Encounters of Violence and Care: Central American Transit Migration through Mexico by Kristin Yarris
A polarized emphasis on origin and destination in international migration studies has left the process of transit itself relatively under-theorized. Taking transit as a site of inquiry moves us as migration scholars beyond the binaries of push/pull factors and origin/destination countries. As medical anthropologists, we are interested in the analytical implications of studying zones of transit for the way we think about illegality, humanity, and encounters of care that sustain the possibilities of life itself for transnational migrants. Further, we view encounters in zones of transit as sites through which we can better understand human vulnerability, risk, and radical inequality, as well as relationality, solidarity, and care. Here, we explore these ideas by drawing on ethnographic vignettes from a recent field research trip in Mazatlán, a particularly precarious site for Central American transit through Mexico (the trip was co-organized by our colleagues at the Universidad Autónoma de Sinaloa – UAS).
We define transit as the encounters, fleeting and permanent, that occur between migrants and the various material, bureaucratic, and social relations that structure transnational journeys and the possibilities of life itself for migrants en-route. Materially, for example, we consider the “bestia”, the Ferromex freight train to which migrants cling as they travel over the thousands of kilometers of tracks that form Mexico’s Ruta Pacífica north from Mexico City and Guadalajara through Sinaloa state towards Mexicali (see Map) and whose imposing steel wheels cut across the landscape (and often across migrant limbs). Bureaucratically, we analyze the structures of legal responsibility surrounding unauthorized migrants that attempt to regulate mobility within the logic of the nation-state. These represent encounters of rupture or disjunction, as when an undocumented migrant in need of urgent medical attention is transferred from a local public hospital to the Mexican National Migration Institute (INM), which then assumes the costs of medical care. At the level of communities, we are interested in how relations of care emerge nearly spontaneously between migrants and local residents who offer them shelter, food, phone calls, and showers. These offers of support are as fleeting and tenuous as migrants’ journeys through these communities, and the relations that form between migrants and community members are entrenched in risk for both.
Materiality of Encounters: Violence
Wendy Vogt has carefully documented how Central American migration through southern Mexico results from the intersection of political insecurity, economic instability, and violence (Vogt 2013). Given historical legacies of civil wars and contemporary realities of insecurity, she writes that, for Central American migrants, “[t]he violence of migration becomes relative to the violence of everyday life at home” (Vogt 2013:768). Besides Vogt’s work, transit migration through central and northern Mexico has received relatively little anthropological attention. In Mazatlán, we heard similar tales of violence, police brutality, and extortion from migrants and their advocates. This stretch of the Ruta Pacífica is, in fact, known to be one of the most dangerous, ironically because it is not controlled by organized criminal entities such as the infamous Zetas, but is rather uncontrolled and therefore ripe for attacks by local-level actors, such as neighborhood gangs, who prey on those journeying along the tracks. Migrants on trains have taken to carrying sticks in their attempts to defend themselves from predators, whether local criminals or police. One group of migrants we met in a Mazatlán colonia while they waited for a departing train told us of having been assaulted and robbed by federal police in La Lechería, an infamous train crossing area just outside Mexico City. According to the migrants, the federales had quite literally offered them food with one hand and robbed them of the little cash they carried with the other. Such encounters are violent reminders to migrants that they are not welcomed in Mexico permanently (El Universal, a Mexican daily newspaper, recently reported that of nearly 10,000 child migrants detained in Mexico in 2013, only 50 were offered asylum).
In fact, the risks of robbery and rape are ever-present and viscerally-felt for migrants in transit. We heard stories of sexual assault of both men and women; for instance, one young migrant was carrying his money inside his underpants and was raped, a theft of both his money and his bodily integrity. For women migrants, the risks of transit are heightened—many start their journeys north by taking a long-acting contraceptive because they view rape as an inevitable part of the process. We met women who formed partnerships with “husbands” or “compañeros”, temporary and strategic kin ties formed in transit that are attempts at mutual protection. Men also benefit from such temporary kin formations because there are various encounters in transit in which travelling as a “family” reduces risk. For instance, we met a private security guard working at a Ferromex train yard who told us that he allowed families—but not single men—past his gated checkpoint (looking the other way while they passed), since it is safer for them to climb aboard the stopped trains before the wheels begin to churn forward along the tracks. These examples illustrate how, within the material violence of transit, fleeting moments of humanity emerge, a point to which we return below.
