3. Global Medical Entrepôts and U.S. Health Care Inequality

A profit-driven biomedical model of health fuels the United States’ inadequate access to health care and insurance coverage, contributing to the excessive costs of the overall U.S. health care system. This arrangement has facilitated the expansion of urban medical complexes and fueled the growth of the urban health care anchor as a replacement or major supplement to declining manufacturing at the core of urban economies. While a hospital can benefit community development as a major employer and service provider, its very success as an urban economic anchor can exacerbate the systemic cost problems of U.S. health care as a whole.1 The United States spends the most of any nation by far on its health care system, which focuses on global outreach of acute care for those with the means to afford it as well as emergency care to address domestic poverty crises.2 With spiraling health care expenditures facilitating the placement of blame on the public sector, the United States has further invested in a corporatized and privatized approach to medicine and public health under the belief that a health market can best regulate costs and quality.3 International trade agreements and financial institutions have catalyzed this commercialization of health globally. Capitalizing on the universal desire to improve health, multinational corporations enter other national public health systems to offer privatized care and disseminate technologies, medical goods and services, and costly innovations. The U.S. health care system supports the anchoring of extractive local practices to revenue-seeking overseas joint ventures and global medical entrepôts that promise American intellectual goods, services, and brand names. These activities are promoted through moralizing discourses of global medical progress and educational mission, yet contribute to vastly inequitable divisions between those who benefit from the current system’s specialized resource-intensive medical services and those who are subjected to the extractive work and adverse social effects of these biomedical operations.

This chapter scrutinizes the U.S. health care system’s entrepreneurial specialty services and medical development complex. This complex features medical centers and hospital networks involved in property-driven development that now seek to establish global clinical research, elite hospitality services, and transnational franchising. The promise of medical technology and expertise enlisted by these globalizing U.S. hospitals conveys a message of deep concern for public health while also supporting the quest for new sources of income and subjects that heed the call for an educative “common good” invested in American training and technology. Their campuses play an important role in the U.S. global health landscape as medical entrepôts of clinical care, research, policy, medical education, and health partnerships. Bolstered by international free trade agreements, these medical centers accumulate capital through parasitical relations with other national health systems. Their competition has ballooned costs and further exposed medical professional ethics and philanthropic claims of civic benevolence to the global marketplace.4 Moreover, by adopting the technocratic discourse of sustainability with its emphasis on administrative, operational, and building-oriented efficiencies, this complex avers environmental responsibility wedded to a transnational development aesthetics of spectacle and luxury. Such efforts advance health colonialism by favoring deregulation, privatization, public sector austerity, and the market-based conversion of user/patient into client/consumer as the means to secure medical quality and health rights. In this geopolitical-economic context, the increased policy emphasis on sustainability in American health care (and global health more generally) compounds the transnational stratification of health; it promotes a technocratic fix in lieu of structural challenges to the political economy of medical services and clinical practices that moors a global medical entrepôt to a domestic medical brownfield within the U.S. empire.

The roots of the modern academic medical center in the United States date back to late nineteenth-century urban development in cities like Baltimore, Boston, and New York City.5 During the Progressive era, medicine advocated clustering hospitals and medical schools into defined geographic areas. By the 1920s, hosting a medical center with a territorial concentration of services was considered an indispensable civic good. In addition to private donations and philanthropy, medical education received significant government benefits. Federal investment in biomedical research rose fifteenfold, from $87 million in 1947 to $2.05 billion by 1966.6 As discussed previously, the U.S. federal government offered extensive subsidies to defray indirect costs, such as utilities and mortgage payments, which allowed medical schools to grow without putting much of their own capital at risk. Hospitals also derived increasing amounts of revenue from patient care; employer-based health insurance and the passage of Medicare and Medicaid in 1965 guaranteed payment and thus substantially reduced the risk of nonpayment that had previously burdened hospitals during the Depression.7 With fewer stipulations than federal grant money, revenue from clinical services could be used to fund future service-line expansion projects in high-demand areas like emergency medical services, cardiac care, and oncology, which transformed hospitals into multimillion-dollar-a-year enterprises.8 According to historian Andrew T. Simpson, these successful not-for-profit hospitals were built using “a range of incentives including access to cheap capital through special bonds, public money to support the creation of the venture capital infrastructure needed to help these organizations diversify into lucrative noncore businesses, and built a regional and national narrative around the triumph of the knowledge economy.”9

