Conclusion: Decolonizing Health

The Covid-19 pandemic exposed vulnerabilities and failures endemic to U.S. health care. It dramatically revealed the system’s unsustainability when revenue-generating elective procedures were halted to meet the demand for ICU beds and other necessary equipment, leading to hospital and clinic closures when they were needed most.1 The promise of future returns and trickle-down benefits collapsed as the immediate emergency suspended the costly elective procedures that subsidize welfare. The United States has the lowest return on life expectancy for health care expenditure, with individuals receiving low-quality care compared to other high-income countries.2 Many Americans cannot afford private health coverage or cannot meet the eligibility requirements of public health programs, so they cannot access quality health care, health insurance, or positive health outcomes. Nor is quality care guaranteed or evenly distributed for the insured. Such fissures in health and access to health care existed long before the pandemic and have been devastatingly intensified by it, as seen in the relentless numbers of deaths reflected on Covid dashboards.

Chapter 3 touched on technocratic efforts to “green” health care that decenter the politics of care and further divide biomedical and socioecological issues under the sign of sustainability. Technological fixes and spectacles of sustainability can eclipse the role of American health care in perpetuating power relations of debt, dependency, and medical inequality that sustain global health apartheid. This is especially true with respect to the extraction of health care labor. The term “green” is equated with renewable energy production, environmental management and conservation, and operational efficiencies that save on resources; it does not necessarily designate jobs that support and preserve health, well-being, culture, intergenerational equity, and the land and ecologies on which we rely.3 Health care sector green projects—including the laudable and necessary goal of reducing energy consumption and emissions—will perpetuate colonial relations with land and labor across a global color line if social transformation is not tied to energy transition. Decarbonization efforts should strive to decolonize biomedicine—and its underwriting of the property system, debt, and devaluation of care work—in favor of more equitable and collective provisioning for everyday good lives and good deaths.

Numerous initiatives at international aid organizations, universities, and schools of public health have advocated for decolonizing global health and addressing power inequities.4 This movement is not new, of course; the intellectual, political, and other labor of communities engaged in high-intensity struggle have developed these critiques as a matter of survival.5 Efforts to acknowledge and respond to these struggles within health fields have made it common practice to refer to what is termed “social determinants of health,” to mark the inequitable conditions of health. However, as Ruha Benjamin, Kim Gallon, and other Black feminist scholars and data ethicists have argued, reliance on quantitative approaches to substantiate the social contexts of health can lead to the datafication of disease, illness, injury, and death—and not necessarily any social change. Exemplifying this, pandemic representations of health demographics have had the effect of reifying nonwhite race as marked for death.6 Racist tautologies wedded to a technocratic worldview are a form of ongoing coloniality. Although colonialism is frequently named as a social determinant of health, colonization is not merely a variable or an isolated historical event. Rather, it is one of developing and unremitting unequal relationships with negative effects on health.7 Colonial processes continue to shape medicine and health care—their material and epistemological foundations, organization, and practices.

This book has pursued an analytic shift from colonialism as a social determinant of health to the active role of U.S. health care in colonialism. The critique is not intended to rebuke the sacrifices and intentions of health care workers across the professional spectrum. It apprehends the contributions and constitutive function of the U.S. health care industry and medical institutions in ongoing health colonialism—that is, sociospatial domination and exploitation, along with the ideological frameworks, logics, and mythologies that underpin this, to produce unequal life conditions, diminished livelihoods, and premature death. Health colonialism takes many forms: devaluation and repression of care work; infiltration of substandard for-profit care in BIPOC communities; and chronic underfunding, fragmentation, and privatization of local health care systems and public hospitals. I have examined health colonialism in terms of the structural violence of U.S. health care, specifically its property frontiers and pedagogies of urban redevelopment and educational mission. The analysis considers the ways that biomedicine colonizes space with health impacts, focusing on the land practices of several prestigious nonprofit hospitals and medical centers within a system that prioritizes profitability and specialized acute care over everyday collective forms of health. To denaturalize the land relations of these institutions, I foreground waste colonialism and the way articulations of waste and race entrench settler and anti-Black domination in order to underscore the noninnocent geographical foundations of U.S. biomedicine. I use the case of racial-capitalist brownfields to open up a broader view of land confiscation within the context of the U.S. settler-colonial property frontier: not only is pollution used as a technique to dispossess, but also the adaptable colonial logic of wasteland extends to the land pedagogies of blight and public use to position inhabitants as lacking “the liberal capitalist insights and technological know-how to properly occupy a city.”8 U.S. health care institutions perpetrate white liberal property violence via the colonial occupation and pollution of land that displace communities and strip assets from domestic development zones.