Bureaucratic Encounters: Structuring Transit
One of our encounters in Mazatlán was with the Sinaloa state branch of the Mexican Instituto Nacional de Migración (INM). Our meeting with the INM director and two immigration agents had been arranged ahead of time by our UAS colleagues and was held in a formal conference room in the INM’s offices, which had been cleaned and prepared for our meeting with a white table cloth and water bottles. Clearly, we were guests of interest, and it was important to the migration officials to portray their work to these visiting academics in a positive light. During the meeting, INM agents attributed the current rise in Central American child migration to the recruiting tactics of coyotes who promise safe passage to the U.S. at the going rate of $7,000 upwards. In this narrative, also prominent in the U.S. media, central culprits in this migration stream of unaccompanied minors are human smugglers, who are portrayed as impersonal, criminal, and malevolent. However, one of our previous field research projects in Nicaragua revealed that coyotes are often known by the families that contract their services; they are extended family, neighbors, friends of friends and their services are sought out by families desperate for ways to reunite with children abroad and confronting their effective exclusion from legal mechanisms for family reunification. This is not to say that there are not highly organized and armed actors involved in the transit of Central Americans through Mexico—there are, such as the Zetas and other cartels that control transit routes. However, there are also lower-level and less formal actors involved. In part, blaming human smugglers for child migration (especially by indiscriminately labeling them all “traffickers”) functions to shift responsibility away from both Mexican and U.S. immigration policies. For, as Wayne Cornelius has shown (2006), heightened securitization at the U.S./Mexican border has created more demand for these smugglers, who promise safe passage. It also forces people into riskier passages, such as across the treacherous Sonoran desert north of Sinaloa, where the Border Patrol has recorded 5,595 deaths of assumed migrants between 1998 and 2012 (see: http://colibricenter.org). Furthermore, the increasing securitization focus of U.S. foreign policy in Mexico and Central America has included training and equipping entities who themselves are implicated in human rights violations against migrants (Vogt 2013: 771). Thus, U.S. policy directly contributes to the dangers of transit encounters.
Interestingly, a 2011 Mexican Immigration Reform Law has resulted in a significant discursive shift among Mexican immigration officials, who emphasize their role as administrative (even humanitarian) agents rather than border police. For instance, in our meeting, INM officials were careful to refer to migrants as “undocumented foreigners”, refusing to use the word “illegal”. When asked about this language, the officials stressed that their new approach is coming from higher up in the INM bureaucracy, and reinforced the idea that immigration officers are administrative agents charged with safeguarding migrants’ human rights by emphasizing that agents are unarmed. They also mentioned their difficulty keeping pace with the flow of migrants through Sinaloa, saying they focus limited resources on monitoring highway (bus and car) travel, rather than the train routes. INM presented themselves as following appropriate bureaucratic procedures with migrants they apprehend, including the evaluation of minors by DIF (Desarollo Integral de la Familia—the equivalent of Health and Human Services in the U.S.), and a series of communications between INM and country-of-origin consulates. Migrants apprehended by INM in Sinaloa are held on-site in the migration offices (which are not intended to serve as shelters), until official clearance is given by home country consulates for their deportation. Perhaps to emphasize the bureaucratic legitimacy of these transfers, at the end of our meeting, INM agents passed around folios of children they had detained and deported in recent months. It was as if these manila files, organized with headshots, dates, notarized stamps, and official signatures, were proof of the legality of forced return set against the illegality of transit migration. Bolstered by these bureaucractic procedures and the discourse of human rights, INM encounters with undocumented migrants are made to seem legitimate and rational even as they are steeped in the radical and irrational inequalities that ultimately determine migrants’ movements.