The United States has generally valorized expensive technologies and drugs, as well as invasive procedures and intensive labor arrangements, “to save us when we are at our sickest rather than address nonmedical and public health approaches that prevent the onset of serious disease when we are at our healthiest.”10 Ramos explains that U.S. systemic emphasis on acute care and emergency services stems from decades of public policy in response to the 1960s uprisings—what he describes as the cannibalization of safety net health services. Since the 1980s especially, this has resulted in the “super acute” health system and state-of-the-art facilities for privately insured Americans, while the poor and uninsured are treated only through expensive emergency room visits. President Ronald Reagan slashed public health budgets while signing a federal mandate that prohibited hospitals from turning away citizens who need emergency services. Cities have thus prioritized resources for publicly funded emergency medical service systems while defunding public hospitals and health education projects, essentially redistributing public health resources to subsidize the build-out of cutting-edge, high-tech solutions that massively amplify costs while helping very little to support the general health of Americans, particularly the poor and uninsured who lack basic community resources.11 The escalating costs of this system are further intensified by the way large nonprofit general hospitals have strategically navigated it, especially their critical role in high-poverty cities. These hospitals often subsidize procedure costs and emergency care charity services with revenues from other procedures. For example, a hospital may bill more for the actual costs of heart surgery or diagnostic imaging in order to use the excess funds to compensate for operations that typically lose money, such as emergency services and charity care for the uninsured.12

Under the rationale of cost reduction in medical services, policy changes in the 1990s sought to create price rivalry by generalizing competition among state, social security, and private sectors and by supporting services attractive to managed care plans. In insurance markets, managed care replaced traditional, free-choice-of-provider indemnity coverage. Whereas indemnity plans retrospectively paid provider-set charges or costs for physical-ordered services from nearly any provider, managed care plans instead used selective contracting to negotiate price and other terms of service in advance.13 Medicare began implementing prospective payments, namely preset reimbursements for services related to diagnosis or procedure for inpatient services. Through selective contracting, managed care plans (in place of individual physicians or patients) negotiated preferable hospital prices. With services and amenities primarily viewed as cost centers, hospitals competed on price by providing services desired by these managed care plans, which were contracting on behalf of large numbers of enrollees and via limited individual subscriber choice.14 In this provider market, price discounting began to dominate professional and nonprofit determinations of prices and resource allocation in order to compete for health care business and acceptance of fee-for-service Medicare and Medicaid payment limits. By the late 1990s, for-profit managed care organizations entered the public sector to generate profits by keeping costs, especially to pay for services to patients, as low as possible while reaping prepayments funded by public systems. By shifting from national to multinational dimensions, corporations would also export this dominant form of U.S. health care organization to other countries, circumventing national laws to install for-profit investor ownership with prepayment services and other financial rewards from international market extension.15

As buyers’ demand for less expensive health coverage legitimized and stimulated these market changes, the ostensibly good effects of moving away from free-choice-of-provider indemnity coverage to a managed care structure of risk contracting were attenuated by the negative impacts on access to care for low-income populations. Markets for health care financing and delivery in general affect the extent of enrollment in health coverage, as well as access and quality of care under Medicaid coverage of the uninsured poor, especially charity care provided by hospitals. Competitive price pressures exerted on hospitals prompted hospital budget cutting, along with downsizing, ownership conversion, and consolidation into larger provider entities. Two for-profit chains—Columbia/HCA and Tenet Healthcare—led the charge in consolidating the industry, including purchasing and closing facilities to reduce duplication and excess capacity. Nonprofit systems, such as Adventist Health and Ascension, have also grown and have acquired other hospitals. With doctors, hospitals, insurers, and health plans all functioning as sellers of services that compete on price, quality, and amenities, the U.S. health care system no longer supports independent unaffiliated hospitals and instead favors the amassing of large hospital networks. Moreover, state policies encouraging competition and slashing health care costs have created a “survival of the fittest” model that has caused institutional hardship where competition has been keenest: in the inner cities and metro regions, where urban hospitals bear much of the burden of providing care for the uninsured by virtue of their location and accessibility to large numbers of uninsured patients.16