When we place brick-and-mortar hospitals within the everyday political economy of real estate development practices, we see extensive divisions among these key health care institutions and the way that some engage in spatial and fiscal eminent domain through land dispossession, clearance, and gentrification. U.S. urban policies have driven hospitals toward property-oriented growth as part of racially oppressive public-policy responses to urban unrest. In turn, U.S. health policies have supported a model of private health care strongholds with emergency services and police forces in the context of general medical scarcity for poor and uninsured people. The property-based orientation of these imbricated policies mobilizes an elastic frontier of urban blight and colonial land grabs in the name of revitalization, sustainability, community development, and education. Pro-growth, pro-development urban anchor policies have secured massive biomedical complexes that actively create blight at the same time that they are hailed as the remedy to urban economic decline. Their operations direct the fiscal futures of their host cities to underwriting medical tourism and franchising overseas facilities and hospitality services. As such, it is imperative to weigh the spatially and fiscally predatory operations and effects of Eds and Meds development projects. Even policies such as healthfields, which hold the promise of local land governance and health access, also tether waste management and environmental benefits to the efficient turnover of land for property value growth, which can lead to land use deracination and community displacement on top of inadequate cleanups that are obscured from public oversight.

Projects that rely on determinations of blight not only potentially exacerbate the problems they claim to remedy and/or harm neighborhoods; such a domestic colonialism also anchors transnational speculative development projects and medical investment frontiers that further intensify global health stratification. Clearly a transnational approach is needed to address U.S. health inequities as well as the territorial, socioenvironmental organization of medical services and clinical practices. From a methodological stance, this involves positioning the typically national framework of public health within the political economy of global health and various legacies of empire and domination; it also involves considering the relations of health stratification across scales, be they local, regional, national, or global. The approach requires demythologizing the educational nonprofit mission of U.S. academic hospitals and confronting the violent tautologies of hospital land use that maintain the property frontier and perpetuate vast asymmetries. Because North American racial formations are connected to global racial projects, land policies and development practices of American hospitals succeed in accumulating capital: they drain public resources from national health systems to advance global medical markets while providing nominal emergency care within the United States’ minimal social safety net. This entrenches a global color line connecting domestic blight to medical tourism, tethering medical brownfields to global medical entrepôts. While claiming that benefits will trickle down, medical joint ventures extend the domestically extractive processes of U.S. hospitals transnationally, further dividing the medical haves from the have-nots in terms of the structural violence of interrelated forms of harm to embodied health. Yet the moralizing discourse of medical progress and educational mission thwarts consideration of the active role of the U.S. health care system in despoiling the conditions necessary for the right to health.

What would the U.S. health system look like if it were based on “nonkilling” rather than the wasting and devaluation of certain groups?9 How might Western medicine’s ethical imperative to do no harm better address the forms of health colonialism I have examined here? How might consideration of the role of health care in making and maintaining health inequities be tied to the pursuit of their unmaking through policy and practice?10 First, rethinking liberal definitions of harm offers an important starting point, one that shifts focus from individual responsibility to broader social-structural relationships. Further, instead of diagnosing harm as the unfortunate failure or disruption of the universal benefits of U.S. medicine, we might instead heed the way harm maintains the health system and how medical institutions have been complicit in historical and ongoing social and ecological violence. This speculative turn would highlight the harmful promises that underpin global health’s claims to universalism. Extending the supposedly universal benefits of global health to more people does not uproot what Kim TallBear calls the “deadly hierarchies of life” that are the existing system’s foundation.11 Within the political economy of health and empire, the fulfillment of modern promises continues to rely on and reproduce divisions of humanity—positioned outside of the realm of ethical obligation and political rights—that are exploitable for the sake of “progress.”12 We see this in the stark accounts of social determinants of health that frequently and falsely attribute violence to the people who are subjected to it, the result of being impoverished, displaced, or disposed by intersecting settler-colonial racial-capitalist frontiers and administrative systems of rule.13

Second, in order to unlearn violent ideologies, desires, and infrastructures and relearn different ways of being together in the world, inquiries about health and care should also strive to decenter liberal ideas about public goods, civic benefits, and public lands and use.14 Public health draws on notions of the public good to make political and ethical demands; indeed, advocates contend that health is a public good. Yet efforts to reclaim advantages and assurances against privatization—to resist neoliberal accumulation premised on the privatization of what was once deemed public—all too often engage in “colonial unknowing” by failing to address the ongoing violence of what is considered civics, public use, the commons, or blight improvement. Following Stein, “it is necessary to ask not only who is the ‘public,’ and who has the power to decide what is ‘good,’ but also, who bears the costs of achieving this ‘good’?”15 Constantly referring to public health or global health as doing good similarly forecloses conversations about structural violence related to the political economy of philanthrocapitalism and the colonizing logic of a global medical commons defined by Western biomedicine.16 It is challenging and controversial to suspend default assumptions about medical institutions doing good, especially in the face of teleological reverence for technological progress and medical advancements in saving lives. I have sought to disrupt liberal nostalgia for public goods and civic moralism by denaturalizing accumulation, white property, and divisions of humanity that undergird U.S. health care regardless of public/private or profit/nonprofit distinctions.

