Barbara Katz Rothman’s The Biomedical Empire: Lessons Learned from the COVID-19 Pandemic is firmly situated in the critical social science health literature investigating biomedicine’s influence on notions of health and examining and revealing the biopower of dominant actors over the health realm. This literature is vital for understanding the COVID-19 era because science and medicine have simultaneously been under attack and held up as the great liberator from the pandemic.
However, while this book maintains the themes of this literature, it is not merely a critique of the weaknesses of biomedicine or, in the tradition of medicalization scholarship, a look into how biomedicine has transformed understandings of health. Rather, it argues that biomedicine is an empire, a colonizing force that has taken over life itself. According to Katz Rothman, invoking the notion of an empire not only is appropriate to characterize the dominance of biomedicine in the world economy but allows us to uncover the hidden ways that biomedical imperialism works to frame societal ideas of health, lives, and personhood. This book provides a compelling argument that only by naming the Biomedical Empire and recognizing biomedical citizenship can we begin to transform societies to act on the fundamental determinants of health.
The central goal of the book is to use the notion of empire to understand biomedicine’s imperialist motives. Katz Rothman invokes the definition of an empire as “the expansion of economic activities beyond . . . national boundaries as well as the social, political, and economic effects of this expansion” (p. 2). The book provides plentiful evidence that the biomedical system meets this definition. By discussing examples such as the risks associated with hospitalization, the inability of the medical model to yield optimal outcomes for birthing people and infants, and the failure of biomedicine to control the diabetes epidemic in Chile, Katz Rothman reveals that biomedicine’s principal goals are profit, productivity, and efficiency, not patient well-being. If biomedicine is centrally concerned with the interests of patients or consumers, why is there so little investment in orphan drugs for rare diseases? In the face of evidence that hospitals pose risks to birthing people and that midwives provide safe, holistic care, why are home births shunned and midwives delegitimized by doctors? The system exists to sustain itself, and decisions are made by powerful actors with corporate agendas. These decisions are made with little regard to the major sources of health and illness: social determinants. Profitable solutions are prioritized.
Katz Rothman skillfully draws on theories in medical sociology to help us understand how the Empire approaches health problems. In doing so, she astutely draws our attention to the language we use around health. Why do people use the word “medical” when they mean “health”? Why is “health care” equated to having “medical insurance”? Words are framing devices that define the boundaries of phenomena, and paying critical attention to their usage sheds light on how individuals delimit the causes of and solutions to problems. Katz Rothman explains that we have come to think of health as confined to medical solutions—drugs, invasive therapies, surgeries. Never mind that global death rates due to most infectious diseases have dropped due to public health interventions, such as improvements in sanitation and clean water, which preceded the development of vaccines and treatments. The book underscores that when people focus on, say, drugs as treatments instead of inequality or racism, they become acceptable citizens of the Biomedical Empire.
What does COVID-19 do for us in understanding the Biomedical Empire? We best understand how authority works when it is challenged, and Katz Rothman argues that COVID-19 represents the biggest challenge yet to the Biomedical Empire. The book shows how biomedicine is our new religion, yet it offered no immediate solution to the crisis; developing vaccines and treatments for an emerging disease takes time. The absence of a clear medical solution in the early stage of the pandemic opened the doors for disagreement between the government and medicine about how to best manage the crisis. What was clear was that biomedical imperialism needed to successfully combat COVID-19 not to save lives, but to save the Empire. Katz Rothman argues that biomedicine’s imperialist authority was at stake. It needs to not just maintain control but expand its reach into more world regions and life arenas. Katz Rothman intuitively highlights the militaristic discourse used in discussions of COVID-19 (“beating COVID-19,” “fighting death”) to show that biomedicine was attempting to establish control over the enemy: disease. Its principal tool in defeating the coronavirus was the vaccine. By developing a vaccine in an unprecedentedly short period, the Biomedical Empire could legitimize its standing in the world sphere.
Like most crises, COVID-19 has exposed society’s systemic fractures and flaws. Katz Rothman investigates its various problematic effects, such as vaccine hesitancy and the politicization of public health policy and management, but she focuses most on the disproportionate impact of COVID-19 on marginalized populations. She emphasizes that to be a citizen is to have rights, but in a system with entrenched social inequalities, not all citizens have equal and full rights. The poor, racial and ethnic minorities, and queer populations whose health views, approaches, and identities are not represented in biomedicine have partial citizenship, so they are treated as lesser. In biomedical imperialism, Katz Rothman argues, rights are afforded to those with money and power, and the system devalues anyone who goes against biomedicine’s values. Perhaps the biggest lesson we can learn about the Biomedical Empire from COVID-19 is how a lack of biomedical citizenship represents an assault on personhood, rendering marginalized populations invisible.
In a time where anti-science sentiment is rampant, Katz Rothman is rightly careful to emphasize that she is not claiming that medical solutions have no role in health. Rather, her point is that medicine’s ability to save lives and improve quality of life does not mean that the Biomedical Empire is less of an empire. Medicine’s successes do not negate its destructive capacities. In fact, these successes, along with the stated goals of the Empire—to lengthen life, improve quality of life, and save lives—can mask its underlying agendas and failures. This book contends that a sociological approach to studying biomedicine, and the notion of the Biomedical Empire in particular, centers its true priorities. In the spirit of the sociological imagination, Katz Rothman translates her sociological perspective into actionable alternatives to biomedical imperialism, such as defunding hospitals and supporting care in communities, based on lessons from COVID-19. Katz Rothman does not mince words in her concluding remarks, proclaiming that restoring public health requires the overthrow of the Biomedical Empire.
This book is wonderfully engaging, with Katz Rothman at times referencing examples from her personal life to illustrate points, and not overly pedantic. Therefore, it would appeal to both advanced academic and undergraduate audiences. In reading, I found myself wondering how biomedical citizenship varies in different countries. The Biomedical Empire has been firmly established, but its effects are different in cultures where biomedical intrusion is somewhat recent. What does being a biomedical citizen mean in a culture where biomedicine is intermixed with traditional therapies? What are the different forms of biomedical citizenship that emerge in these contexts? This is an exciting line of investigation for future research.