The cost-control imperatives heralded by market-oriented health care reforms have exacerbated conditions of medical scarcity and austerity in urban centers. By using broad discretion over coverage and reimbursement, states have undermined city health care sectors by slashing the number of patients receiving state subsidies and generating more uninsured customers for urban hospitals, cutting reimbursement rates that hospitals receive per patient, and fostering competition between city and suburbs.17 U.S. health care policy has supported a mode of health care delivery dominated by for-profit managed care companies—and nonprofit systems that operate similarly—undermining the preventive care and quality control that managed care reform in the United States had purportedly valued.18 Instead of improving conditions for the poor, market-oriented reforms have deteriorated the public sector safety net, as was made tragically clear when numerous hospitals that pivoted to treat the onslaught of Covid-19 failed because of the dramatic decrease in expensive voluntary procedures at a time of unprecedented need for pandemic-related medical care.19 Hospital and physician strategies over the last decades have evolved this survival-of-the-fittest model into what some health care commentators call a “medical arms race” among entrepreneurial-oriented medical centers that operate as revenue generators rather than merely as cost centers.20 Teaching hospitals, for example, have turned to the measure of the marketplace as a dominant standard of value, with the market playing as crucial a role as professional ethics and service.21 Some of these academic and large nonprofit hospitals have accrued considerable market power by buying up hospitals to establish regional multisite networks and by building expansive urban biomedical complexes, research facilities, physician offices, and even long-term residential care facilities. This has been fueled by the rise of specialty medicine and the proliferation of specialty services. Faced with growing competition for patients, hospitals have in recent decades returned to fee-for-service payments and have adopted strategies dedicated to increasing the flow and filling beds with well-insured patients—a health sector trend that has increased costs and reinforced vertical schemes focused on specific treatments and diseases rather than universal health coverage and attention to the social and economic dynamics that influence health outcomes.22

The ensuing cost-inflating competition partly stems from Reagan-era policy opposition to place-based regulations on medical specialties, such as state-based certificates of need. Such regulations aimed to reduce the duplication of services by requiring health care providers to obtain state approval before offering new or expanded services. However, many states have allowed a proliferation of specialty hospitals and ambulatory care centers that focus exclusively on high-revenue procedures such as cardiac, orthopedic, and outpatient surgery. Such deregulation undermines the place-based welfare function of nonprofit hospitals, instead supporting speculative demand-driven competitive endeavors that purportedly bestow local benefits. Further, this enlarged field of specialty service competition undercuts efforts by individual hospitals to subsidize charity care with high-paying specialty services. By the early 2000s, hospitals were developing and marketing discrete and profitable specialty service lines and engaging in “nonprice competition”—namely retail-oriented, quality dimensions of care and amenities targeted at consumers directly and at physicians who refer patients.23 This strategy has sought to expand revenue and margins by raising inpatient specialty service volume and adding outpatient centers that can generate additional diagnostic testing and inpatient care.24 An entrepreneurial specialty services and outpatient complex increasingly untethered from charity care and subsidies for emergency response thus dominates American health care provision, escalating already inequitable access to care. Hospitals continue to add centers for ambulatory surgery, diagnostic testing, and treatment, extending outpatient locations across ever-wider geographic areas in order to increase market presence and referral volume. Teaching hospitals in particular create niche services to attract patients with specific diagnoses to their facilities, aggressively marketing self-designated “centers of excellence” to claim market leadership and establish brand loyalty to attract more patients to their highest-paying services.25

Hospitals and physicians are organizing and promoting unique services that are based on specific diseases, organ systems, and populations—heart institutes, orthopedic hospitals, women’s clinics, children’s services, surgery centers, stroke centers, mental disease specialty clinics, and so forth. Some of these are centers within a general hospital and include physician specialists; others are freestanding specialty clinics and outpatient facility joint ventures between hospitals and physicians. An increasing number of physician-owned ambulatory specialty facilities also aims to attract consumers who seek more choice of care. Specialty service-line organization in the outpatient sector reflects the long-standing specialization of physicians. Now joining ambulatory surgery centers are a myriad of facilities dedicated to diagnostic imaging, sleep disorders, cosmetic surgery, radiotherapy, cancer chemotherapy, peripheral vascular disease, gastrointestinal endoscopy, coronary care units, and so on. The extent to which service-line development actually reorganizes care varies; it could comprise completely separate profit centers and freestanding units that support the rest of a hospital, or it could comprise purely marketing exercises that rebrand and administer special service lines within general hospitals.26

