Book Review by Kristie Serota

At ninety-nine short pages, Shiloh Krupar’s new book Health Colonialism: Urban Wastelands and Hospital Frontiers (2023) is an epistemological heavyweight. This small book, one in a series of thought-in-process scholarship from the University of Minnesota Press, is light to hold and heavy to read. Krupar explores the geographical foundations of US biomedicine using a critical political economy approach and, in doing so, exposes the operation of modern-day colonialism in US health systems. The book delves into a diverse range of topics including, but not limited to, structural violence; anti-Black and anti-Indigenous racism; the seizure and redevelopment of land, both domestically and internationally; the logic of biomedicine and the logic of extraction; and public health ethics. Krupar explains how these contemporary colonial practices achieve their ends under the guise of benevolence and community care. Becoming our tour guide, she leads readers through this dense theoretical landscape with beautifully articulated examples. We follow her along city streets and through the architecture of hospital campuses of enchanting global destinations from Minnesota to Abu Dhabi. Each of the three chapters identifies a different policy field and explores how these policies are enacted and leveraged to justify the continued development of hospitals in the US and their satellite and partner locations abroad.

In the first chapter, Urban Brownfields and Health Policy, Krupar explores the relationship between racism, land seizure, and the development and expansion of health centres on urban brownfields. Brownfields are defined as:

“[A]bandoned or underutilized industrial and commercial sites that are, or are perceived to be, physically, chemically, or biologically contaminated…[including] idle, abandoned, derelict, damaged, vacant, underused land or buildings with poor land conditions…land with known documented and perceived pollutants and hazardous wastes, or to land that is not being used to the potential of its perceived or imagined value” (p.9).

Krupar argues that redeveloping brownfields into hospitals and health centres is a racial justice issue that reflects and perpetuates histories of colonial land seizure from Indigenous peoples. While there are positive aspects to these development projects, they create jobs for local residents (albeit primarily low-wage service positions), remove waste and contamination from the local area, and improve access to health care for the local community. Simultaneously, the displacement and gentrification they engender “paradoxically entrench health inequities, economic injustices, and environmental hazards stemming from segregation and previous rounds of land seizure” (p.30). Drawing on compelling examples from Florida, Krupar showcases how communities of Black and Indigenous people of colour (BIPOC) are the most severely affected. This framework provides the roadmap for the following two chapters that explore the expansion of hospitals domestically and abroad.

In the second chapter, Hospital Growth Machines and Colonizing Brownfields, Krupar explores the policy terrain of large non-profit hospitals, dubbed Eds and Meds. Research university medical centres and teaching hospitals are criticized for taking advantage of urban brownfields in their real estate pursuits. Land for non-profit biomedical institutions is “made available for redevelopment through colonizing discourses of blight, public improvement, and health tied to economic productivity, which erase or denigrate nonwhite spaces and communities to prime land for seizure” (p.34). Our tour guide walks us readers around the expansive campus belonging to the Cleveland Clinic and Johns Hopkins University. Krupar shows us how these renowned institutions set up the conditions of medical apartheid within their respective urban landscapes. We watch as the neighbourhoods surrounding these institutions are bulldozed to expand research centres conducting world-class studies. Meanwhile, BIPOC residents in the local community suffer elevated rates of disease and infant mortality. Not only do these non-profit health systems weaken the local tax base and introduce new police forces, but they also neglect to invest in low-cost prophylactic care that might engage the local community and build capacity for preventative medicine.

In the third chapter, Global Medical Entrepôts and US health care Inequality, our tour goes global as we are led through the stunning architecture of the US-branded health systems operating abroad. Krupar walks us through medical tourism destinations such as the Cleveland Clinic Abu Dhabi, which boasts a marble foyer, views of the Arabian Sea, and private VIP suites for the country’s royal family. The author paints beautiful architectural descriptions that give the reader a sense of being in the spaces described.  Krupar labels these US medical outposts as entrepôts which the Oxford English Dictionary describes as: “a port, city, or other centre to which goods are brought for import and export, and for collection and distribution,” and she criticizes the globalization of American health care for its extractive, profit-based logics. “Rather than addressing structural issues that limit health care access and coverage, US 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” (p.83). This chapter also explores efforts to ‘green’ healthcare domestically and abroad. While efforts to reduce carbon emissions are commendable, these internationally celebrated feats can obfuscate the harms enacted on local communities. Despite these ‘greenwashing’ efforts, the division between biomedical advancement and socioecological issues continues to grow. Krupar’s argument that inequity between the public health system and the medical care offered to global elites is intensified through these transnational colonial projects, is a convincing one. The author’s talent for marrying critical theory with vivid real-world examples makes this book a compelling read.

Krupar’s tour ends with a discussion about decolonizing health in the modern world and provides several examples of how this complicated unravelling project might begin. Throughout the book, the author explores how biomedical logic works to create a chasm separating biomedicine and technology from broader geographical and social contexts, including ecology, culture, politics, and local economies. Companies, governments, and financial structures enact frontier logic and participate in land grabs, claiming land they deem underutilized, contaminated, etc., and redeveloping it for the ‘good of the community.’ Meanwhile, neoliberal market logic promotes individual social responsibility, obfuscating the perpetuation of racist, colonial relations internationally and locally. This book engages cross-disciplinary audiences, including geographers, public health advocates and scholars, urban planners, disability justice advocates, critical bioethicists, and those interested in conducting critical political economic analyses. Health Colonialism inspires readers to walk around their hometowns with a new theoretical lens that allows them to view their local environments through the lens of contemporary colonial expansion.

Kristie Serota is a PhD Candidate studying Social and Behavioral Health Sciences at the Dalla Lana School of Public Health, University of Toronto.