Encounters of Solidarity and Care
While transit migration is shaped by vulnerability and violence, it is also comprised of very local, often fleeting, encounters of support, solidarity, and care. On one hand, migrants are assisted by formal non-governmental organizations, such as Cáritas, a relief and social service organization of the Catholic Church. In Mazatlán, Cáritas runs a shelter located about a kilometer from the train tracks. (Not all migrants are willing to risk the walk there, however, since they face attacks by local gang members or apprehension by local police in the neighborhoods through which they must pass.) The animated young social worker at Cáritas, “Ana”, told us she registers an average of 10-15 migrants every night, men and women (children are referred to DIF). Ana showed us the registry she keeps as an Excel spreadsheet; it was overwhelming to look down the names, ages and photographs of hundreds of migrants who had sought shelter since January 2014. Also notable was that a good number of these migrants were in their late 60s and 70s; while we don’t often hear about older-age migrants, they are certainly particularly vulnerable to the extremes of transit. At Cáritas, a volunteer physician attends to migrants’ health needs; on the afternoon of our visit, he described the politraumas of transit he encounters in his patients: injuries, loss of limbs, skin infections, foot wounds. However, even before medical care and a hot meal, migrants entering the Cáritas shelter seek showers. After weeks of travel, the ability to bathe and change into clean (donated) clothes reinvigorates and re-humanizes them.
Just as the INM officials have their own discursive way of framing transit migration, so do Cáritas workers. Motivated by their religious orientation towards social justice and service to the poor, all the staff we met at Cáritas referred to migrants as peregrinos. While this word can be generally defined as “someone moving from one place to another”, it has a more specific meaning within popular Catholicism as one on a pilgrimage, who “for devotion or belief seeks to visit a sanctuary”. In the shelter, men’s and women’s dorms, showers, a closet full of linens, and even bottles of hair gel were all labeled with this term, peregrinos. The framing here was one of equality and of service, and it shaped relations of care, such as the offer of a shower, clean clothes, and hot meals—all micro-encounters in transit zones that embody a shared humanity and enable life itself.
Where Cáritas is a formal humanitarian organization, we also encountered other, informal, local actors who offer support to migrants on their journey North. In a Mazatlán colonia situated alongside the train tracks, we met a woman who runs a small venta (store) who for years has been offering migrants bottles of water and a location to have money wire-transferred from relatives back home. In another neighborhood, we met “Eva”, who voluntarily runs a community kitchen (or comedor) several blocks from the train tracks where she cooks hot meals every single day. Word of mouth spreads as it is wont to do, and migrants find their way to her tables to have a meal and replenish their strength. Many of Eva’s neighbors don’t look fondly on what they see as her “attracting” migrants (and the violence that follows them) to their neighborhood. And yet, Eva has created a local network of completely informal care to support migrants—her kitchen is staffed by several neighborhood women volunteers and, nearby, she recruited another neighbor who generously offers her shower to migrants waiting for departing trains.
On one occasion, we visited the comedor to find that a group of migrants had missed a disembarking train. The migrants were at the neighbor’s house showering as they waited for the next departure and that is where we talked with them about their journey. The travelers were from El Salvador, and several stated they were family (husband, wife, 2 year old son; two female cousins). One young woman, “Silvia”, told us she had left El Salvador because the gang violence in her neighborhood had become so intolerable that she felt she had no choice. A female cousin of hers was recently assassinated by a gang, which threatened Silvia that she was next. She cried as she told of the two children, aged 1 and 4 years, that she had left behind in the care of her mother. Silvia was visibly racked with anxiety, her hands trembled as she told us of the danger she and her traveling companions had experienced, which included an attempted rape, several robberies, hunger, cold, heat, and exhaustion from trying to hold onto the trains for days on end without sleep. She seemed to be encouraging herself, however, when she told us that she believed the hardest part of her journey was behind her. We had not the heart to tell her that the next phase of her transit—north through Sonora’s desert and then into the border regions of Mexicali and Tijuana—could be much worse. Indeed, it is estimated that only 20% of all Central Americans who travel through Mexico make it across the border into the U.S. (even fewer actually arrive at their U.S. destinations). For days after our conversation with Silvia, we wondered if she would be among that statistic, or among the other, larger group whose dreams end in detention, deportation, or worse: death.