These niche centers and their associated physicians have escalated competition over control of specialty services, siphoning off the most lucrative patients and procedures. Less profitable services are then relegated to general medical hospitals, who subsequently experience decreased revenues even as they must find ways to subsidize the provision of uncompensated care.27 Single-specialty clinics that focus on fewer profitable services may be able to “provide many amenities and take market share away from community hospitals struggling to provide and cross-subsidize a wide range of general services.”28 Supporters of specialty hospitals and clinics assert that increased choices available to health care purchasers will result in a rise in the total amount of health care available to the population; inequalities exacerbated by these facilities are permissible under the proviso of increasing competition to improve quality of care and lower costs.29 However, health care markets serve those who can afford to purchase services and erode the cross-subsidies that have financed access to care in the United States. Large elite nonprofit general hospitals have responded to service-line competition by recouping revenue losses from out-migrated services and uncompensated care by raising prices and volumes of specialty-line services as well as locking in specialist physician admissions to induce demand for services.30 Academic medical centers—forced to compete with often more efficient private hospitals and specialty clinics—have assiduously courted patients from overseas in order to improve their financial edge because the care of overseas patients is not subject to Medicare and Medicaid restrictions or insurance reimbursement requirements. “Super hospitals” seek to extend their international clientele and form alliances with civic-oriented and business organizations to support the needs of patients traveling overseas and to create different “catchment areas” that target specific populations, in some cases reaching global dimensions.31

American hospitals offer a unique blend of medical research and innovative clinical techniques. Building on international awareness of U.S. medical expertise, an array of hospitals now market luxury primary care clinics to recruit wealthy foreign patients, including Massachusetts General Hospital, New York Presbyterian, the University of Miami, and the University of California, San Francisco. Hospitals branch out to offer hospitality services and joint ventures, enlisting spectacular architecture and exclusive amenities. Given that the overall structure of the U.S. health care system favors corporations and high-technology products and services, the pursuit of global architectural boosterism and technologic innovation by these medical institutions requires dramatic capital expenditures that help drive up the overall cost of health care worldwide.32 The strategy also promotes an ideology of demand-driven consumer health satisfaction and the opportunity to opt for the best, most exclusive care tied to the latest medical technologies and services as a way to ensure quality. Executive health programs at leading hospitals, for example, organize corporate packages of health physicals that function like visits to a spa. Nearly three thousand individuals visit the Mayo Clinic each year for a two- or three-day itinerary of customized and comprehensive services at multiple global locations. In addition to cardiovascular counseling, lifestyle assessment, and in-depth, one-on-one review by a personal executive health physician, patients have access to amenities ranging from business lounges to Botox.

To reach international patients, hospitals have developed international hospitality organizations that secure referrals and generate revenue to subsidize hospital teaching and research programs.33 The Cleveland Clinic’s main campus, for instance, showcases a posh international center with interpreter services and foreign newspapers, special diets, convenient transportation, insurance assistance, and infrastructure dedicated to obtaining preadmission overseas records. The clinic also owns several hotels managed by the Cleveland Clinic InterContinental Hotel Group, which advertises internationally and attracts patients via airline magazines, hospital exchange programs, embassy contacts, corporate agreements, and listings in international medical directories. Hospitals sign cooperative agreements to collaborate on patient referrals, physician visits, medical education, and administrative training. They also initiate separate start-up companies or special international service centers that adapt procedures and workflows to assist international clients. The International Program at Johns Hopkins Hospital successfully ballooned the international patient population from five hundred before 1994 to more than seven thousand by 1998, and Johns Hopkins Medicine International—a for-profit venture jointly owned by JHU and Johns Hopkins Medicine—forms strategic overseas partnerships that facilitate medical tourism.34 Additionally, hospital links to embassies and medical travel intermediaries—for example, Companion Global Healthcare and International Patient Services—curate a prequalified selection of hospitals and advise on care options, set up appointments in U.S. hospitals, and essentially operate as specialized travel agents.35

A focus on user experience and architectural spectacle tied to wellness pervades these efforts to attract international clientele and patients able to afford specialty services. As the top-ranked and largest private medical center in the United States, the Mayo Medical Center’s main campus in Rochester, Minnesota, features the acclaimed Leslie and Susan Gonda Building, designed by Ellerbe Becket and Cesar Pelli & Associates. Constructed in 2000–2001, the Gonda building’s northern section incorporates a flowing curtain wall system with granite spandrel and column panels. A seven-story skyway connects the north side of the building to another Mayo building across the street, while a stone-clad elevator lifts people up the building’s twenty-one floors—soon to be expanded by an additional eleven floors.36 With a marble-sheathed lobby overlooking a sunken garden, the building is also fused to another Ellerbe creation, the Mayo Building (1954), trimmed with rose-tinted windows and a marble exterior.37 The Mayo campus and Rochester’s outer districts contain numerous other architectural trophies from Franklin Ellerbe, Frank Lloyd Wright, and Eero Saarinen, revealing long-standing efforts to foster monumental therapeutic design attractions.38

