On a fresh autumn day in 2019, under Madrid’s deep-blue sky, I went for a morning coffee with Ernesto, an infectious-disease physician working in one of Spain’s largest public university hospitals, located in the city center. At the time, I was doing fieldwork on the consequences of Spain’s austerity policies for public healthcare in Madrid. Before passing through the hospital gates, which open onto a busy two-lane street filled with busses, taxis, and delivery vans, we passed by a colorful sign in the hospital gardens that stated: “We are building the hospital of the future.”
When I asked Ernesto who would be paying for the hospital extension, given the lack of money in Madrid’s health service, he answered dryly: “The regional government is paying for the new building; it’s public money, well-spent here. But then there is the whole construction industry and new jobs are being created – that’s good PR. You know, this construction of a new building allows the hospital management to make highly symbolic announcements. What doesn’t interest them are the little things, the day-to-day (el día a día).”
Change of setting, nine months and one global pandemic later.
Just after the first wave of the global COVID-19 pandemic, on June 8, 2020, the president of the Autonomous Community of Madrid announced the imminent construction of a brand-new “emergency hospital” (hospital de emergencias) in the city at an overall cost of 50 million euros, which Madrid’s inhabitants simply call “the pandemic hospital”. By then, the COVID-19 pandemic had resulted in almost half a million cases and 30,000 COVID deaths in Spain. Madrid had been the epicenter of the disease. A few weeks later, 14 companies and four architectural firms had been contracted in an economic emergency procedure that legally suspended the ordinary rules of public contracting. Construction has been in full swing ever since, and, on December 1, 2020, the president of the Autonomous Community officially opened the hospital, baptized as the “Hospital Enfermera Isabel Zendal”, despite it still largely being a construction site.
During the inauguration ceremony, the president announced: “Today is a day of hope and excitement. … Madrid and Spain can count on a new, world-class center without precedent in Spain and Europe.” The 40,000 square meters of the hospital, once fully completed, are to be equipped with approximately 1,000 beds and will host four modular pavilions for patient treatment and centralized equipment storage. The regional government affirmed that the hospital is capable of responding “to any type of epidemic/pandemic in the future.”
Yet, despite these extremely positive statements the hospital has been highly contested. During its inauguration, unionists, concerned citizens and health professionals assembled before its gates to protest the opening. The protesters could be heard chanting “It’s not a hospital, it’s a set” (No es un hospital, es un decorado), and in media interviews construction workers stated “It’s not a hospital, it’s a construction site” (No es un hospital, es un solar). In my contribution, I propose thinking of this as-yet-unfinished hospital as a speculative infrastructure that gives material form to a spectacle of care. I thereby intend to reflect on what this spectacular hospital infrastructure might teach us about hospitals as such; that is, “hospitals as they are diversely built, inhabited, maintained, worked in, transformed, destroyed, closed, imagined, experienced or judged by different people and their realities” (Chabrol and Kehr 2020).
Hospital ethnography, in its narrow definition as ethnographic fieldwork inside a hospital, was not an option for me when researching the new pandemic hospital, for two main reasons: it is still currently a construction site, and I was unable to travel to Spain due to COVID-19. My argument therefore relies mostly on written sources, such as media reports, Twitter conversations or press releases related to the building process, and on regular email and telephone conversations with health professionals in Madrid. While my contribution thus remains silent on such “classical” topics of hospital ethnography as clinical practices or patient experiences, political, legal and economic challenges come to the fore, which I have already investigated ethnographically in Spanish medical institutions. Such difficulties linger in hospitals all over the world, but are oftentimes overshadowed by the primacy of day-to-day practices of medical treatment and illness experience. Through a focus on the public health context, the construction process and the multiple criticisms of a hospital-in-the-making, I explicitly foreground these latently lingering more-than-medical issues. I thereby try to show the extent to which hospitals are not only “affective infrastructures” (Street 2012) where “ordinary medicine” (Kaufman 2015) takes place, but also spectacular infrastructures where spectacles of care and speculation are rendered possible through specific affective, economic and legal regimes. Modern medicine functions within these regimes in Spain today.
