You may be an American, a Brit, a Canadian, a German, an Indian, a South African—but we are all citizens of the Biomedical Empire. Your country may issue your citizenship papers, but they will ask for your birth certificate to do so. Trans people talk about needing a medical approval of their sex identity—but we all get our sex identity assigned on our birth certificates based on a medical evaluation. Your access to the goods and services of your nation-state depend on your biocitizenship.1 Biomedicine is the ruling empire, colonizing the planet.
For a long time, along with many of my colleagues in medical sociology, I have been talking about the “Medical Industrial Complex”2—that riff off of Eisenhower’s naming of the military industrial complex. Like the military, biomedicine is tightly and powerfully tied to industrial capitalism, and the consequences are visible everywhere.
But of late I have gone beyond that powerful but limited understanding of the role of biomedicine in contemporary society, and started talking about the Biomedical Empire.3 A basic definition of empire is “the expansion of economic activities . . . beyond national boundaries as well as the social, political and economic effects of this expansion.”4 Those effects include not just the economic, but faith and legal backing as well. Biomedicine, as I will be showing, has these key elements. Empires are economic powers, and biomedicine is one of the largest economic forces in the world. There is an element of quasi-religious belief in all imperial power—think of all the times you’ve heard people say they “believe in” this or that element of medicine. And there is the rule of law—your citizenship depends on a medically authorized birth certificate, and you won’t leave this earth without a medically authorized death certificate. In between, over and over again, you will find yourself awaiting a “doctor’s note” for everything from skipping a day of school to accepting a Fulbright appointment. What is and is not a medical practice or medical condition has the authority of law.
The COVID-19 pandemic has made the place of biomedicine as an imperial power in the world more obvious and—not unrelated—brought forward its largest and most visible resistance. This has been happening to some extent throughout the world, but is—maybe not surprisingly—happening more loudly, strongly, and wildly in the (dis)United States.
Along came this new disease for which medicine had no cure. And yet people turned to medicine. It’s not just that we were asking medicine to develop a cure or a vaccine, but right then, this person with the condition, right this minute—call your doctor! Some of that is about symptom management. You get sick, that means various bodily functions aren’t working normally, and those are symptoms. Some of them can be treated: You’re not getting enough oxygen from normal breathing, so medicine can give you oxygen. Actually medicine seems to have the lock on doing that. My grandmother had an oxygen tank in her apartment when I was a kid, and when the pandemic started, I wondered why we weren’t distributing those now for people with COVID-19 breathing problems. But no, anyone with breathing problems must go to the hospital, while we simultaneously bemoan how overcrowded and overwhelmed hospitals are—and how the gathering of people with COVID-19 increases the spread of COVID-19. Hospitals became hot spots. As they always have been, of course, places where diseases are transmitted, in what were named nosocomial infections, the word created for infections specifically picked up in hospitals. Why would you go there if you didn’t absolutely have to?
One of the things that the COVID-19 pandemic has done is make people reconsider hospitals. Pre-pandemic, we could visit our elderly grandmother in the hospital if she went in for tests or treatment. But now we’re not allowed to visit, and she’d be isolated to prevent the spread of disease in the hot spots hospitals are known to be. So more people have started thinking about managing illnesses at home. And if our grandmother were actually dying, why lock her up for that? At the other end of life, the concern many of us have been raising for years about home and birth centers as better places to give birth than hospitals began to make sense to more and more people. How to handle both birth and death became subjects of considerable debate, and—as I will show later—highlighted long-standing problems with medical management of the gates of life.
The Biomedical Empire was in a period of enormous vulnerability. The immediate response was a push to slow down the spread of the virus, “flatten the curve,” so that biomedical management could catch up. The hospitals were overwhelmed; the drama of the exhausted medical workers, and the patients laid out in overcrowded hallways or literally piled up as bodies in refrigerated trucks outside of hospitals, was put on display everywhere one turned. Slow it down, flatten the curve.