Specialty clinics like the Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas, Nevada, enlist architectural boosterism to challenge the clinical atmosphere altogether, supporting specialized research and care through spectacular fundraising events. Opened in 2010 in the sixty-one-acre Symphony Park, the outpatient treatment center for Alzheimer disease, Parkinson disease, Huntington disease, multiple sclerosis, and ALS was designed by architect Frank Gehry and comprises two buildings joined by a steel trellis shading an outdoor patio. Costing $80–100 million, the approximately 65,000-square-foot complex is draped with mountainous metal-clad skin, faced with shingled panels, and punctured by a grid of different-size windows.39 The metal wrapper forms a freestanding structure that envelops a soaring sculptural volume with a cathedral-like event space: the Life Activity Center. Patients follow a breezeway to the entrance of the separate four-story medical building of jumbled boxy forms in white stucco and glass that houses exam rooms, offices, research center, and the nonprofit Keep Memory Alive headquarters.40 Boasting 65,000 hours of engineering, with 199 windows (none alike) and 18,000 stainless steel shingles (each cut to unique measurements), the building projects an image of its own exorbitant cost in a bid to draw patients and raise further funds.41

Joint ventures and global medical hubs extend elite U.S. hospital operations and clinical practices into global trade circuits, with locations and architecture that network medical expertise and prestige for elite medical tourism and trade. Over three dozen U.S. hospitals and health systems now operate overseas. Alliances vary from medical school exchanges to transnational jointly managed clinics. For example, Harvard Medical International works with Wockhardt Hospitals Group in India; the Children’s Hospital of Philadelphia coordinates with the United Arab Emirates (UAE) and Massachusetts General Hospital with Jiahui Health, a private system in Shanghai; and Miami Beach’s Mount Sinai Medical Center has partnered with hospitals in Guatemala and the Dominican Republic.42 Beyond consulting with foreign companies, these partnerships can involve directly investing in a foreign hospital facility via full or partial ownership, or establishing a management contract for all or some hospital functions without ownership interest.43 In some cases, prestigious American universities or health care systems open branches where they are directly responsible for providing care and linking activities of medical research, education, business, and clinical treatment in a centralized medical hub. A missionary ideology of advancing research and education internationally, as well as improving clinical services and quality, pervades these competing medical spheres of influence. The developmentalist drive to set new global standards and “give back to the world” articulates with efforts to elevate one’s brand and international profile, commercialize intellectual property, and network lab services, analytics, protocols, and virtual products. The transnational operations of U.S. hospital systems extend Western biomedical concepts of health and competition while seeking international talent, treatments, research, technologies, and pharmaceuticals in order to boost revenue.44 Even as they index the historical vestiges of Western colonial legacies, these medical entrepôts reconfigure center–periphery relations by performing globality in branded networks within the political economy of empire and international public health.45

The over $14 billion University of Pittsburgh Medical Center (UPMC) exemplifies the international orientation and competitive market for specialty clinic outposts. UPMC International has aggressively established multiple cancer treatment centers in the United States, Ireland, and Italy.46 In Italy, UPMC formed a joint public–private partnership with the region of Sicily and local hospitals to establish a leading European transplantation center, where they perform thousands of transplantations, clinical therapies, and treatment alternatives since its establishment in 1997.47 The Palermo-based partnership further established the Cell Factory—laboratories that produce cells to treat end-stage organ failure.48 UPMC also bought a stake in the Chianciano Spa in Tuscany to offer personalized diagnostic screenings and procedures, a medical wellness center, and healthy lifestyle programs in connection to the spa’s thermal water therapies.49 In Ireland, UPMC took over the operations of the largest private hospital in the southeast of the country and expanded UPMC Sports Medicine to its first overseas clinic location in Waterford to treat athletes and active people. In 2019, UPMC Kildare Hospital entered a partnership with the largest ophthalmology service in Ireland—the Institute of Eye Surgery—to create a national Ophthalmology Network of Excellence that features the cutting-edge research and clinical trials of world-renowned UPMC-based Dr. José-Alain Sahel to prevent and cure blindness.50 That same year, UPMC signed an agreement with the China-based multinational conglomerate Wanda Group—one of the world’s largest real estate, film, children’s entertainment, sports, and tourism companies—to jointly build and operate multiple hospitals in China, with UPMC providing expertise in hospital design, procedures, and management best practices.51 In a strategic entrance into Eurasia, UPMC also works with Nazarbayev University to establish Kazakhstan’s first fully integrated academic medical center, upgrading the teaching hospital and anticipating greater profit margins than U.S. hospitals.52