A Spectacle of Care
The hospital Isabel Zendal, with its storehous-like appearance, was modeled on the “hospital de IFEMA”: a temporary field hospital set up in one of the buildings on the site of Madrid’s international fair at the height of the COVID-19 epidemic in mid-March 2020. Set up within days, this improvised infrastructure was often referred to in media and government reports as a “miracle hospital” (hospital de milagro). Four thousand patients were treated there between March and April 2020. For government representatives, the IFEMA hospital has become the symbol of “society’s and the government’s fight against the virus”, not unlike the makeshift hospitals in Wuhan. The first pictures of the IFEMA field hospital were indeed spectacular: hundreds of new hospital beds meticulously aligned, storage areas with thousands of boxes of personal protective equipment, temporary hospital rooms awaiting large numbers of patients so as to alleviate Madrid’s collapsing public hospitals. These pictures stood as a visual symbol of order, material upscaling and medical command during the chaotic uncertainties of an evolving epidemic.
The new permanent emergency hospital, according to the Madrid government, will aim to replicate “IFEMA’s success”. It is built to be “flexible” and “quickly upscalable”, “multipurpose, based on sectorizable wards … so that only the necessary parts can be staffed”. Equipped with the “most advanced” medical technologies, it is advertised as a “reference center”, capable of “adapting to any functional plan”. Once finished, it will host “50 ICU and intermediate care stations, diagnostic imaging areas, a laboratory, as well as a space for research, training and development, and a center for the simulation of new therapeutic solutions for pandemics”.
But while excavators, cranes and constructions workers have built new hospital walls, arranged beds and installed the latest computer systems in next to no time, there is, to date, no solid plan regarding who will actually work inside the hospital. Recent media articles have reported that it might be staffed with “voluntary personnel” from Madrid’s existing public hospitals and primary care centers, but professional unions have for now refused. Instead, a wave of indignation continues to sweep the community of healthcare professionals in the region, some of whom regard the pandemic hospital as a nonsensical project. Many in Madrid indeed see the new hospital as a structure unnecessary and overpublicized. According to the major newspaper El Pais, rather than being an efficient public health solution to the ongoing pandemic, the hospital exhibits “a great fondness for bricks”, with a “bias towards the building, the beds, what you can see and feel”. Professional organizations, such as an independent nursing association, made similar comments on Twitter: “There are plenty of bricks left over but not enough professionals (sobran ladrillos, faltan profesionales)”. The term brick, ladrillo in Spanish, has long been a symbol of the country’s speculative construction industry, which contributed to the 2008 housing and mortgage crisis and subsequent recession in Spain (Ravelli 2013). Severe austerity measures in healthcare followed, which are partly responsible for the considerable strain on the public health system in Madrid that we are witnessing today (Kehr 2019).
To recap: a new hospital is being built by the regional government, without the support of health professionals or a plan to staff it. The goal of the construction, as health professionals’ vocal critiques reveal, thus seems to be neither pandemic control nor medical care. Rather, the government has literally constructed a spectacle of care with bricks, in which “the goal is nothing, development is everything”, to borrow the words of Guy Debord from his work The Society of the Spectacle (2005, 10). By constructing this emergency hospital, by showcasing plans, cranes and the construction site, by communicating about beds and ventilators, the building of the new hospital infrastructure has become a goal in itself. It is also “a reflection of the ruling economic order” (Debord 2005, 10) in Spain, its health system included, where political promises of care rely on economic speculation with bricks. In Madrid in particular, it also illustrates how far hospitals have become deeply entangled with national real-estate.
