Politicians want us to think there are only two options for healthcare: Obama or Trump. ER doctor Frank Coughlin has a much more radical proposal.
Towards Health Autonomy: Interview with Dr. Frank MD
Name the materials necessary for the common good, or how about just your top three. Health is an arguable front-runner, no? It should be way up there, alongside things like freedom and the environment.
Medical care’s active role in healing denotes its intrinsic value to our common human experience, and for that our communities have a real dependence on Healthcare. Please note its capital ‘h’. The medical industrial complex touts both material and nonmaterial forces in its ranks. Knowledge, profit, and taste keep us under the authority of Health. Yet there could be hope. According to my friend and comrade Dr. Frank, we may be living through a time of immense change in the way health services function.
Frank and I met at Woodbine, an experimental hub in Ridgewood, Queens that hosts workshops, lectures, and discussions. It serves as an organizing space for various autonomous projects. The Woodbine collective means to develop the skills, practices, and tools for building autonomy. They also serve a mean communal dinner every Sunday.
For Frank, Woodbine represents both the material and the ideal. “It is a local aggregating point, a space for ideas to take shape, while on a larger level it exists for the goal of building a revolutionary life.” He says the way to build that life is to build communally, to find the means for collectivities to grow, and to shape them in a way that overcomes the limitations of the context we find ourselves in today.
In search of the common good, I asked Dr. Frank how we might address Health dependency, if he could imagine entirely different models than what are offered, and what he suggests we do now to develop generative communal health care.
You’re a doctor but you’re also a radical organizer and active member of the revolutionary autonomy collective Woodbine. How’d you get into this?
When I was in high school I wanted to be the surgeon for the New York Mets. I had this grand plan to go to a good college, get into a good medical school, go to orthopedic surgeon residency, and drive BMWs by the time I was thirty. Yeah, I guess I fell off that track, now I ride a 70s Peugeot bicycle to work.
I work in the ER at Bellevue Hospital, I’ll wrap up my residency in July. But, I came to medicine circuitously; I was a chubby kid and I broke my arm a lot. The last time I broke my arm I told myself I’d be a doctor so I could fix it and not go to the ER anymore. It’s funny, but it got me on this track.
In college, I learned about structural violence, structural oppression, and got into international politics. I still wanted to be a doctor, but I moved to emergency medicine because it’s skill based. I wanted to have something to offer a large movement. Most practices are somewhat theoretical and highly dependent on hospital infrastructure. ER medicine is dependent upon ER infrastructure, but it also offers more procedural based learning like suturing, splinting, and dealing with trauma.
Salvadore Allende, Che, and Rudolf Virchow were all doctors who went into medicine understanding that the larger social determinants of health is a social issue primarily and a medical issue secondarily.
I remember thinking when the revolution happens in some Latin American country, I’ll speak Spanish and I’ll go [there] to be the doctor. In ER medicine, we learn a little about everything so I could deliver a baby, suture an arm, and deal with a chest wound. I thought future struggles would include both acute injuries from gunshots or bombs and sub-acute chronic diseases. I wanted to be like the Che of that country or something. It was a good illusion because it allowed me to have radical beliefs without having to do anything.
After that, I worked in California for a bit and then finally went to medical school in Boston. It was there, while still involved in international health work, that I realized how ridiculous that idea was, how selfish it is to think someone else in some other country is going to start an uprising and I’m going to help. I began questioning myself, like, why am I not trying to foment that here?
Toward the end of medical school, I still had some idealism about changing medicine from within and I did some programs to teach other med students about radical thought and structural violence. I got fed up with that, though. I began to see doctors as a class, that we’re too far gone or too brainwashed by that point to change. I realized the institution itself is the problem.
Through Occupy, I came to New York City in search of a community to build the structures for a revolutionary life, who could ask what that would look like here in the US. For two years, I went to every meeting I could – every socialist group, anarchist group, and communist group – and of course I got burnt out. Around the climate march, I was fed up with the movement, or that our end goal was just to march. After all the meetings, it just felt pointless. I question the strategy and it takes up so much energy. Sure, it can help others get into things and it is worth it sometimes, but I don’t know how much effort we should put into it. You have to ask, is this doing anything?
After the climate march, I found Woodbine through an event and felt it was the group I could ask these questions with. For me, it provides the material ground seeds of ideas need to grow, to begin building the worlds of the revolution.