The academic medical teaching and research arm of JHU, the Johns Hopkins School of Medicine, has joined hands with big oil by inaugurating a joint project with the energy and integrated global petrochemicals company Saudi Aramco. Collaborating in 2013 to create the first-of-its-kind health care joint venture, Johns Hopkins Aramco Healthcare serves Aramco employees and their descendants and retirees, who all receive care free of charge. In addition to owning equity in the joint venture, Johns Hopkins provides education, training, and clinical programming; operations management and support; and direct clinical care by rotating Johns Hopkins faculty in subspecialties. Patients are seen at Dhahran Health Center, a 330-bed tertiary care hospital, as well as other satellite outpatient facilities.53 The Dhahran primary care clinic specializes in cardiac surgery, cardiac rehabilitation, complex electrophysiology, palliative care, endovascular therapies, and noninvasive imaging; it also offers weight management and smoking cessation programs.54 The facility features an automated pharmacy, a children’s play area, a sanctuary garden, and the new patient-centered Suite Six, which places the patient at the center of care: medical services largely take place in one room with a care team, a desirable alternative to making patients navigate the complex institution.55 The website and promotional materials, which are central to marketing Johns Hopkins Aramco Healthcare, plot a timeline of innovative medical practices that parallel drilling operations in Saudi Arabia, starting with a single doctor in 1936 and establishing the need for a hospital and pharmacy to address employees’ medical needs attendant to refinery establishment. The narrative progresses with Aramco’s accreditation success and placement of Saudi students in top U.S. medical schools, including Harvard, Tulane, and the University of Alabama, and peaks with the 2013 partnership that boasts the only health system outside of the United States that officially bears the Johns Hopkins name.56

Similarly, the largest health care network in the UAE, Abu Dhabi Health Services Company (SEHA), has partnered with the Mayo Clinic on the joint operation of one of the UAE’s largest hospitals for patients with complex medical conditions, now known as Mayo Clinic Sheikh Shakhbout Medical City.57 With collaborative ventures on seven continents, the Mayo Clinic entered the Middle East as a shareholder in the new operating company, thus marking a new type of international health care relationship in the UAE with the company/SEHA that owns and operates all of the public hospitals and clinics in the emirate of Abu Dhabi.58 After the 2019 development agreement, the 3.2 million square foot, multispecialty, state-of-the-art hospital will be staffed with more than four hundred internationally trained physicians and will invest in medical technology to promote advanced diagnostics, specialized procedures for arteries and burns, and less invasive techniques, all complemented by a new medical research center designed to promote comprehensive interdisciplinary learning.59 The $817 million facility features four towers with patient rooms, each of which offers views of the campus and access to rooftop gardens; in addition, designated floors offer enhanced privacy, with two presidential suites and thirty-six VIP suites.60 Mayo Clinic International roots the project in the legacy of its founders—Will and Charlie Mayo—who traveled the globe and established Mayo’s legacy as an international organization that “learns from others and shares knowledge and expertise to benefit patients.”61 Mayo Clinic faculty will now supervise the clinical training of Gulf Medical University students at the medical complex in order to strengthen medical education, professional development, and clinical research.62