Illegality, Violence, and Care in Transit Encounters
In Mexico, Central Americans face a triple liminality—unsafe in their country of origin, unaccepted in the country of transit, and marginalized in the destination country (that is, if they make it that far). While the notion of “illegality” does important work in shifting our conceptualization of the lives of (im)migrants, it doesn’t adequately capture the conditions of existence of those in transit. While unauthorized in Mexico, these migrants in transit don’t intend to stay, but are driven towards their hoped-for destination in the U.S. What motivates these journeys of risk is an even more “bare life” in Central America—a sense that even in the country of one’s birth, one’s existence is threatened. For this reason, in addition to thinking about migrants in transit existing in “liminal” or “illegal” spaces, we may borrow the framing of Cáritas and think of migrants in transit as “peregrinos” — “pilgrims”, travelers, those en route. And yet the English “pilgrim” lacks a sense of risk, danger, and vulnerability that the Spanish “peregrino” contains. Marginalized from power, work, and citizenship within contemporary global capitalism, these Central Americans risk life itself in search of life itself. Like the undocumented migrants in France that Ticktin writes about (2006), who are willing to risk HIV infection for the possibility of legal status, Central American transit migrants face rape, robbery, dismemberment and even death in exchange for the possibility of legality in the U.S.
In zones of transit, which are structured by national immigration laws and shaped by contemporary global capitalism, state power is manifest produced in everyday, local interactions (Aretxaga 2003). However, social relations of transit are not fully determined by laws nor politics, but by a sort of local antipolitics, which we are describing here as transit encounters. They are moments, interactions, and exchanges broadly structured by geopolitics of illegality, yet offering the possibility of humanity through gestures of care, however fleeting. Sarah Willen (2014) has used the concept of “inhabitable spaces of welcome” to describe social spaces crafted by unauthorized migrants in Israel in order to lessen the risks and burdens of illegality. Comparing the transit encounters we describe here to Willen’s spaces of welcome reveals important insights. First, we find transit encounters shaped by relations between local community members and migrants in transit—these encounters usually are forged by some gesture of humanity, act of solidarity, or expression of care by Mexicans towards Central Americans. Further, these encounters are less welcoming than they are life-sustaining, even in their impermanence. Transit encounters also involve significant risk and are fleeting. Cáritas shelter staff risk allegations they are aiding unauthorized movement through Mexican territory, the security guard risks his job by allowing migrant families into gated train yards, Eva risks her reputation among neighbors who criticize her for encouraging migrants—and the violence that may follow them—into their colonia, and migrants risk everything: material security, social ties, bodily integrity, and life itself. Finally, as analysts of these encounters, we face the challenge of how to write about them, how to interpret them in ways that don’t contribute to further illegalization of persons in transit nor stigmatization of those who come to their aid.
To conclude, we reflect on how our own encounter with transit migration has somewhat unexpectedly corresponded with heightened public discussion of Central American migration to the U.S. over the past several months. Not wanting to contribute to further misrepresentation of a highly-charged political issue, we find that our ethnographic encounters in Mazatlán have grounded us and informed our nascent thinking about encounters in zones of transit. While we certainly recognize the ways undocumented Central Americans clinging to trains in their transit hacia el Norte embody the vulnerability, violence, and inequalities inherent in contemporary geopolitics of migration, we are also drawn towards the encounters within transit, which are structured by violence but also embody a committed sense of care and common humanity. Recent scholarship on care in medical anthropology emphasizes relationships of obligation and commitment to the well-being of others while acknowledging that caregiving can reproduce social inequalities (for example, see Elana Buch 2013). The relations of care we observe in transit migration are transitory, not based on long-term relations of kinship and reciprocity; care within transit encounters is structured by the very same radical inequalities that shape transnational migration. Thinking about transit encounters is pushing us to rethink our notions of illegality, marginalization, and deservedness (ideas we have been working through elsewhere; see Yarris & Castañeda, in press). By studying zones of transit, we gain new insights into contemporary human relationships, shaped as they are by violence, inequality, and risk, but also by care, support, and solidarity.
Kristin Yarris is Assistant Professor in the Department of International Studies at the University of Oregon. She has a PhD in Sociocultural Anthropology (2011), an MPH in Community Health Sciences (2004) and an MA in Latin American Studies (2004) from the University of California, Los Angeles. Her research areas include: transnational migration, intergenerational & informal caregiving, mental health and illness, and sociocultural determinants of health.
Heide Castañeda is Associate Professor in the Department of Anthropology at the University of South Florida. She received a PhD in Anthropology from the University of Arizona (2007), MPH from the University of Texas (2002), and MA in Anthropology from the University of Texas at San Antonio (2000). Her primary research areas include migrant health, health policy, undocumented/unauthorized migration, and constructs of citizenship.
