Introduction

The uneven devastation of the Covid-19 pandemic shows how different life conditions shape health. From Covid data dashboards to virtual and physical memorials honoring the deceased, efforts to reckon with the pandemic—algorithmic and embodied alike—evince the disparate impacts of the disease. The phrase “social determinants of health” attempts to convey, soberly and irrefutably, that the environments and relationships wherein people are born and live affect health risks and outcomes.1 Vast inequalities among populations lead to different coronavirus susceptibility and survival rates. Within the health arena, scholars, practitioners, and policy makers advocate the framework of “structural violence” to heed the power relations that undergird such grossly divergent life chances. Simultaneous with the pandemic sweeping across the globe in 2020, calls to “decolonize health” repeatedly surfaced in hashtags, academic articles, and health organization public statements.2 Importantly, these critiques acknowledge the central role that medicine and medical institutions have historically played in colonialism: tropical medicine to protect colonizers and cordon sanitaires to secure borders; epidemiology and inoculations that buffer industry, trade, and military activity. The analytic scope, however, remains limited to institutional politics and the unbalanced partnerships between Global North and Global South. A biomedical framework that partitions medicine and technology from ecology, culture, politics, and economy dominates solutions and champions social responsibility. This obscures the ways that contemporary medicine advances colonial relations of health disparity.3

In response to these efforts and the pandemic, this volume foregrounds health colonialism. I position U.S. biomedicine as a colonial frontier and U.S. hospitals as settler-colonial institutions driven by extractive racial-capitalist logics that dominate space with health effects. I look at the political geographies of social determinants of health, specifically how property relations organize waste and race and entrench settler and anti-Black domination. I thus consider health colonialism in terms of land as property and as pedagogy (as blight, public use, etc.), and in doing so denaturalize liberal assumptions about health and the structural violence of U.S. health care. The arc of the analysis shows how land policies and development practices of American hospitals succeed in concentrating capital via parasitical relations with place locally and with other national health systems transnationally by providing expensive acute and emergency care within the United States’ minimal social safety net. This entrenches a global color line connecting domestic land grabs to elite medical hubs as interrelated forms of health colonialism. In other words, domestic health colonialism of urban centers serves as the material-extractive basis for globalizing U.S. biomedicine and health trade. It supports medical entrepôts that further divide the medical haves from the have-nots while claiming that the benefits of globalizing health services and trade will trickle down. Any challenges to mounting medical apartheid globally must question social relations of land/property and health as well as the globalization of U.S. biomedicine.

There is a dearth of attention to the land practices and territorial operations of U.S. hospitals. This is surprising, given that top-tier hospitals have been expanding their clinical practices in the form of massive inner-city health campuses and overseas hospital franchises. These development projects use enormous resources, land, and labor; receive tax breaks and other incentives in the name of charity and philanthropy; and seek to generate wealth and trade on brand-name expertise through domestic operations that rely on local assets. This volume attends to this lacuna by examining land redevelopment projects led by U.S. hospitals. The book surveys the real estate practices of hospitals and queries their role in gentrification and land revitalization, the massive public subsidies and infrastructure they require, and the ways that elite nonprofit U.S. hospitals have carved out real estate empires in their host cities to underwrite international prospecting for patients, transnational specialty clinics, and overseas hospitality services. The account scrutinizes how elite hospitals actively perpetuate conditions of poverty and ill health in their surrounding neighborhoods even as their philanthropic/civilizing missions and nonprofit status rhetorically obscure harmful effects, be they industrial pollution or escalating local disease and morbidity rates. In this way, hospital land redevelopment projects may profit from the very blight that they claim to remedy.

I examine policies that seek to build hospitals on contaminated land and, more generally, that facilitate land seizures in the name of improving public use and environmental health. These policies propagate a colonial process that identifies certain spaces as blighted—a racially charged discourse in the United States that has resulted in repeated struggles over so-called public use and civic benefits. Using a critical geographical framework that addresses racial capitalism and settler colonialism, the account focuses on the racially inequitable political-economic operations of these medical institutions and their effects on neighborhood spaces and livelihoods. The analysis registers the damages of land dispossession in order to establish property and pollution as central to health colonialism, and to show the material and pedagogical ties between waste, land, and race made by health institutions that pursue urban expansion projects. I specifically scrutinize how particular medical centers and hospitals create a frontier of contaminated or underutilized land parcels primed for redevelopment via financial incentives that limit liability in the private property market and strip assets from communities, all while averring public improvements. Drawing on the policy term “brownfields,” I call this frontier “medical brownfields” (see chapter 1); I track its consolidation and anchoring of hospitals as transnational investment frontiers within the political economy of U.S. empire and biomedicine.

Globalization has challenged the national “containerization” of health systems. The book plumbs hospital policy literature and political-economic practices that inaugurate global medical hubs—from Las Vegas to Abu Dhabi—and that function as international economic and educational ventures. These satellite hospitals trade medical expertise, procedures, supply chains, financial practices, and land strategies while in the process tethering the prestige of these elite hospitals and their international outposts to the reproduction of domestic blight and inequality across borders. This transnational extension of medical brownfields stratifies territory and populations, consolidating the locally extractive, environmentally damaging work of this frontier to buoy branded medical services and the so-called global medical commons. Thus, campaigns to decolonize health must address hospital land practices and the territorial, socioenvironmental effects of their medical services and clinical practices across scales of operation.

In what follows, I discuss three policy fields that support hospital development projects. Chapter 1 establishes the settler-colonial and racial-capitalist nature of medical real estate projects by focusing on brownfield property revitalization and the relationships between waste, race, and health. The analysis extends to what is known as healthfields policy that offers hospitals tax breaks and other incentives to redevelop contaminated land in neighborhoods with limited medical services. The policy aims to enhance public health yet in practice can target minority communities and lower liability to remedy toxic blight, thus ensuring that possible contamination continues to endanger human health.

Chapter 2 shifts policy terrain to “Eds and Meds” projects that seek to remedy postindustrial blight and that stimulate urban growth tied to medical research centers and teaching hospitals, which are perceived as powerful economic engines. Participating institutions are able to exploit public subsidies and devalued land; they implement predatory forms of financial extraction using the colonial rhetoric of educational mission and nonprofit charity work even as local communities evince some of the worst disease rates in the United States.

Chapter 3 investigates the expansion of U.S. hospital branches and joint ventures that support profit seeking outside the constraints of U.S. charity and emergency care requirements. Particularly where U.S. hospitals open franchises in oil-rich countries and special-service enclaves in the United States that cater to global elites, they compound inequality by extracting domestically to support speculative international projects couched in global cross-cultural exchange and educational mission, thereby intensifying health and environmental inequities.

The conclusion takes up the call to “decolonize health,” drawing on Frantz Fanon’s anticolonial argument about the centrality of land to health. I point to the inadequacy of Western medicine’s ethical imperative to do no harm, which fails to account for the status quo of health colonialism. In a speculative turn that questions what a health system based on “nonkilling”—or, in Fanon’s words, “breathing and bread”—would look like, I argue that decolonizing global health requires reckoning with the ways the Western biomedical model stems from the liberal tradition.