Praise for Dr. Michael Fine and On Medicine as Colonialism: “Michael Fine’s On Medicine as Colonialism is a rich overview and critique of the US health care enterprise—certainly not a ‘system’ of care, but a fantastically costly conglomerate of multiple providers of health-related services that enriches them. . . . This is a sobering diatribe on health care in America, and it merits all of us fed up with the relatively low return on our investment in health to seek changes—to get more ‘health’ out of ‘health care.’” —David N. Sundwall, MD, professor emeritus of public health, University of Utah School of Medicine, and primary care physician “Michael Fine has lifted up the hood of medicine’s dysfunctional engine and explained how all the parts are working against us having a healthier population.” —Michael Rocha, MD, cardiologist “On Medicine as Colonialism explains why our health care system has catastrophically failed. . . . It also explains how the flawed values of our medical care system infect the other systems in our society, compounding the problems. The Big Lie is that the 2020 presidential election was fraudulent. On Medicine as Colonialism reveals that the Biggest Lie is that our health care system is primarily concerned with protecting and improving health. The truth is, it’s about money and power achieved by colonialist values and tactics. This book will make you angry—I hope angry enough to join others in advocating for change in the basic structure of our health care system.” —Edward P. Ehlinger, MD, MSPH, public health metaphysician “On Medicine as Colonialism details the sociopolitical realities that undergird health injustice and offers a realistic perspective on achieving health equity.” —Jewel Mullen, MD, MPH “Wide and deep, meticulous with small facts and big issues, Dr. Michael Fine wins his big-hearted argument that American medicine is colonialism, not just for the poor but for all of us. It is a desecration of our health care system by the same old robber barons, the rich. Money wins out, with our ‘care’ in the hands of private equity, venture capital, and private insurance monsters—with their buying and killing or selling for-profit ‘hospital chains.’ Only university hospitals manage to escape—dedicated to a sense of ‘healing.’ With a sharp IQ and a big heart, this doctor- activist is pointing us to solutions. Everyone should read it.” —Dr. Samuel Shem, author of The House of God and The Spirit of the Place and professor of medical humanities at NYU Medical School “Michael Fine is one of the true heroes of primary care over several decades.” —Dr. Doug Henley, CEO and executive vice president of the American Academy of Family Physicians, 2000–2020 “As Rhode Island’s Director of Health, Dr. Fine brought a vision of a humane, local, integrated health care system that focused as much on health as on disease and treatment.” —US Senator Sheldon Whitehouse On Medicine as Colonialism Michael Fine Foreword by Christopher Koller On Medicine as Colonialism © Michael Fine 2023 This edition © 2023 PM Press All rights reserved. No part of this book may be transmitted by any means without permission in writing from the publisher. ISBN: 978–1–62963–990–1 (paperback) ISBN: 978–1–62963–994–9 (ebook) Library of Congress Control Number: 2022943209 Cover design by John Yates / www.stealworks.com Interior design by briandesign 10 9 8 7 6 5 4 3 2 1 PM Press PO Box 23912 Oakland, CA 94623 www.pmpress.org Printed in the USA Contents Christopher Koller vii foreword xi acknowledgments Two Stories and a Definition 1 introduction Medicine and Colonialism 8 chapter one Hospitals 17 chapter two Pharma and Pharmaceutical Retailers 36 chapter three Specialists, Surgicenters, chapter four Radiologists, Cardiologists, and Tests 54 Administrators, Consultants, chapter five Lawyers, and Doctors 67 Primary Care 75 chapter six Insurance Companies 82 chapter seven Research 93 chapter eight Medical Colonialism as, Well, chapter nine Colonialism Itself 106 COVID-19 124 chapter ten Final Thoughts, Summary and chapter eleven Conclusions, and a Little about How to Fix This Mess 132 137 notes 146 bibliography 148 index 153 about the author Foreword vii Foreword y mid-2022, at the time of this writing, coronavirus had claimed more than one million lives in the United States. B On a per capita basis, that puts the country’s death rate from the infection at three times Canada’s, more than eight times Australia’s, and ten times Japan’s, Singapore’s, and Taiwan’s.1 And the toll is not even. According to the Centers for Disease Control and Prevention, American Indian, Latino, and Black populations are all about twice as likely to die from the disease as white populations. This alone is a searing indictment of a health care system that consumes almost 20 percent of the country’s