Construction projects like this make nationalist promises of care that perpetuate a long-standing hospitalocentric vision of healthcare in the country (Perdiguero-Gil and Comelles 2019). Already in the 1960s, new social security laws materialized in the building of hospitals in the form of “sanitary cities” (cuidades sanitarias) by Francisco Franco, the Spanish dictator who ruled until 1975. This happened in all major Spanish cities from 1964 onwards (Pieltáin Álvarez-Arenas 2003, 78). Thus, hospitalocentrism was but one facet of a technocratic infrastructural building programme in totalitarian Spain that also included dams and motorways, and in which engineers and architects were held in high esteem (Camprubí 2014; Swyngedouw 2015). Such infrastructural projects and their nationalist specters are reappearing once more in Madrid’s new hospital of speculation. Visiting the construction site in October 2020, the president of the Autonomous Community of Madrid said: “This is a Spanish brand and shows how our engineers and architects are the best”. The pandemic hospital, much like IFEMA before it, is thus not only a highly symbolic, sovereign spectacle of control during the uncertainties of a global pandemic that has left deep scars and a profound sense of helplessness in the lives of many Spaniards. It is also an act of political and economic speculation with care for the nation. In this hospitalocentric exercise, where spectacle and speculation meet, there is little space for the difficulties of ordinary, day-to-day medicine and its “little things”, as Ernesto would say.
Day-to-day medicine in Madrid, be it in public hospitals or in primary care settings, is indeed much less spectacular than the newly built emergency hospital. Usually, public hospitals and primary healthcare centers are staffed by health professionals who are either civil servants or, increasingly, public employees on fixed-term contracts. Spain established a national public health system in 1986, a decade after the democratic transition, that is tax-funded and universal in access. The country’s autonomous communities have a high level of sovereignty in the organization and financing of medical personnel and infrastructure. In the Madrid Autonomous Community, the public health system is one of the most drained in the country today: hospital services and primary care centers have been on the brink of collapse since the onset of the pandemic, with wards overpopulated, staff exhausted and medical supplies out of stock. Currently, primary care physicians attend to from 40 to 80 patients a day; in hospitals, staff on sick leave or vacation are habitually not replaced; hospitals – their facades, pipes and elevators – are literally crumbling.
This crisis of maintenance, resources and workforce is genuinely not new, though. It has been going on for a decade, due to the implementation of austerity measures which have left hospital services at a structural limit in terms of beds and personnel, primary care centers severely underfunded, and professionals in increasingly precarious situations. Almost 3,000 hospital beds have been closed in Madrid during the last 10 years, that is three times the number of 1,000 new beds promised with the emergency hospital, and there are 3,200 fewer healthcare employees in the region than 10 years ago. Bea – a friend, fellow medical anthropologist and primary healthcare physician – recently told me of her frustration about her medical everyday: “One of the issues now is that primary healthcare is collapsing without anybody paying attention to it … . The workload is unbearable.” Since our email exchange, she has quit her work in primary care, like others in the small but active #YoRenuncio (“I resign”) movement.
To those familiar with this unglamorous medical “day-to-day”, as Ernesto called it, that “nobody is paying attention to” as Bea said, the government’s investment in a new hospital amounts to “selling smoke”, vender humo, which means making a false promise. I often heard the expression vender humo during fieldwork when I talked with health professionals or patients about proposed investments in relation to promised healthcare infrastructures, for example the rebuilding of the famous Spanish hospital La Paz from scratch at a cost of 350 million euros in 2018. “Selling smoke”, here, describes spectacles of care, through which the government sporadically invests in spectacular infrastructures, like hospitals, thereby obscuring the ordinary conditions of medical practice. In this sense, spectacles of care are a communicative play with people’s expectations of care and, currently, epidemic anxieties, that veils the steady dismantling of public health services and the ever tighter management of staff and maintenance that has been ongoing for at least a decade. The expression vender humo expresses well the double movement of obscuring the material and experiential difficulties of ordinary medicine, while selling promises of care through spectacular infrastructures.
