In Part 5 of the Hospital Charity takeover, Fanny Chabrol reflects on charity in the building and operating of hospitals, detailing its inextricable links with capitalist cultures.
Charity may sound like an old-fashioned, paternalistic form of institutionalized medical care, deriving from a time when hospitals were erected mostly to confine the poor and “undesirable”. Yet, charitable giving continues to play vital roles in hospitals across the world. As an anthropologist who explores hospitals as infrastructures of medical care, imperial ruins, as well as future-oriented projects, I became fascinated by two hospitals that condense particular political affects and architectural features: Charity Hospital in New Orleans (a large medical center which closed just after Hurricane Katrina in 2005) and the Butaro Cancer Center in northern Rwanda. The latter was built in 2011 with funds from US charities and foundations via the NGO Partners in Health, while Charity Hospital inherited its name from its inception in the 18th century. Both are exemplary cases of the affinities of global capitalism and healthcare delivery.
Charity Hospital and disaster capitalism
Closed and abandoned for almost 20 years, Charity Hospital is now a ruin in downtown New Orleans. The gigantic Art Deco building stopped operating just after Hurricane Katrina devastated the city (Chabrol 2018). It was flooded when the levies broke after the storm hit in November 2005. Staff and patients fought heroically with no electricity and shrinking resources while desperately awaiting evacuation. However, a few weeks later, the New Orleans authorities decided that the hospital should be closed because the damage was “irreversible” and the risk of contamination persisted. Despite intense protest from a social movement comprising patients, staff, and locals, and various plans for its reopening, it never resumed operations.
At the time of its closure, Charity Hospital had already witnessed historical transitions, particularly during the period when it was founded when the health of the population started to matter for large-scale production and the birth of industrial capitalism.
Founded in the 18th century by a French shipbuilder to look after the poor population of the French colony, the Charity Hospital was originally called the Hospital of Saint John or L’Hôpital des Pauvres de la Charité (The Charity Hospital for the Poor).
It was run by nuns of the Sisters of Charity and other religious orders until the 20th century, when it became a medical center and a teaching hospital. Charity Hospital faced acute epidemiological challenges – including infectious diseases, such as tuberculosis and HIV/AIDS– as well as the rise of chronic diseases, violence and trauma. In 1992, the building was sold to the state of Louisiana and became part of the Medical Center of Louisiana at New Orleans (MCLNO) system. According to various sources, Charity Hospital was known for looking after the poorest people and providing excellent medicine, as was celebrated in several TV shows and a documentary called Big Charity (2014) released 10 years after its closure.
This living ruin has been called a “perfect storm” (Ott 2012) or a case of disaster capitalism, to quote Naomi Klein (Klein 2007). The catastrophe indeed offered the opportunity for radical reform—in this case the withdrawal of the State and the end of a medical system that provided subsidised access to good-quality clinical care and all medical and surgical specialties for all, including the poorest citizens and those without insurance. Closing this hospital symbolized the ending of the charity systemof access to public care for all. The argument in November 2005 was that damage required the hospitalto be closed and replaced, and this formed the background for the construction of two brand-new hospitals very nearby. Opened in 2015, the University Medical Center New Orleans and the US Department of Veterans Affairs Medical Center are both part of a new BioDistrict, a zone of economic development dedicated to the biosciences sector. The BioDistrict project opened the door for legal and administrative policy change that favoured privatization projects. In this neighborhood, disaster capitalism led to the adoption of neoliberal reforms in an exceptional context, which fueled the construction economy through public-private partnerships. Publicly supported healthcare became diluted in private schemes typical of biomedical capitalism and the marketization of healthcare. As of October 2024, the ‘the Spirit of Charity Innovation District’ is leading strategic plans for the renovation of and investment in the hospitals with commercial projects as well as research centers for Tulane University.
Butaro Cancer Center, a ‘partnership hospital’
Another fascinating example of US charitable giving is Butaro District Hospital in northern Rwanda, built in 2011 through a partnership between the Government of Rwanda and the NGO Partners in Health (PIH). Bringing high-quality care to the poorest is PIH’s mission. Since its creation in Haiti in 1987 by Paul Farmer, Jim-Kim, and Ophelia Dahl, PIH has established hundreds of programs in Haiti, Peru, Sierra Leone, and Rwanda to promote social medicine and equitable access to medical care, as shown in a recent documentary about this NGO. Since 2007 PIH has developed a partnership with the Rwandan Government to rebuild the Burera district health system. Butaro District Hospital was built in response to local needs: there was simply no hospital in the Burera district. It continued expanding its services to meet demand, and became a referral center for cancer, in particular breast and cervical cancer. It was upgraded to a teaching hospital in October 2023. The hospital is extremely well integrated into the landscape: It was built with local materials and an architectural sensitivity to air circulation and infection control. The young Chicago-based architect and design firm MASS Design has volunteered to coordinate all PIH construction projects in Rwanda.
Butaro attends to the poorest in the region, through a national insurance scheme that is mandatory (mutuelles de santé), and most healthcare workers are hired by the Government. PIH collects funds from a variety of donors, among them the wealthiest families and corporations in the US, and these are key to the continuous delivery of medical care. It’s a typical “partnership hospital” in the African continent, such as those that started to develop in the mid-1990s when HIV/AIDS programs were heavily funded by the philanthropy of western organizations like the Bill & Melinda Gates Foundation (BMGF). These programs formed well-funded enclaves within extremely under-resourced hospitals (Sullivan 2012), and are emblematic of the global health era and the philanthrocapitalism (Bishop and Green 2008) that supports it. Paul Farmer, a US clinician and an anthropologist, often described as a missionary, has been able to mobilize donors and catalyze important and recurrent donations from the wealthiest individuals in the US and to create partnerships to support meaningful programs. It is important to stress that Rwanda dedicated 7.32% of its GDP to health expenses in 2021 (when the mean investment in Subsaharan Africa is 5.1%) and has committed to developing a health system rooted in local communities.
Charity and the future of hospitals
From 18th century western cities’ institutionalized care to philanthrocapitalism at the beginning of the 21st century (Birn 2014), hospitals have always been important locations for charitable giving. The anthropological gaze allows us to be impressed by such projects and affective infrastructures (Street 2012) but at the same time to scrutinize the local arrangements and tensions arising from the fact that the world’s wealthiest individuals give only a tiny portion of their fortune to provide healthcare to the poorest of those “most in need”. Can there be healthcare in resource-poor settings without charitable money from global corporate capitalism? A complex question, worth asking in a time of deteriorating planetary health (David, Le Dévédec, and Alary 2021), when the damaging impact of the capitalist economy (real estate, construction, the food industry…) on the health of the people and the planet itself has become so evident. How can we not see an enormous paradox for the future of hospitals?
About the author
Fanny Chabrol is an anthropologist, IRD-research fellow at the Centre Population et Développement in Paris, and visiting research fellow at the Institute for the Humanities in Africa (HUMA) at the University of Cape Town.
References
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Chabrol, Fanny. (2018). Goodbye Charity Hospital. Anthropologie & Santé 16. Online.
David, Pierre-Marie, Nicolas Le Dévédec, and Anouck Alary. (2021). Pandemics in the age of the Anthropocene: Is ‘planetary health’ the answer? Global Public Health 16(8‑9): 1141‑1154.
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