to accept the chaos and uncertainty of nature, but many others still have families to think about and so need to keep on living in order to provide for them. There are also other issues of class: Some may have the resources at a certain point in their lives to embrace death more actively than others—but if you haven’t built up savings or inherited some, you really need to live as long as you can if there are others relying on you.

Ehrenreich would likely agree that this is a fair objection, as it’s absolutely true, at least in the United States, that capitalism has taken not only retirement but the prospect of a worry-free death from many of us. But she would also respond by noting that part of the problem with this line of reasoning is that it still assumes that, as individuals, we are in the driver’s seat, when in fact nature doesn’t care about what our families need from us any more than it cares what we need from it—which has always been the point of creating a social safety net in the first place, from the banding together of hunter-gatherers to the post–World War II nationalization of health care in Europe.

There is also a different kind of criticism of Ehrenreich’s argument. It’s difficult to agree with her when, writing about gynecological and other annual checkups, she suggests that “one problem, though certainly not the only problem, with these regularly scheduled invasions of privacy is that they do not save lives or reduce the risk of illness.” For example, while a 2016 study found that the reduction in breast-cancer-mortality rates was due to treatment rather than screening, the adoption of routine cervical-cancer screening in the US has reduced mortality rates of cervical cancer from the leading cause of cancer death in women to the 14th. One can recognize the inevitable way in which nature works, the lack of individual choice, and the inconsistency of our personal decisions in shaping our own health outcomes, without entirely rejecting preventive screening.

And yet Ehrenreich is ultimately right that we need to know when to let go—or, at least, how to prepare for it. Shortly after I gave birth, I developed a complication and was given a CT scan, which found a tumor on my adrenal gland. I was referred by the ER team for an MRI, and two days later, I opened an attachment to an e-mail from my doctor’s office showing the results: The radiologist had concluded that the tumor was likely malignant. I searched “adrenal carcinoma,” only to find that the life expectancy for this highly aggressive cancer is about five years. In three weeks, while I waited for the results from the lab work, I lost 30 pounds and woke up many times in the middle of the night to write letters and record videos for my son, so that one day he would know his mother’s voice. When I was finally able to get an informed opinion from a specialist, I was told the MRI image was misleading (for complicated reasons I won’t get into here) and the test unwarranted in this case, since the original CT scan had strongly suggested that the tumor was benign. The overabundance of caution on the part of the ER doctors led to such anxiety in the first weeks of my child’s life that my breast milk dried up. This did not have to happen; it was the product of a medical system rooted in fear, a desire to avoid professional liability—I’ve been told many times by oncologists that radiologists have to cover themselves—and rapid intervention without consideration for a patient’s symptoms or circumstances.

It’s better than the alternative, you could say—but is it? Even after the fact, I concluded that I’d rather not have known, and enjoyed the one or two good years left to me, instead of five miserable years of chemo. There’s little doctors can do in the case of adrenal cancer—as is the case with many disorders—besides let you know you have it and give you an estimate of how much time you have left. Death is inevitable; the question is how much foreknowledge we really want.

And fear is not the only consequence of overscreening and misdiagnosis. An estimated 70 to 80 percent of thyroid-cancer surgeries performed on US, French, and Italian women (who are far more prone to thyroid tumors) from 2003 to 2007 were later deemed unnecessary, Ehrenreich tells us. All surgery carries with it the risk of death, and thyroid surgery usually makes patients dependent for the rest of their lives on hormone medication, which isn’t always effective and can leave them feeling profoundly exhausted.

My own experience with misdiagnosis did lead to a few positive outcomes: an extraordinarily vivid investment in the present—I lived each day to wake up to my son’s smile—and the conviction that my child would need to bond not just with me, but with my husband, parents, sisters, and friends (not incidentally, a common strategy in societies with high maternal-mortality rates). More important, it confirmed my commitments to demanding universal child care and health care as a human right, already ignited by an earlier cancer diagnosis. When we are forced to rely only on ourselves and our own private regimes of health and fitness, we are just one malignant tumor or a few cheerleading macrophages away from leaving our families without providers.