Let me say a few more words about the location of the new hospital, which is not accidental. The hospital is situated in the far north of the city, in Valdebebas. This large urban development area is bordered by motorways, the international airport hub Adolfo Suárez Madrid-Barajas, and the Ciudad Real Madrid, the training complex of the world-famous football club. The hospital construction is an intrinsic part of the urban development project of this business and public service area, surrounded by major traffic junctions. Only recently the president of the Autonomous Community declared that very soon “all Madrid residents and all Spaniards can enjoy a new public hospital next to an airport, in a matchless location”.
Forms of emergency contracting in healthcare, be it the construction of hospitals or the provision of personal protective equipment, were rendered possible in pandemic Madrid through the royal pandemic emergency law and, as far as the hospital construction is concerned, the regional 2001 land law’s special clauses on “exceptional public interest”. The latter permitted the government to obtain permission to build the hospital on communal land in Valdebebas through a shortened real-estate procedure as provided for “in art. 161 of the Land Law (Ley de Suelo)”. Also, faced with the COVID-19 emergency, as stated in the aforementioned new Royal Decree 7/2020 of March 12, contract adjudications for construction firms have been speeded up: the call for tender on the hospital project was much quicker than public contracting procedures usually are and was severely limited in terms of transparency and corporate responsibility, as contracts were adjudicated “by hand” – that is through individual decisions. Also, payments from public funds are regularly made in advance to private companies, that is even before the agreed assignments have been executed.
This legal regime thus allowed for the rapid spending of public money on the emergency hospital in the first place, without public or professional deliberation. Around 100 million euros or more of public capital, that is at least double the amount announced at the beginning of construction, thereby flowed into private firms within a matter of weeks. All this happened while primary healthcare has been gradually collapsing in the region, while hospital wards that had been built in the 2000s remain closed (see below), and while the regional public health service lost 3,000 healthcare workers within 10 years. Most of the 14 firms commissioned to build the hospital are large Spanish enterprises that operate globally, such as Ferrovial Servicios, Dragados and Sacyr Infraestructuras, to name just three major ones that are listed on the Stock Exchange. Unlike smaller firms, they have been able to make rapid offers for tender because of their large reserves of machines, materials and a quickly employable and exploitable workforce. All of the firms were also already operating within the public health system in Madrid. Ferrovial Servicios is in charge of hospital cleaning for some of Madrid’s major public hospitals, which have been in the eye of the storm during the pandemic, like La Paz and 12 de Octubre. Dragados, a firm owned by the president of Real Madrid, Florentino Perez, has constructed the latest airport terminal, Terminal 4, nearby. The firm also built Madrid’s forensic institute, commonly known as “The Donut”, which was used as a morgue for hundreds of corpses during the first wave of the pandemic, and around which the new hospital is being constructed. Sacyr Infraestructuras was involved in the construction of the twelve public–private partnership hospitals in the 2000s, during the years before the financial crisis, and during the height of the pandemic in March 2020 was quickly providing ICU beds at a high cost for the repurposed library areas in the public hospital where Ernesto works.
New hospitals are the paradigmatic infrastructures of a speculative healthcare economy, which operates through a double market of value. Care is performed through public spectacle by building expensive new infrastructure with public investment, while maintenance as well as ordinary medicine remain structurally under-resourced through a shortage of staff and funds. In Spain, public investment in spectacular infrastructures heavily relies on real-estate development, which itself is a form of capitalist power. David Harvey has shown that, “command over space … is always a crucial form of social power”, that is “both expansive (the power to do and to create) and coercive (the power to deny, prevent and, if necessary, to destroy). But the effect is to redistribute wealth and redirect capital flows to the benefit of the imperialist or hegemonic power at the expense of everyone else” (David Harvey cited in Korcheck 2015, 100). With the emergency hospital, the government has built a spectacular infrastructure, thereby creating a spectacle of care. At the same time, sufficient means for the existing landscape of public healthcare are continually denied, and ordinary medicine, or rather its unglamorous facets, have slowly been ruined over more than a decade. In pandemic Madrid, public healthcare materializes in a tiring everyday, for patients, families and healthcare staff. But it also materializes in the mode of “disaster capitalism” (Klein 2007), where ever more public money is transferred into private hands, especially in times of crises.