Aretxaga, Begoña. 2003. Maddening States. Annual Review of Anthropology 32:393-410.
Buch, Elana D. 2013. Senses of Care: Embodying Inequality and Sustaining Personhood in the home care of older adults in Chicago. American Ethnologist 40(4):637-650.
Cornelius, Wayne A. 2006. Impacts of Border Enforcement on Unauthorized Mexican Migration to the United States. At: http://borderbattles.ssrc.org/Cornelius/printable.html
Ticktin, Miriam. 2006. Where ethics and politics meet: The violence of humanitarianism in France. American Ethnologist 33(1): 33-49
Vogt, Wendy A. 2013. Crossing Mexico: Structural violence and the commodification of undocumented Central American migrants. American Ethnologist 40(4): 764-780.
Willen, Sarah S. 2014. Plotting a Moral Trajectory, Sans Papiers: Outlaw Motherhood as Inhabitable Space of Welcome. Ethos 42(1): 84-100.
Yarris, Kristin and Castañeda, Heide. In press. Introduction, Special Issue, Discourses of Displacement and Deservingness: Interrogating Distinctions between ‘Economic’ and ‘Forced’ Migration. International Migration.
When I teach Medical Anthropology, we talk about globalization and infectious disease, with a focus on the increasing speed of global travel. Typically, I discuss a hypothetical epidemic that could accompany a traveller from a distant continent to the local airport. This year, a hypothetical epidemic will not be necessary. Instead, we have the rapid spread of Ebola, poised to make this airline-mediated leap. Of course, showing how it may be coming to get “you” is a means to help students understand that viruses in distant lands are not so distant after all. In a Milwaukee Journal-Sentinel article, Paul A. Biedrzycki of the Milwaukee Health Department reminds us that we should care about the Ebola epidemic for reasons that extend beyond our own fears of contagion: “The Ebola epidemic is not so much a public health wake-up call as it is a call to action on part of the entire global community to protect and take care of each other. The question remains whether we have the courage and determination to heed the call.”
As of August 28, WHO reports that 3069 people have contracted Ebola in Guinea, Liberia, Nigeria and Sierra Leone since March, and there have been 1552 deaths, with an overall case fatality rate of 52%. The New York Times supplies interactive information and maps. “Patient Zero” is reported to have been a two-year old boy living in an area of Guinea that borders Sierra Leone and Liberia; the disease spread to his grandmother, and mourners at her funeral brought it with them as they returned to their own villages. A brief article in the NEJM explains how this conclusion was drawn, including a detailed outline of the likely paths of transmission. Incremental reports of epidemic spread can also be found at ProMED-mail, a system that allows doctors and health officials to report disease emergence as it happens, and it can also be viewed in mapped form.
A form of quarantine called a “cordon sanitaire,” which restricts movement from an entire area, has been established in some countries. In a New York Times article, this method is considered notable because it has not been seen for almost a century, being more associated with “the medieval era of the Black Death.” Monica Green, a historian of medicine (including Black Death) offers some valuable teaching notes to aid in understanding Ebola both in the present and within the historical context of global health. Another historian reminds of the disastrous consequences of a cordon sanitaire imposed during an outbreak of bubonic plague in Honolulu’s Chinatown.
Returning to the local scope (both temporal and geographic), we encounter the question of intervention, medical treatment, and trust, with mistrust resulting in riots in many communities, including a case in Guinea where residents rioted in response to sprayed disinfectant: “Health workers and the hospital in Nzerekore were attacked by people reportedly shouting: ‘Ebola is a lie.’” Fear of doctors, including fears that doctors from MSF or the Red Cross are themselves spreading the disease, has at times lead to attacks on clinics. After the Cholera outbreak in Haiti was traced to UN workers, it is not difficult to understand this sort of fear. Not surprisingly, anthropologists have something to say about this situation. For a consideration of the biomedically-mediated disposal of infected bodies, local meanings of burial and ancestry, and notions of risk, listen to the discussion of “Ebola and Virology” on the podcast “This Anthropological Life.”