It was informative to watch the conflict over opening up the economy and flattening the curve. People who violated stay-at-home demands were not showing their allegiance to the Biomedical Empire. They did a lot of flag waving, claiming it as an American right to exercise their economic and bodily choice. It felt as if American governmental power was being placed in conflict with biomedical authority. Different leaders emerged to represent each force, and ordinary collaboration between government and biomedicine was made public precisely because of the aberration of the dispute. In the US, Anthony Fauci perhaps most clearly represented the biomedical imperial power and Trump the American governmental power.
Face masks quickly became a kind of tribal flag, signifying membership in the Biomedical Empire. The surgical mask design seemed to add some cachet, those bands around the ears made them seem more medical.
If our only choices are allegiance to one or the other of these empires, I’m signing on with biomedicine. But can we acknowledge that as the pandemic spread, we didn’t have a lot to put our faith into? The Biomedical Empire did not know how to fix this pandemic. Maybe there would be some totally risk-free, 100% effective vaccine researched and developed in a totally ethical way. Or some perfect treatment that cures the disease. Could happen.
Until then, we were in the midst of a clash of struggling empires. And, as I have always told my students in difficult, challenging, threatening times: Take notes! Yes, because putting one’s intellect to work on the problem is a good coping strategy. But more importantly, these rough moments are rough precisely because the chasms between world views are laid bare. This is when sociology can step up to the plate and help us figure out what is happening—and understand better what has been happening all along.
As the Biomedical Empire faced its greatest challenge, it became easier to see how that empire has served and how it has failed its people.
An analysis and critique of the Biomedical Empire is not a call to bring back smallpox or polio, or to deny that biomedical imperialism is responsible for ending those epidemics. But imperialism is not static, and biomedical imperialism has changed substantively and substantially with its corporatization. We think of medical progress as moments of individual scientific breakthroughs: the discovery of penicillin, the invention of a vaccine. An apocryphal story has Salk claiming credit for the invention of the polio vaccine but saying that patenting it would be like “patenting the sun.”5 In today’s Biomedical Empire, individual scientists are not situated so as to even have a voice in the distribution, let alone patenting, of their findings: The university or lab one works for would be the owner of record, and patenting would be inevitable. At a meeting I attended at the United Nations on the issue of patenting the human genome, a seemingly thoughtful, caring young man representing the industry rose up and spoke eloquently on the absolute necessity of patenting the genome, or else, he told us, “There will be no incentive to cure cancer.” Presumably a room full of people could think of other reasons we might want to cure cancer, incentives other than the profit motive. But he was correct in the essence of what he was saying, which was less about incentive and more about mechanism: The Biomedical Empire has left us with no mechanisms other than profit to do something presumably all human beings want done. If curing cancer will be enormously profitable, there will be work done to make that happen. If not, like the “orphan” diseases of the world that are too rare to be profitable, the work will not be done. Sparing people grief, pain, early death—these are not workable incentives in biomedical imperialism. Profit is.
This is the world in which we live, in which biomedical imperialism is a dominant force and we are all its citizens.
1. Concept introduced by Nikolas Rose and recently expanded in Kelly E. Happe, Jenell Johnson, and Marina Levina, eds., Bio-Citizenship: The Politics of Bodies, Governance, and Power (New York: New York University Press, 2008).
2. Barbara Ehrenreich and John Ehrenreich, “The Medical Industrial Complex,” Bulletin of the Health Policy Advisory Center (Health-PAC Digital Archive, November, 1969); Arthur S. Relman, “The New Medical-Industrial Complex,” New England Journal of Medicine 303 (1980): 963–970.
3. With much appreciation to conversations with my colleague Alan Petersen.
4. Howard Waitzkin and Rebeca Jasso-Aguilar, “Empire, Health, and Health Care: Perspectives at the End of Empire as We Have Known It,” Annual Review of Sociology 41 (2015): 271–290, 272.
5. Jonas Salk, TV Interview with Edward R. Murrow, April 12, 1955.
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