resources. How can this be? This is the question Michael Fine explores in this book. Fine approaches the question as Rhode Island’s answer to Wendell Berry. Trading Kentucky’s tobacco farms for the Ocean State’s tenements, Fine brings Berry’s deep respect for the value of human relationships and equally deep skepticism for the supposed benefits of our political economy to an exami- nation of how health care is organized, financed, and delivered in the United States. Fine is a physician by training and a novelist by heart, and his diagnosis is a metaphorical one—in the US, he maintains, health care has “colonized” whole communities. It is at first an odd analogy. In health care in the US, there is no invading force from a foreign land. There are no subjugated native populations. But the hallmark of colonialism, Fine maintains, is the use of power by outside entities for the purposes of wealth extraction Foreword viii from communities for personal or institutional benefit. And whether the community is defined geographically, ethnically, or economically, Fine asserts, the health care industry has succeeded magnificently at this process of wealth extraction. In successive chapters, he analyzes how hospitals, the pharmaceutical industry, specialist physicians, the admin- istrative bureaucracy, the hallowed (and hollowed) primary care sector, insurance companies, and biomedical research have allowed their public good functions to be perverted by an economic model that puts profits over people and turns care into a transaction. The result is wealth accumulation, uneven financial gains, and the impoverishment of entire communities. The wealth that has been extracted by medical colonialism is not merely financial—although with over half of health care paid for by the government, it is indeed just our own money being moved around and accumulated. The real wealth is in the vitality of communities. In Fine’s telling, towns and cities have replaced diverse small-business economies with ones based on medicine and education, where the only hope of economic mobility is a terminal job as a clinical assistant in a big health system. Repeatedly, health systems have extracted trust—an even more precious commodity—from Black and Brown communities, who have experienced persistent discrim- inatory treatment. The result is a collective loss of agency, of connectedness, and of hope. Like his muse, Berry, Fine writes with the eye of both a humanist and a practitioner. He has worked these health care fields—as a clinician, public health official, and community organizer—and his passion for individual lives and concern for the common good is what drives his outrage at what has been wrought. Health care practices its own version of manifest destiny. Its model of organization and financing is ineluctable in its power and direction, Fine maintains. This colonization may not involve invading foreign forces, but a group with power is seeking to impose its notion of what is good while enhancing its Foreword ix own personal wealth and status. And however well-intentioned its participants may be—the physicians, health professionals, scientists, and administrators who march forward as part of this force—they are doomed, like zealous missionaries, to create harm even as they labor to help. Colonization is inevitable, and “All our trusted health professionals and institutions are involved,” he laments. The abysmal performance of the United States in preparing for and responding to COVID-19 cannot be laid entirely at the feet of our health care system, however. Our cultural values and political leadership have both refused to realize our collective interdependence and the personal sacrifice that sometimes entails. As we shun limits on health care choices and budg- ets, so we shun limits on personal freedoms. Similarly, Fine’s possible ways forward in his final chapter involve broad cultural reforms—and accompanying shifts in political and cultural power—far beyond the health care system. This continues his previous writing about the political engagement he thinks is required to construct stronger, healthier communities—ones in which wealth in all its forms is built, not extracted. This prescription for a cure can be a tough pill to swallow for most people, who just want care and answers when they are ill and vulnerable and who often place their faith in the power of vague nostrums like “unleashing market forces” or “univer- sal health care.” It is no easier for the incrementally inclined health-reform advocates among us who promote technical changes like “bending the cost curve,” value-based provider payments, patient consumerism, and evidence-based medicine. But a lesson from history is that few colonialists give up their advantages willingly. Christopher Koller President The Milbank Fund