Publicly funded hospitals figure uneasily here. They are speculative infrastructures, precisely because they are spectacular ones. As in most other places in the world, hospitals are the flagship sites of modern medicine; they are “affective infrastructures” (Street 2012) that deeply matter to people. Hospitals indeed perform what many Spaniards think of proudly as spectacular work. But there is more to the spectacular. Hospitals are also prone to being advertised in political spectacle in Debord’s sense, much more than the other building blocks of medicine, like primary care. “There is lots of money in hospitals, also because they are high profile electorally speaking”, one of my interlocutors, a hospital physician and local politician, told me during fieldwork in 2018. “There are things that sell and things that don’t”, she went on. “So, the things that sell are the hospital things. Some of them are indeed truly amazing: a child that has undergone transplant surgery and has survived, for example.” Hospitals are spectacular infrastructures in the sense that the spectacularized facets of modern biomedicine open up profitable possibilities of public spectacles of care. This co-presence of spectacular work and public spectacle makes hospitals prime sites of economic speculation.
In Spain particularly, public hospitals are those sites within the country’s crumbling national health system in which medical care is as much an everyday reality as speculation and capital accumulation, which run economically, politically and historically deep. Some hospital projects share traits – albeit only very partially – with the thousands of private housing development projects now lying in ruins (Korcheck 2015) that became world famous during the 2008 financial crisis and the bursting of the real-estate bubble in Spain. For many healthcare professionals in Madrid, the erection of the new emergency hospital conjures specters of the 2000s, when twelve hospitals were created as public–private partnerships, some of which are understaffed to this day, some with empty wings, where promises of care were ultimately not kept.
The investment in new public hospitals is without doubt important. They have a central care function in contemporary societies that most people would not want to miss out on. But hospitals are also objects of political spectacle and economic speculation, an aspect that cannot be written out of them. Hospitals are not situated outside capitalism and speculative finance, even if publicly funded. Hospitals are but one of capitalism’s ambivalent nodes, where capital accumulation and different economic and social values intersect. This does not impede precious forms of medical care, but shows the extent to which hospitals are spectacular infrastructures that are multiply meaningful and valuable, in medical as well as monetary, political and affective terms.
Janina Kehr holds a Ph.D. in social anthropology. Her research encompasses infectious diseases, global health, medicine and the economy. Currently she is writing up work on public health infrastructures and practices of care at the intersection of debt economies, state bureaucracies and peoples’ experiences in austerity Spain. Twitter: @janinakehr
I wish to thank Tomás Sanchez Criado and Fanny Chabrol for commenting on earlier versions of this text, Julene Knox for precious English language edits and Miguel Salas Capapey for continuing conversations and the photos of the yet unfinished hospital he generously took for this contribution.
 Data retrieved from the European Centre for Disease Prevention and Control on September 7, 2020 https://www.ecdc.europa.eu/en/cases-2019-ncov-eueea
 The hospital is named after the public health nurse Isabel Zendal, who in 1803 became the first woman to accompany a smallpox vaccination expedition in the Spanish overseas colonies. On the expedition, children were used as human vessels to transport the live smallpox vaccine. For a historical account see (Mark and Rigau-Pérez 2009).
 See her Twitter feed from October 24, 2020 on the reasons for quitting: https://twitter.com/bearagonm/status/1319928792656338946
 For a critique of the emergency contracting procedures, see https://hayderecho.expansion.com/2020/05/19/el-mal-uso-y-los-abusos-en-la-contratacion-de-emergencia-para-salir-corriendo-y-no-parar/
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