Table Of ContentPraise 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
