By Cory Bhowmik
“The truth, the whole truth, and nothing but the truth” is an ideal we try to espouse, but the field of medicine can be rightly accused of not telling “the whole truth” on many occasions throughout history. The Tuskegee syphilis study [1] and the involuntary sterilization of Native American women [2] are a couple examples. A particularly damning example is when we invoke “social determinants of health” upon encountering disparities healthcare that are based on race, sexuality, gender, etc. This invocation—though a statement of fact—is not “the whole truth”, as it doesn’t identify the reason why social determinants of health exist. In fact, the term “social determinants of health” is a placid moniker for the violent systems that have resulted in today’s healthcare disparities.
The advent of colonialism and capitalism
When we start a family, we make appropriate accommodations to ensure everyone is fed, housed, and taken care of. Even non-human animals do the same. So, it isn’t surprising that many societies throughout history have been based in community, with communal systems of food distribution, housing, and education. [3] Of course, there have been empires and kingdoms that have invaded other peoples and sequestered wealth—but not as pervasively as in today’s society. [4]
Today’s shift away from communal society is attributed to the system, originating in western Europe in the 16th century, wherein a small group of the elite can rule over a lower class. Upon the creation of a system in which there were virtually no bounds on individual profit, European merchants began a violent race for spices, minerals, and other goods—including people. And so western Europe began to plunder civilizations around the world, instituting hierarchies that forced indigenous people into the lower class—thus beginning the brutal era of colonialism. [5,6]
Colonialism was made possible by the economic system of exploitation that is capitalism. Capitalism, by definition, requires the existence of a lower class. [7] That fact, regardless of any other, should allow us to abolish it. But, of course, capitalism continues to be promoted by the promise of innovation, even though innovation has since been shown to occur at similar rates in socialist societies. [8] It should be noted that another key piece of propaganda in the promulgation of colonialism and capitalism is God. Colonialism was justified by branding indigenous people as uncivilized and unChristian. For example, the pursuit of religious freedom for western Europeans was used to justify their original settlement into the 13 colonies of the United States. [9] And “manifest destiny” was used to justify their westward expansion and continued genocide of Native American people. [10]
For capitalism to thrive, it requires a source of people to serve as the lower class. And so, it is not surprising that western Europeans invented the concept of race science, which led them to enslave millions of people from Africa. [11] Indigenous people in other colonies were also seen as less-than-human, resulting in indentured servitude and isolation from resources. This concept of racism and capitalism being mutually beneficial for the purpose of exploitation is called racial capitalism, and it has been vital to the violence of colonialism. [12]
Unfortunately, there is a system that can rival the violence of colonialism—and that is settler colonialism: a brutal form of colonialism that involves settlers taking land and establishing residence in the occupied society, with the goal of expulsion and/or alienation of the occupied indigenous people. Examples of settler colonies include the United States, Australia, and New Zealand. [13]
Resultant Impact on Health
Descriptions—mere definitions, even—of colonialism, setter colonialism, capitalism, and racial capitalism should instill in anyone feelings of disgust, and it should be obvious how these violent systems result in adverse health outcomes, but let’s lay it out with some examples:
During the height of colonialism, many famines were levied onto colonized people. One example is the Bengal famine of 1943 in India (along with tens of other famines across South Asia), which resulted in adaptations of the body to a state of starvation. Today, this adaptation—within a mere 1-2 generations—has resulted in increased rates of cardiovascular disease in South Asian populations. Studies have shown that the presence of a famine in one generation doubles the subsequent generation’s risk of diabetes and obesity. [14,15] So, is this just a social determinant of health, or is this better described as a violent result of colonialism and capitalism?
In the settler colonies of Australia (where the Aboriginal people have been displaced) and New Zealand (where the Māori people have been displaced), both groups of indigenous people have less access to land, higher rates of discrimination, and higher rates of mental health related disease. [16,17] Is this just a social determinant of health, or is this a result of colonialism and capitalism?
In the settler colony of the United States, millions of enslaved people from Africa have been under brutal physical and mental stress for hundreds of years. Today, evidence shows that there are increased levels of stress in descendants of enslaved people, likely originating from the stress of oppression and slavery via a harrowing phenomenon called Post-Traumatic Slavery Syndrome (PTSS). [18,19] Is this just a social determinant of health, or is this a result of colonialism and capitalism?
In the United States government, the Indian Health Service (IHS) exists to provide healthcare services for Native Americans. (Pause, for a moment, to consider how dystopian it is for the Indian Health Service to exist. This makes it seem as though it is a special service, for a people who are indigenous to this land.) In the 1970s, the IHS was responsible for the nonconsensual sterilization of more than 25% of Native American women of childbearing age. And in 2020, Native Americans had some of the highest COVID rates, partially due to the underfunding of federal reservations. [20] And so, is this just a social determinant of health, or is this a result of colonialism and capitalism?
What does this mean?