Third, reconceiving global health as an ongoing commitment and process means questioning liberalism’s “implicit horizons of justice, hope, futurity, and change.”17 Challenging U.S. health care entails reckoning with the Western biomedical model and cultivating better understandings and practices of health without resorting to heroic liberal subjects and sacrifice. The liberal tradition entails social relations of property that desocialize medicine and that partition the body from ecology and embodied health from the environment and politics. The Western division between medical ethics and broader socioenvironmental ethics means that U.S. biomedicine and the health care system do not address their institutional effects as situated practices that actively influence health conditions. The disavowal of their role in urban political ecologies and property frontiers can justify confiscation of land, devaluation of labor, and uneven distribution of disease and illness, even as they conduct the work of saving lives and supporting wellness. Thus, it is imperative to elevate the ideal of “do no harm” beyond the notion of helping others. “Do no harm” must prioritize eliminating oppressive systems; rediscover roots in social medicine and collective health; and engage in forms of solidarity committed to social change as the only potentially therapeutic approach to many health problems, whether human, ecological, or planetary.18 Rather than reducing health services to hospitals or aid organizations, we would instead consider public health everywhere, thus galvanizing specific geographies of justice-oriented decolonial, ecological, and reparative efforts within and beyond biomedicine.19

While the adoption of antiracism as an explicit value in global health has led to important introspections on altruistic motivations, charity, aid, and wanting to do good, this work too easily accepts the status quo of deep economic injustices that have created power and resource imbalances.20 A fourth implication of this book is that any platform for raising global antiracist priorities in health policy—and growing health systems grounded in solidarity—must address the land practices of medical institutions and their role in intensifying the global color line within the context of medical investment frontiers that remain dependent on capitalist imperatives. Without this critical interrogation, this nonredistributive antiracism can serve as ideological cover for the expansion of U.S. medical brownfield frontiers at home and abroad, thus disguising humanitarian imperialism with developmentalist rhetoric and aesthetics, discrediting public institutions, subjugating care workers to further financial-administrative logics of extraction, and undermining the common sense of universal health coverage.21

As key players in urban economies, hospitals, such as the nonprofits I target for criticism, are a crucial sector within struggles for liberation and the politics of land. As Frantz Fanon has made clear, the most essential value of a colonized people is “first and foremost the land” because it “will bring them bread and, above all, dignity.”22 Using Fanon as an ecocritical muse, Stephanie Clare continues: “Dignity is not about ‘embodying a set of values.’ It has ‘nothing to do with human dignity.’ . . . The dignity of land . . . is the dignity of not being ‘arrested, beaten, and starved with impunity.’”23 It is the dignity of simply living and transforming land and livelihood, of refusing to constitute an “inert panorama” or backdrop within which colonizers live.24 For Fanon, “life” is the quality of being directed toward the future, activated by relations with land that support “breathing and bread.”25 Reorienting hospitals toward “breathing and bread” could entail things like shared governance with their surrounding communities; support for public low-cost medical education; divestment from the financial category of blight as the rationale for land seizure and tax-increment financing; and growing health care facilities as land rematriation trusts, limited equity cooperatives, and other ways of liberating territory to support “the life-sustaining and life-giving work of caring for the land and caring for each other.”26 Given the global justice dimensions of U.S. policy on health care, debt cancellation offers another crucial way to prioritize solidarity over profitability and everyday collective forms of health over empire, to “free up critical public fiscal space for countries to invest in their health and care infrastructure systems,” especially for countries hard hit by Covid and without critical resources to support health care during the pandemic.27 Policy attentive to the relations between climate change and the racialized, gendered transnational stratification of care labor could also strive to eradicate the occupational segregation that places women of color and other vulnerable migrant care workers internationally in such underpaid and devalued essential work, and implement pathways to citizenship. In cases where land is not explicitly the goal, strategies to subvert the practices and rationalities that reduce people to “human debris”—what Sylvia Wynter characterizes as the predicating of “liberal man” on demarcations of human difference—can catalyze spatial reorganizations of colonial geographies.28 As diverse anticolonial projects and positionalities are well aware, securing more control over the social and political mechanisms that organize human relationships, from political groups to education to care labor, involves rearranging race, property, land, waste, and/or space. My obligation to that work has been to arrange a critical geography of the property frontiers, civic moralism, and transnational development aesthetics of U.S. hospitals, and to invigorate abolition of the mounting global color line of medical apartheid by delineating medical brownfields as the base map of health colonialism.