What does it mean to you as a doctor to have a radical perspective?
For one thing, I still view being a doctor in the sense of what can it do for others. I mean, the history of doctors is already radical. Salvadore Allende, Che, and Rudolf Virchow were all doctors who went into medicine with a social context, understanding that the larger social determinants of health is a social issue primarily and a medical issue secondarily. They were all politically active. They were protectors of the belief in a right to health. For me, that will always counter a proto-capitalist narrative. For me, that is what it means to be a radical doctor. It is community organizations with the idea of de-professionalizing health and trying to decrease the reliance on health institutions to put health back into people’s hands. I think it can only be done inside communal milieus or communities of service.
During medical school and residency, I tried to start initiatives to ask what radical medical application could look like, but unfortunately, there’s been a professionalization of medicine. Doctors tend to carry ideologies or idealisms when they’re younger, thinking they’re going to change the world through the medical system, but then eventually it goes go away and it’s just a means to an end.
After Trump was elected though, I noticed at work, where I have a bit of a reputation, that these ideas were being respected more – political revolution or social upheaval is not as crazy as it seemed before because really, what we want is not that crazy. We want a world where people are healthy, where we can support each other, where we can have families, and people are not oppressed or discriminated against. We want clean water.
I think this is new to our generation, but there still must be a betrayal of your class to some extent. Most doctors come from upper middle class or middle class socioeconomic status. There is a strong subculture of petite bourgeois ways of life, that you must remove yourself from and negate to produce autonomous means of medicine.
It appears class distinction is built into your profession. It does go with the stereotypical projection of doctors: scrubs, stethoscopes, and millions of dollars behind them.
If people want revolutionary change, they have to accept their lives will not be comfortable anymore. Change is chaotic, especially for doctors. Doctors are in a very comfortable position.
That came about in the fifties and sixties with the rise of insurance companies, especially Medicaid and Medicare, and the idea that people should no longer pay out of pocket for services. Insurance companies paid comparatively massive reimbursement rates in regards to out of pocket payments by using collective pooling. Outside payers with large sums of money came with increases in medical technology and higher and higher rates.
Before that, you had a generic local doctor, who carried a black bag to your house. Maybe they were more affluent than others, but they were part of the community. They couldn’t easily charge a neighbor for services they couldn’t afford. There was more respect for the profession, for the ability to help heal and they, in turn, had more responsibility in the community.
But to become a doctor today your family has to have money, or you take on massive loans. And if your family has wealth, statistically you will be less understanding or empathetic to the poor, or even if you are empathetic, it is unlikely you will betray your class upbringing. And if you take out loans, well, some argue the debt is meant to control you. Doctors tend to owe upwards of 400k when we graduate, which is honestly a crushing amount of debt. It can force you to cater to debt: to work a nice job, have car payments, maybe a house and kids. Debt traps you in a certain way of living.
Now, there’s systemic pressure on doctors to worry about their loans first, or their lifestyle first. It’s subtle and maybe this is clouded because I’m in residency, but there is a sense that doctors need to get theirs. That, as a doctor, you deserve a certain level of living: happy hours, vacations, apartments.
That could stunt the movement.
I think it is the same with any revolutionary group. If people want revolutionary change, they have to accept their lives will not be comfortable anymore. Change is chaotic, especially for doctors. Doctors are in a very comfortable position.
Drastic change in this country means war and you may not be on the winning side. You’ll lose material comforts and psychological comfort. Right now, I can get a job anywhere in the country and it’s an amazing privilege that I have, but to let go of that is still too much for doctors. I have communal support, people who support these ideas, but if I was on my own with a family it would be hard to think about the positives of revolutionary change. That’s why more and more people take a pragmatic approach to change, but I don’t think we’re in a time in which a pragmatic approach is possible.
Does Obamacare or the repeal of Obamacare concern you?
What concerns me is that we don’t think of health as a human right. We’re forced to think of health insurance coverage as a product to buy and, in the current system, everyone should buy that product, even when it does not guarantee the ability to receive health care. Obviously, there are differences between Trump and Obamacare, like Trump’s is more free market-based, but [to go from Obamacare to Trump] isn’t as big of a shift as, say, if Canada were to switch to a free market system. That’d be a huge ideological leap.