Food insecurity in predominantly Black areas, increased disease rates in prisons (which incarcerate 4 times as many Black people as are in the general population [21]), increased work hours to maximize profit, lower quality of healthcare due to insurance, and the creation of “third-world” countries secondary to resource extraction and servitude—it would not be a stretch to say that these phenomena, along with the above examples, and almost all “social determinants of health” are secondary to colonialism and capitalism.
Of greatest import, these systems have not disappeared. There are colonial (and neocolonial [22]) powers even today, and capitalism continues to perpetuate violent healthcare disparities. If we are to eliminate healthcare disparities—as medical school curriculum advocates—then colonialism and capitalism must go. Any lesser solution is mere symptom management.
References
1. Centers for Disease Control and Prevention (2022). The untreated syphilis study at Tuskegee – Timeline. Centers for Disease Control and Prevention. https://www.cdc.gov/tuskegee/timeline.htm
2. Blakemore, E (2019). The little-known history of the forced sterilization of Native American women. JSTOR Daily. https://daily.jstor.org/the-little-known-history-of-the-forced-sterilization-of-native-american-women/
3. Taylor, I (2018). Pre-colonial political systems and colonialism. African Politics: A Very Short Introduction, Oxford Academic. https://doi.org/10.1093/actrade/9780198806578.003.0002
4. Khilnani, S (2022). The British empire was much worse than you realize. The New Yorker. https://www.newyorker.com/magazine/2022/04/04/the-british-empire-was-much-worse-than-you-realize-caroline-elkinss-legacy-of-violence
5. PBS NewsHour (2015). How the West got rich and modern capitalism was born. PBS NewsHour. https://www.pbs.org/newshour/nation/west-got-rich-modern-capitalism-born
6. DuBois, WEB (1976). The world and Africa: An inquiry into the part which Africa has played in world history. Kraus Reprint Co.
7. Marx, K (1991). Capital: A critique of political economy. London Penguin Books in Association with New Left Review.
8. Rodney, W (1972). How Europe Underdeveloped Africa. Verso.
9. Foster, J, Taylor, M, Boecklin, D, Tanner, M, & Luyken, J (1998). America as a religious refuge: The seventeenth century, Part 1 - Religion and the founding of the American republic. Library of Congress. https://www.loc.gov/exhibits/religion/rel01.html#:~:text=Beginning%20in%201630%20as%20many,far%20as%20the%20West%20Indies.
10. Getchell, M (2023). Manifest Destiny. Khan Academy. https://www.khanacademy.org/humanities/us-history/the-early-republic/age-of-jackson/a/manifest-destiny#:~:text=Manifest%20Destiny%20was%20the%20idea
11. Harvard University (2022). Scientific Racism. Harvard Library. https://library.harvard.edu/confronting-anti-black-racism/scientific-racism
12. Laster Pirtle, WN (2020). Racial capitalism: A fundamental cause of novel coronavirus (COVID-19) pandemic inequities in the United States. Health Educ Behav. 2020 Aug;47(4):504-508. doi: 10.1177/1090198120922942.
13. Wolfe, P (2006). Settler colonialism and the elimination of the native. Journal of Genocide Research. 8:4,387-409. doi: 10.1080/14623520601056240
14. Bakar, F (2022). How history still weighs heavy on South Asian bodies today. HuffPost UK. https://www.huffingtonpost.co.uk/entry/south-asian-health-colonial-history_uk_620e74fee4b055057aac0e9f
15. Brown University (2016). Famine alters metabolism for successive generations. (n.d.). Brown University. https://www.brown.edu/news/2016-12-12/famine
16. McGlade, H (2023). First Person: Aboriginal Australians suffer from “violent history” and ongoing “institutional racism”. UN News. https://news.un.org/en/story/2023/04/1135827
17. Harris, RB, Cormack, DM, & Stanley, J (2013). The relationship between socially-assigned ethnicity, health and experience of racial discrimination for Māori: Analysis of the 2006/07 New Zealand Health Survey. BMC Public Health, 13(1). https://doi.org/10.1186/1471-2458-13-844
18. Scott-Jones G & Kamara MR (2020). The traumatic impact of structural racism on African Americans. Dela J Public Health. 2020 Nov 7;6(5):80-82. doi: 10.32481/djph.2020.11.019.
19. Halloran, MJ (2019). African American health and posttraumatic slave syndrome: A terror management theory account. Journal of Black Studies, 50(1), 45-65. https://doi.org/10.1177/0021934718803737
20. Williams, R (2021). Native American deaths from COVID-19 highest among racial groups. Princeton School of Public and International Affairs. https://spia.princeton.edu/news/native-american-deaths-covid-19-highest-among-racial-groups#:~:text=After%20adjusting%20their%20data%20for
21. Wertheimer, J (2023). Racial disparities persist in many U.S. jails. Pew. https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2023/05/racial-disparities-persist-in-many-us-jails
22. Halperin, S (2020). Neocolonialism. Encyclopædia Britannica. https://www.britannica.com/topic/neocolonialism