The Cleveland Clinic has taken further steps to open its own independent medical hubs in other countries, prominently using its name on buildings, signs, and lab coats. Joining Cleveland Clinic Canada in downtown Toronto (2006), Cleveland Clinic London began welcoming patients in March 2022. Located across the street from Buckingham Palace, the clinic operates without a local partner and offers elective surgeries for the privately insured. Emergency services are not planned, as they are not required, nor considered to be financially lucrative. Before the venture, in 2015, the Cleveland Clinic developed the multispecialty Cleveland Clinic Abu Dhabi in the heart of the UAE city’s new central business district on Al Maryah Island. Collaboratively planned with the government-owned Mubadala Development company, the twenty-three-acre facility extends the U.S.-based Cleveland Clinic’s model of care to 364 beds (expandable to 490 beds), five clinical floors, three diagnostic and treatment levels, and thirteen floors of critical and acute care inpatient units.63 The clinic and each of its specialized care areas were designed with the input of more than three hundred physicians and clinical personnel, as well as hundreds of architects, planners, and interior designers.64 The clinic, which cost approximately $2.5 billion, holds the title of the largest structural steel building in the UAE and has received accolades for blurring the line between hospital and luxury hotel. The facility displays distinctive diamond glazing and a glowing double-skinned patient tower; sleek glass walkways connect inpatient spaces with a 340-exam-room outpatient clinic, 210 faculty offices, conference center, simulation center, and administration building. Clad in perforated and corrugated metal skin, the highly textured surface of the complex’s podium refracts sunlight and is capped by a flowing glass structure that illuminates the metal base at night with LEDs that create a moiré effect.65 Patients enter a lobby wrapped in marble, stone, and wood, with modern interiors, verdant gardens, and expansive common spaces, including an upscale retail gallery overlooking the city. The color palette riffs on the surrounding natural elements: glass echoes the radiant turquoise of the gulf’s waters, while onyx and an array of neutral tones reference the arid landscape. Interior patterns and motifs invest in a burgeoning vernacular of arabesque patterned screen elements; indoor water features provide white noise to calm patients.66 Patient rooms are intentionally designed with large family spaces and abundant windows with views of lush rooftop gardens and the Arabian Sea. The exclusive hospital features private suites for VIPs and a floor reserved for the royal family, with a secure entry, private elevator access, and private quarters for the patient’s doctors. Its opening drew more than five thousand physicians from around the world to apply for the initial 175 doctor positions in the hospital, with 80 percent of the successful applicants trained in the United States and the rest in Europe.67

While such transnational branches and joint ventures may facilitate international education, cross-cultural understanding, and a global medical commons, they also extract considerable resources, and their role as a domestic welfare and development strategy is debatable. International revenues can improve health care standards and reinvest in local economies and cities. However, these profits remain a small portion of institutional portfolios and do not curb costs.68 Furthermore, this burgeoning network of medical entrepôts of American health care depends on domestic extraction, burdening public resources and thriving on land grabs and real estate developments. Rather than addressing structural issues that limit health care access and coverage, U.S. policy has focused more on creating transnational brand extension and management arrangements, global networks of accredited health care providers, and cross-border insurance mechanisms to support overseas treatment.69 U.S. for-profit entities and nonprofits that function like for-profits—hospital systems, health maintenance organizations, and pharmaceutical and biotechnology companies—extend internationally to find new revenue streams, address labor shortages, and cut costs. They increasingly outsource business functions, found technology transfer offices, establish start-ups and incubators, and become entrepreneurial exporters of management consulting, real estate, and other practices perceived to fuel innovation. The increasing amount of for-profit care options creates a predatory business climate: for-profit success depends on betting against public systems in other countries and banking on private alternatives to taxpayer-funded health systems.

This incursion of market-driven foreign private health services challenges the territorial governance of health care. Governments partly derive their political legitimacy from ensuring the welfare of their national populations; indeed, “entitlement to receive health care and responsibility to financially contribute to the health system that provides such care, therefore, are frequently considered part of a broader package of national membership.”70 However, the penetration of private enterprises into national health sectors eliminates the prioritization of domestic providers. In the United States, the strategy of using international for-profit operations to subsidize local development and research/teaching missions perversely poaches patients from national health care systems overseas while doing nothing for the approximately 27.5 million of the population without health insurance.71 The globalization of American health care has privileged profit over health coverage. Where U.S. hospitals open overseas hubs, they support international patient prospecting and global circuits of trade in hospitality services that inflate costs, compound climate change, and further divide elites from the poor. There is nothing inherently wrong with many of the special health services examined here; wellness and nutrition programs, for example, focus on everyday health and environmental awareness. However, the political-economic positioning of such services reveals the massive discrepancies of health attendant to this transnational U.S. medical development complex. Elite hospital systems offer specialty private care through increasingly ambiguous governance; they engage in predatory relations with overseas national health care systems while outperforming large U.S. urban hospitals, which are left to subsidize uncompensated care through specialty services that can no longer compete financially. Telemedicine adds further levels of complexity to governing such transnational practices—especially their environmental impact and relationship to place-based labor.