We talked about this at Woodbine recently, during a Trump lecture series. The Affordable Care Act increased coverage for people, up to forty million people, but there is still at least twenty million people uninsured. It covers preexisting conditions and limited what health insurance companies could reject. A lot more people come to the ER with insurance, which is great, but they come because they don’t have access to the other services that they are paying for, like primary care or referral services. The ACA increased access to coverage but it did not increase access to health care, which are separate things often lumped together. Now more people have insurance coverage, but health infrastructure was not increased. People have a primary care doctor but often coverages say they can only see their primary care once every six months. This begs the question: if they cannot easily access their primary care doctor, do they even have one? It mandated coverage for birth control and maternal health – each beneficial for greater society, but the problem is that it enshrines insurance coverage. It enshrines the idea that people need a third party to get health care.
What about the Republican plan?
We need ways to mitigate risk, but we should still act. We can't wait for the government. We can't wait for healthcare models to change
The Trump program is just an exacerbation of free-market based policies. It tried to deconstruct certain regulations to further health care as a commodity. The idea is that if given unrestricted access to the market, the best product will come out. This, in theory, makes some sense, if you are buying a car, but in health care, you can’t have educated consumers. There’s too much difference in the understanding of medical problems. If someone says you must get something otherwise you’ll die, it is not a fair situation. Health care shouldn’t be on the market at all. Trump’s plan is a rough continuation of neoliberal policies that Obama, Clinton, and others carried. Now it appears we’re in this situation where we don’t want the repeal of ACA but we also don’t want to defend it, that’s the tricky area people are falling into.
With the idea of health care tied to health coverage, the term doctor immediately connotes higher education and institution. Do you believe health care can be emancipated from the medical industrial complex? Do you see a future in communal medicine?
That is something I think about often and I think it is possible. There’s starting to be a failure of the medical system piece by piece. People don’t want to have health insurance because they don’t see a lot of the benefits. Even myself, I only have emergency health insurance. A lot of younger people are not going to see a need to pay for something that they’re not using. There will be more of an emphasis on preventative, holistic living. I think it is possible, but I think doctors must make a choice.
I worry the Healthcare fight will further individualism, though. There is already hyper-specialization and right now no one can afford to become a community doctor – myself included. I went to emergency care because I could not contemplate the idea of dealing with insurance companies all day. We’re somewhat shielded from it, but as health care costs increase and health care education increases, people will more and more go into specialties because that is where they’ll make money.
Right now, one of the major obstacles for community based healthcare models is fear in medical communities and regulations. For example, if I open an autonomous health clinic, I’m liable to lose my license and never practice again. Due to the legal push to treat patients like customers, with campaigns to increase patient satisfaction, we now treat medical care as a commodity. Initially introduced to protect patients against pseudo-doctors, it has made it impossible go without licensure in a formalized bureaucratic structure, which makes it nearly impossible for health practitioners to practice anything resembling autonomous care.
The regulations compel us to work within the system of medicine. But, still, I believe these are risks doctors must take. We need ways to mitigate risk, but we should still act. We can’t wait for the government. We can’t wait for healthcare models to change.
Do you have experience with autonomous health care models? I know you’ve worked with the Zapatistas.
I’ve been to Chiapas a few times to work with a doctor who trains health promoters. They have a bare-bones clinic, few medications, lots of outdated stuff and because of their lack of resources they rely on preventative, intuitive models integrating holistic and western models of medicine: herbalists, bone setters, and preventative medicine. The health promoters train the community to recognize and treat basic diseases normally treated in a hospital. Vaccines, blood pressure checks, and glucose checks are basic preventative care.
For the Zapatistas, it is too risky to go to the hospital, for fear of violence. They could be detained by the police and you know, it gets worse from there. It is also terribly expensive, so its almost impossible to go, but sometimes they are forced to, if someone might die without medication. Their idea is to limit that and educate the community to recognize red flags.
The doctor I worked with has been doing this for fifteen years. Eventually, the health promoters will teach the next generation so they’re not reliant on outside doctors. If someone is sick, they do have connections to the hospitals, albeit western style hospitals in Mexico, with a lack of resources all around.
The Zapatista model shows us we have to be flexible, we have to be scrappy, and we have to be okay with having no money or resources and building from there.
And you sense we’re in a time of societal change in regards to health?