And here we arrive at Ehrenreich’s final point. Since nature operates randomly and is not often guided by individual choices, we must act together as a society to try to equalize health outcomes as much as we possibly can. (And even then, they will still be grotesquely unfair.) Contemporary society, Ehrenreich writes, is “so deeply invested in the idea of an individual conscious self that it becomes both logically and emotionally impossible to think of a world without it.” And yet, “there is one time-honored salve for the anxiety of approaching self-dissolution”—not endless rounds of chemotherapy, or the insistence that you’re a fighter and that you’re going to make it, which has practically become the recommended etiquette for those with a cancer diagnosis—but the submergence of “oneself into something ‘larger than oneself.’”

What this “larger than oneself” means for Ehrenreich is largely left unsaid—and when she does discuss it, she does so in vague and ephemeral terms. In contrast with much of her previous work, Ehrenreich here offers an original, multifaceted critique without a political prescription, other than the vague reminder to hold your loved ones every day. But if one looks back at her earlier work, one can find clues as to the kinds of policies she might suggest.

Natural Causes may be a book that offers little comfort to many. But it is radical. It’s now strange, almost quaint, for those of us living as consumers in a capitalist society to be told to accept the fragility of our bodies and place our faith in the power of our collective humanity. Given that most of us are supporting others and will likely have to do so for the rest of our lives, whether it’s our children or our parents without Social Security, the need to postpone death is not antisocial; it is a pressure felt by anyone who’s not an heiress. But Ehrenreich gives us something else instead, reminding us how important it is to build social “utopian” supports that can mitigate the pain of a dystopian body. In this way, Natural Causes is, if nothing else, the culmination (though hopefully not the last book) of a career spent insisting on a common-sense morality that is actually visionary.

The Great Equalizer :  Barbara Ehrenreich and the ethics of dying. By Megan Erickson. The Nation. September 18, 2018.

On November 27, King Willem-Alexander of the Netherlands presented  Barbara Ehrenreich  with the 2018 Erasmus Prize in the Royal Palace in Amsterdam. Previous recipients of the prize, which comes with an award of 150,000 euros, include Charlie Chaplin, Vaclav Havel, and the artists Oskar Kokoschka and Henry Moore.

Barbara Ehrenreich’s Erasmus Prize acceptance speech :

Your Majesties, Your Royal Highness, Your Excellencies, ladies and gentlemen,

Wow. Amsterdam is completely disorienting to an American. I’ve been here for more than a week and haven’t heard a single gunshot. Even the dignitaries, like the king and queen, are warm, kind people. When I met the Dutch ambassador to the US last spring, in connection with this prize, he was so pleasant and jolly that I had to question his credentials.

And now this: For me, this is like a fairy tale come true. We’re in the royal palace! With the king and queen! And I’m here with everyone I love including all the people who have enabled me and inspired me for so many years! Thank you so much to all the Dutch people not only for the Erasmus Prize but for this unforgettable moment!

Well of course I’m saying all these nice things about The Netherlands in the hope that you will, when necessary, grant me refugee status. Me, my family and friends, that is.

One thing about this country that is strange, even exotic, to an American is that you seem to lack the steep class divisions that are so visible almost everywhere in my country. You may eventually get to the same divided condition as my country — this is the way most industrialized countries are trending — but at least for now, the Dutch welfare state remains strong enough to prevent that from happening. In the US, by contrast, we have virtually no welfare state to protect the poor and downwardly mobile, and the results are visible even to tourists.

Take Manhattan, that once-beautiful island that, according to legend, the Dutch bought from the Indians for $24 — and that’s a real estate deal that even Trump would have to admire. Today, Manhattan land sells for $1000/sq. foot, so $24 would get you a few square inches.

One sad consequence of the current prices is that only the super-rich can afford to live in the upper story apartments where the sun still shines. Walk around on the sidewalks of Manhattan today and you will be in the perpetual shade of the sky-scrapers housing American — and Russian and Chinese — billionaires. Actually, you’ll be in the shade of the empty apartments of the super-rich – because when you have 6 or 7 homes you can’t be in any one of them much of the time.

I have spent a lot of time in that shade. I was born into the relative poverty of a working class family in Montana and spent a good portion of my adult life struggling economically. Partly because I chose to be a writer and a journalist. This seemed like a good fit for me because I’d been educated as a scientist and journalists have the same goal — finding the truth and getting people to pay attention to it.

