Extraterritoriality at the end of life: disregard and the exceptional in St. Croix, U.S. Virgin Islands

ABSTRACT

This article approaches the theorisation of extraterritoriality through an ethnographic examination of the shaping of end-of-life experiences and trajectories through federal healthcare governance in St. Croix, an island in the unincorporated territory of the U.S. Virgin Islands. Drawing on critical phenomenological approaches to the organisation of attention, I advance disregard as a central dynamic shaping how the end of life unfolds on St. Croix through the constitution of the U.S. Virgin Islands as exceptional. I demonstrate the workings of disregard and the reproduction of exceptionality through analyses of the everyday workings of Medicare, the universal health coverage programme for American citizens 65 years old and over. Specifically, the case study examines how the bureaucratic disregard within Medicare worked to create and then maintain a situation in which the medical equipment that can support and extend the capacities of older adults’ bodies in the territory was unavailable. I suggest that this points to the broader import of disregard and the reproduction of exceptionality in constituting the extraterritoriality of the U.S.’s insular areas, and to the importance of the body as a locus of extraterritoriality.

KEYWORDS:

• Critical phenomenology
• end of life
• extraterritorial
• Medicare
• U.S. Virgin Islands

Acknowledgements

My thinking and writing about disregard have in large part been founded in conversations with Jason Throop and Christopher Stephan; I thank them both wholeheartedly. I also thank members of the ‘Team Phenomenology’ working group, specifically Lisa Guenther and Jarrett Zigon. I am very grateful to the editors of this special issue, Zachary Androus, Magdalena Stawkowski and Robert Kopack, for all of the work required to bring this collection into the world, as well as for feedback and support throughout the writing process. I also thank two anonymous reviewers whose comments pushed me to refine my argument and clarify my ethnography in ways that significantly shaped the final version of this article. Finally, Stacy Flaherty was invaluable in the final stages of editing this article.

Disclosure statement

No potential conflict of interest was reported by the author.

Notes

1 My research took place during 14 months of ethnographic fieldwork in the U.S. Virgin Islands (2014, 2015–2016).

2 See, for instance: Central Intelligence Agency 2021; The Henry J. Kaiser Foundation 2017; United States Census Bureau 2021; U.S. Virgin Islands Bureau of Economic Research 2015.

3 This is a point closely in line with Schutz’s (1962) ‘topographic’ account of social knowledge and relevance.

4 The case of Hawai’i is an important complication to the tidy continental/contiguous versus insular narrative. Officially annexed in 1898 and established as an incorporated territory in 1900, Hawaii became a state in 1959. It is thus an important element of any complete account of the U.S.’s colonial legislation of non-contiguous lands at the turn of the twentieth century (see Merry 2000). Here, due to space constraints, I focus on how historians of unincorporated territories have characterised this moment in American history.

5 The origins of the task force are complex. It was part of a ‘Quality’ program being established by CMS in communities across the U.S. which involved community organising to improve Medicare outcomes. The leaders of the task force worked for the Quality Improvement Organisation contracted with CMS to implement this program. However, the specific aims of the taskforce emerged in response to local conditions.

6 Notice, however, that the difficulties in obtaining medical equipment from Puerto Rico are also due to Medicare’s regulatory infrastructure, not from any ‘inherent’ difficulties in inter-island commerce.

Additional information

Funding

This work was funded by the UCLA International Institute; Department of Anthropology, University of California, Los Angeles; Society for Psychological Anthropology/Robert Lemelson Foundation Fellowship.

Notes on contributors

Devin Flaherty

Devin Flaherty is a medical and psychological anthropologist. She received her Ph.D. in Anthropology from UCLA in 2018 for her work studying ageing, care and end of life in St. Croix, U.S Virgin Islands. Since 2019, she has been an Assistant Professor in the Department of Anthropology at UT San Antonio.