We are in a chronic crisis and as far as health is concerned it is a horrific time. I think we’re going to see the dismantling of people’s access to health care. This is a crucial time when we should look at models like the Greek solidarity clinics. When there’s an economic crisis, there must be pop-up clinics. The same with the Zapatistas creating their own healthcare systems, and Rojava, which had a decimated health care system and they tried to recreate it. The benefits of looking at these models is that because they lack resources they focus on primary care and preventative care. They advocate not just healthy diets and daily exercise, but mental health care. They mean to keep people healthy. In the US, we treat sick people and that is very resource intensive.
Another example is the GynePunks in Barcelona, they essentially do do-it-yourself gynecological exams and create their own speculums for lab testing, because those services are not around. You look at the war on Planned Parenthood, it is not hard to imagine how a woman’s ability to get an abortion is being impacted and at some point, our clinics are going to need underground services again. How do we develop that capacity? This is something we must think about.
Do you follow these models at Woodbine?
Our clinics are going to need underground services again. How do we develop that capacity? This is something we must think about.
Woodbine’s Health Autonomy track does skill shares to de-professionalize health. To share health knowledge with people, but also create an idea of community care. Our mental health is a detriment right now. Most of us don’t have an idea of being in community. Caring for people in the community is foreign to a lot of people. So, we ask: How can we normalize community and also put it in practice? What do we do when a friend has a cut, or how do we help a sick parent? How can we create communities that can take care of elders and kids? But also, what do we do when one of us has a mental break down? What do we do when the police beat our friends up? We can’t all become surgeons and we cannot all deliver babies. We can however find and balance the needs of the community and how we can project our proposed resources into the future.
What other community medical roles can we fulfill today?
Let’s start with chronic depression and chronic anxiety. There is a chronic feeling of unease that can be treated in a community setting, perhaps it can only be treated in community settings. We need to recognize our limitations, like if someone is having an acute psychotic break, we may not be able to treat them. Sometimes there is a role for medications, but those are last resort versus our first resort.
We can start with the basics of health. We can learn how to cook for ourselves. We can learn what is generally good food. We can learn physical fitness and get away from bad habits. We can deal with basic injuries because most injuries are not that acute. And we can learn to name the more acute things, what we cannot address.
In April, we’re having a herbal medicine series, not to make people into herbalists, but to show some basic herbs that you can try. In the ER, a lot of what we see in the public hospitals are chronic issues, back pain for example. Lots of people have back pain, but the majority of back pains are not acute issues, like those caused by muscle strain or poor posture. These can be treated by non-medical modalities like massage or acupuncture. When people with back pain go to a hospital they get funneled into a way of thinking about pain which will inevitably lead to surgery, imaging, MRIs, and things like that. Often, that’s not the best way to deal with it.
We had an acupuncture series and we’re going to have another. And another basic first aid series. Start with things your grandmother might talk about, holistic home remedies, like putting honey on burns – which actually have a lot of truth to them.
For the record, herbalist/holistic methods work?
Absolutely. There is a lot of evidence for it. Addressing that fact is a good start. That and the fear of the body perpetuated by consumerism, objectification, individualism. Like the hatred of aging, we still fear this thing as the cause of our problems. We need to stop fearing our bodies so we can focus on the materiality of what is going on, otherwise, we’ll just get caught up in the bullshit of 4chan, Twitter wars, and all things that are meant to drive you crazy. I think that stuff is meant to wear you out.
What’s next for you in regards to autonomous health?
At Woodbine, we are hosting an “Intro to Health Autonomy” in the next few weeks and will be focusing on three areas: physical, mental, and communal. Health autonomy is split up but each relies on the other. To me, communal care addresses the physical needs of the individual, be it through collectives farming food, growing medicinal plants, or just taking care of the physical body. This can also attach to ideas of fighting and resisting, to the idea that what our movements often fight against is the oppression of the physical body like the contamination of water via pipelines or the price of goods. The second is the mental, that our mental health is as real as our physical health. People are anxious, depressed, manic, and suicidal. These each need to be addressed, and historically, we have viewed them from individual means alone. We’re trying to change that model to represent mental health as indivisible from the third aspect, which is the communal. We all need to feel part of collectivities, to have groups that support us. We all have a human desire to be part of something more.
Hear more from Frank and Woodbine at woodbine.nyc.