At the beginning of my career, I could earn enough to support my family, at however minimal a level. But starting in the 90s that began to change. Newspapers and other news outlets were taken over by large corporations that were concerned only about the bottom line. They cut their staffs, including journalists, and closed those magazines and newspapers that weren’t making enough money, at least by the standards of their new owners, with the result that, today, writers aren’t paid well when they’re paid at all.

To make things worse, I often chose to write about poverty — about all the people who are left out of America’s fabulous wealth, who try to get by on about $10/hr while raising children and paying exorbitant prices for rent and medical care. This seems so unfair to me, so easily fixable. Why not, for example, open up the empty sky-high apartments of the super-rich as squats for the homeless while their super-rich owners are off in London or the Caribbean?

But this of course is not the kind of thing that the new super-rich owners of the media business want to hear. I found the demand for my kinds of stories diminishing. Editors urged me to write less about economic inequality and more about “feminine” topics like the first lady’s fashion choices and the secrets of success of female CEOs. I could no longer make a living in journalism, and had to find other ways to support myself.

What is worse, I could not be sure I was actually making a difference. I had started in the 80s doing the conventional type of journalism: interviewing people and getting their stories published. This was my way of debunking the common prejudice that the poor are only poor because they want to be – because they don’t make an effort, or because somewhere along the way they forgot to get an education for a high-paying career.

I got some praise for “giving a voice to the voiceless” but nothing changed. In fact, things were only getting worse: Wages started going down relative to the cost of living; the welfare state began to disappear; unions were becoming weaker.

So I decided to turn things up a notch, to try “immersion journalism,” in the style of the German journalist Gunter Wallraff who went undercover to report on the lives of Turkish guest workers (I had not heard of him at the time.) I left home, found the cheapest housing I could, and took the best paying jobs I could find – as a waitress, a hotel housekeeper, a cleaning lady, a nursing home aide and a Walmart employee. I didn’t deliberately select these jobs: They selected me. These are the only kinds of jobs I could get without using my actual credentials. (Not that my credentials would have helped, since I never did see a job advertisement for a political essayist, especially not a sarcastic feminist political essayist.)

To my utter surprise, the book that I wrote about my experiences became a bestseller, and helped reinforce the ongoing movement for higher wages. To my even greater surprise, many people praised me for my bravery for having done this – to which I could only say: Millions of people do this kind of work every day for their entire lives – haven’t you noticed them?

And I learned a very important lesson: I never use the word “unskilled” any more to refer to anyone’s work. I learned the hard way that every job takes skill, intelligence and concentration – and should be paid accordingly.

Now I’m in my third and final phase of my personal campaign for social justice. Six years ago, it struck me that people living in poverty (or near poverty) don’t need someone to “give them a voice.” They have voices and they know what they want to say. They just need some help, some support to allow them to write and help them get published.

So I created something called the Economic Hardship Reporting Project for exactly that purpose. In our 6 years of existence, we have raised money from philanthropists to help support over 100 people – factory workers, house cleaners, and many professional journalists who have fallen on hard times.

We’ve turned some lives around. We’ve called attention to issues no one was thinking about — like the plasma business, which pays poor people for their vital blood proteins, at considerable cost to their health. Or the growing number of childcare centers that operate 24 hours a day, because their parents have to work pretty much around the clock … about homeless Americans who live year-round in tents … and about the epidemic of suicides among American farmers.

We are very proud of what we do. Some of our people have won prizes and awards. All of them have had their work published in widely read media outlets. A few have gotten book contracts or actual paying jobs. We like to think that we’re making a difference.

And maybe we are. But it’s a tiny difference compared to what needs to happen. And I guess that’s the story of my life as a journalist: You try and try to bring attention to what is really happening and to all the unnecessary pain in the world. Most of the time you fail. You don’t change the world. You may not even get paid for your work.

But once in a while, very rarely, you are recognized and applauded for what you are trying to do. This is one of those moments — and not only for me. I am encouraged and emboldened to work even harder for a just and equitable society, as are my many friends and colleagues and loved ones. I thank you on behalf of all of them.

Barbara Ehrenreich Speaks Truth to Royalty. Inequality, November 30, 2018.