The detrimental consequences of neoliberal global trade agreements and the resource-intensive domestic operations of U.S. hospitals should raise alarm over the environmental governance of this burgeoning transnational medical development complex. In response to the damaging environmental effects, myriad organizations have emerged to “green” U.S. health care and advocate regulatory and social responsibility–based actions. These efforts have targeted hospitals for emissions reductions as a means to decrease the 6.7 to 7 million annual fatalities and countless other health problems estimated to result from poor ambient air quality worldwide. Reducing emissions also seeks to lower the mounting 34,000 annual cancer cases in the United States attributable to occupational and environmental exposures.72 Other initiatives seek healthy, locally sourced food in hospital cafeterias and food service; sustainable local furniture, bedding, and supplies; and safer alternatives for pest management, cleaning, disinfection, mercury elimination, and hazardous waste removal. While there are clear benefits to this sustainability drive, we also see the treatment of the environment as a mere staging ground for operational cost-effectiveness and design efficiencies, rather than addressing the globalizing health care system’s active role in perpetuating environmental inequality, thus reinforcing the specialized vertical structure of ineffective health systems while failing to improve access to care. Sustainability in health care is not equated with public socialized health but instead with technical enhancements to the highly inequitable profit-oriented acute care and privatized insurance, or with reducing “government waste” by lowering public funding and implementing further medical “deservingness” qualifications in Medicare and especially Medicaid.

Environmental greening initiatives at the global scale mirror the language used in U.S. brownfield land conversions. Both impose a certain model of health justified in terms of improvement—bettering a contaminated land parcel or resource-intensive building, or tapping into an untouched market. Yet as previously discussed, hospital systems themselves contribute to blight and intentionally expand into environmentally vulnerable places; they exacerbate the environmental health hazards and risks experienced by populations in these places, especially via their interactions with labor and service lines that support elites. The transnational hospitality and service extensions of U.S. hospitals and medical centers financially depend on the colonial operations of these domestic medical brownfields to underwrite their overseas branches and enlist sustainability indicators to buttress their competitive growth. Thus, however ostensibly “good” these sustainability measures appear, they also greenwash systemic issues of structural inequality, violence, land dispossession, and public sector predation.

Cleveland Clinic Abu Dhabi emblematizes the contradictory implementation of sustainability in the context of proliferating specialty clinics, executive health programs, and joint ventures that extend patient catchment areas and stoke a globalizing medical arms race. The clinic seeks to green its development aesthetics to the extent that international accounting for adverse impacts on climate has become a new “zero-waste” frontier. Even as the high-end hospital demands intense resources—which run the gamut from masses of concrete and steel in its construction to energy-intensive HVAC systems and medical waste streams—the facility was awarded a Gold sustainability certificate for new construction by the most widely used green building rating system: Leadership in Energy and Environmental Design, better known as LEED. It became one of the first hospitals in the Middle East and North Africa region to use a greenhouse gas tool to log all of its greenhouse gas emissions. It has implemented countless waste elimination measures, including reducing reliance on desalination plants, using solar water heaters, and converting food waste into compost for the hospital’s gardens.73 Yet it has focused exclusively on building efficiencies in a closed ecology; it has created a profitable loop of the hospital’s waste and wastefulness, ignoring the complex material geographies upstream and downstream of the facility and the inequities fueled by its billion-dollar existence. The political economic positioning of the Cleveland Clinic system and its extensions into global circuits of capital and medical tourism, combined with the adverse environmental racism of its domestic operations, contribute to vastly inequitable territorial stratification of health and disease burden. The absurdity of its greening initiatives in the context of austerity, home foreclosures, and Covid devastation at its U.S. home base of Cleveland further underscores how ameliorating the emissions of medical hospitality services and clinical practices at the Abu Dhabi campus decenters care and politics by dividing biomedical and technological practices from socioecological issues.

Under the sign of sustainability, “green” functions as a settler-colonial ideology that allows for the technocratic disavowal of the health care system’s harmful impacts. While claiming benefits trickle down, medical joint ventures and global hubs extend the domestically extractive processes of U.S. hospitals transnationally, further dividing the medical haves from the have-nots, thus advancing health colonialism. The colonial relations of development that underpin U.S. medical outposts globalize profit-oriented private acute care and perpetuate tautologies of racial violence along a global color line.74 The moralizing discourse of medical progress and educational mission—coupled with architectural spectacles of sustainability—severs the fundamental tenet of health care practice, do no harm, from considerations of the active role of the U.S. health care system in socioenvironmental and political-economic violence. As such, it is imperative to weigh the harm of policies that rely on determinations of blight and their anchoring of transnational speculative development projects that further intensify health, environmental, and geopolitical inequalities.