UC Press Blog

Cancer Intersections is an ethnographic analysis of the complex and paradoxical efforts to access neoliberal, market-based oncological treatments in Colombia, a country where all patients are legally guaranteed access to medical services, including high-cost ones. Drawing on years of fieldwork in the city of Cali, Camilo Sanz explores the deep entanglements between medical, legal, and policy practices that share a common goal of treating and curing cancer but are hindered by bureaucratic procedures, pernicious financial interests, and class politics. Cancer Intersections shows how the interplay of these hurdles dictates the rhythm at which patients access treatment and how even in resource-rich settings, patients suffer because of market imperatives that shape how cancer treatments unfold. Through careful and measured observation, Sanz unveils how a neoliberal universal health care regime delays access to care for those reliant on public assistance, which means that some patients will start expensive treatments only after it is unlikely to change the course of the disease.

Camilo Sanz is Assistant Professor of Anthropology at the University of Oklahoma.

A free ebook version of this title is available through Luminos, University of California Press's Open Access publishing program. 

What motivated you to write on this topic?

I’ve long been interested in exploring how socio-economic inequalities get under our skin, increasing the risk for disease onset and shaping treatment outcomes. Growing up in Colombia during the 80’s and 90’s, I witnessed how life and death are shaped by estratos (strata), a caste-like system of socioeconomic classification. This system dictates the neighborhoods we live in, the taxes and utility bills we pay, the health insurances we get enrolled in, and, consequently, the time it takes to access medical services. These socioeconomic divisions are so deeply embedded in the Colombian imaginary, that they have become an everyday reality, almost too close to us to perceive—like the air we breathe.
 
In 2011, I returned to Colombia as a graduate student to conduct a two-year ethnographic study at public and private hospitals in the city of Cali. My goal was to understand how socioeconomic status and health insurance enrollment shape oncological practice and its consequences. I quickly learned that existing inequalities had worsened since the 1993 neoliberalization of the national health care system, particularly affecting low-income patients diagnosed with “high-cost” diseases like cancer. Despite universal health insurance enrollment, and health care being a fundamental right, not everyone can access the same hospitals, examination rooms, physicians, or chemotherapy treatments. Hence the Spanish phrase, “Juntos pero no revueltos” (Together but not jumbled). We all have the right to medical services, but in a highly stratified country like Colombia, the speed at which we can access these services is dictated by our ability to pay and the type of health insurance we can afford. My hope is that Cancer Intersections will help to highlight these pernicious class politics and entrenched inequalities that have shaped public health policy and continue to do so.

What does the book reveal about the challenges of neoliberal universal health care? Can you give us a specific example?

My ethnography reveals the serious flaws in assuming that societies can promote population health through neoliberal healthcare models. Colombia’s situation uniquely underscores the contradictions that arise when the right to health is paired with a market-based system, where health insurance companies compete by controlling costs without explicitly denying care. 

Cancer Intersections discusses two main reasons why oncology treatments often cause more exhaustion and pain for Colombians. First, health insurance companies delay treatments to maximize their profits. Second, biomedical practices, especially under capitalism, promote aggressive, early, and costly cancer interventions, even when diagnoses are unclear. This latter issue is not just a product of neoliberalism or capitalism but a feature of high-tech biomedicine itself, which aligns well with market-based logics. People with financial resources primarily face the latter issue, while low-income individuals encounter both the former and, to some extent, the latter when they can access biomedicine through tutela writs, which are legal mechanisms designed to protect fundamental rights such as health and life. 

What was something surprising or especially intriguing that you discovered while researching the book?

One particularly surprising insight I gained is that the market-based healthcare system has managed to reconcile incompatible rationalities and practices so effectively that it seems as though remediating them is no longer necessary. This is the case of tutela writs. Even though this legal mechanism was created to protect fundamental rights and make claimants visible before the state, my interlocutors tended to file it only after their right to health had been systematically violated and their lives were seriously threatened. Their goal was to provide judges with “indisputable” evidence that their lives had been endangered because of treatment delays caused by their health insurances. When these patients obtained favorable court rulings, however, it was too late. Chemotherapy had turned into a potent chemical abrasive, its effectiveness was now limited to extending life for a few weeks or months.

Additionally, although tutelas are largely filed against insurance companies for not providing prescribed treatments, at the time of my fieldwork these writs were being used by the insurances themselves to protect their finances from “high-cost” claims. This practice transfers the financial responsibility to the state. It involves court rulings against health insurance companies that authorize them to access public funds to subsidize the same treatments they have been sued for not providing.

What’s one key message you hope readers take from the book?

The stories in this book are not as much about patients’ will to live, as they are about their persistence to become visible before the state and protect their rights. Gaining access to anti-cancer treatments is a vindicatory practice in and of itself, regardless of treatment outcomes. My low-income interlocutors taught me that the point of accessing their prescribed treatments was to exercise their rights and “regain wasted time.”

While fighting to protect their right to health care may have granted patients access to medical services, it also inflicted more pain and suffering at the end of life. When cancers became terminal or metastatic, these individuals tended to be more focused on keeping the services rather than reducing therapeutic efforts or transitioning to palliative care. Instead of calling for more effective strategies to diagnose and treat cancer early or advocating for equitable and prompt access to anti-cancer treatments, dismantling the health insurance model—all of which are much needed interventions—I hope the readers see that counteracting the perverse effects of a neoliberalized health care system is not only about improving access to medical services that enhance and prolong life. It is also about the right to refuse care. Palliative care and euthanasia (physician assisted-dying) carry emancipatory possibilities. These two medical practices may have the potential for developing new relationships with decay and death, as well as for counteracting the tensions between a disease of self-devouring growth (borrowing Julie Livingston’s term) and an economy of unlimited growth.