As the epidemic spreads, of course people begin to worry about “What Would Happen If Someone Got Ebola in America?” (Or in the UK. Or in Sweden. Or specifically at SUNY Plattsburgh). The Atlantic’s America scenario goes like this: “You wake up and feel a little weak. It’s almost like you have the flu. You stumble to the medicine cabinet and grab a thermometer. You have a fever, so you pop two Tylenols and go back to bed. The fever does not go away. You see your primary care physician, who says it looks like flu and to call her if the symptoms change. The next day, the fever is going strong, and you feel even worse, wracked with chills and a headache. You remember that you recently butchered a West African fruit bat, for some reason. You call 911.” While the fruit butchery example is presumably meant to convey the unlikeliness of this scenario (just in case, here is a picture, so that you can more easily avoid it), Ebola arriving in North America is nevertheless not a trivial concern. The Daily Beast reports on a near-miss case: If he had not died from Ebola in Nigeria the day before, a man traveling from Liberia could have been on his scheduled flight to Minneapolis.
Ethics – particularly concerning resource allocation – have been discussed at length in relation to this Ebola epidemic. Two Americans were airlifted out of West Africa for treatment at Emory University Hospital, and this has generated a great deal of debate about unequal treatment, which is throughly summarized here by The Hastings Center. The use of the experimental drug ZMapp (so far with great success) on these Americans also sparked discussion on many levels, including whether these same drugs should be used broadly for patients in Africa, and more generally, who gets access to these experimental drugs? The WHO has concluded that distributing this drug is ethical. The next questions will undoubtedly continue to focus on supply, logistics, and the responsibilities of the global community to areas devastated by this epidemic; Laurie Garrett at the Council on Foreign Relations argues that the US should already be doing much more.
For further reading, and to trace ongoing developments:
- Commentary from Paul Farmer
- Liberian Observer, “Health Ministry Rejects ‘Saltwater’ Treatment To Cure Ebola”
- CDC Ebola information
- WHO Disease Outbreak News (DONs)
- MSF Ebola information
- New York Times Ebola coverage index
- Scientific American, “Ebola: What You Need to Know”
University of California Press, 2013, 478 pages
This textbook was written for an undergraduate course on global health at Harvard University, compulsory for those enrolled at Harvard Medical School. It aims to introduce ethical, social, economic, and political theories and methods to medics in order to critically inform their analyses of the frameworks used to build and justify global health movements. As such, the emphasis is on giving the reader the capacity to do the analysis him/herself rather than laying out the full exegesis in the book, which focuses more on outlining theories with brief illustrative examples and case studies.
It is edited by eminent physician-anthropologists Paul Farmer, Arthur Kleinman and Jim Yong Kim, the last of whom is now president of the World Bank. Refreshingly, and perhaps indicative of the optimistic tone of the book, the final editor has not yet finished his graduate studies. He is global health activist and joint MD-PhD student, Matthew Basilico. So they are all (or will be) doctors who are also trained in what they refer to as the “resocializing disciplines – anthropology, sociology, history, political economy” (p.3). One key thesis of the text is that the practice of medicine and the theorising of these other disciplines inform one another; both are required to forge the new multidisciplinary global health practice that they advocate. They propose “biosocial analysis” (p.xix) as a means of developing global health to become “more than just a hobby” (p.xvi), using this book as a “toolkit of global hope” (p.xvi). These quotations from the preface immediately set the tone for a text that is frequently stirring and emotionally charged, while mostly remaining balanced and lucid, as we have come to expect from Farmer and Kleinman. (I cannot comment on Yong Kim and Basilico’s previous work as I am not familiar with it).
There are 12 chapters and 478 pages; I do not propose to describe and analyse all of them. They cover a broad range of topics: unpacking the meaning(s) and history of health and global health, exploring the ethical and political claims for and against health for all, exploring how aid does and doesn’t work, as well as examining healthcare delivery models. Instead, I seek to elucidate the key theses, using two chapters to evaluate the arguments and case studies used in the book to support them in order to produce a broad assessment of the successes of the book.
The authors describe the first decade of the 21st century as a “golden age of global health” (p.302). They trace the history of public health from colonial medicine to international health, to Alma-Ata and the primary healthcare movement, to selective primary healthcare, to the neoliberal era and finally to this golden age (which appears to be at risk of ending with the global financial crisis). So what do they mean by this emotive term? In the fifth chapter, Luke Messac and Krishna Prabhu use the example of AIDS to show how technoscience, biosocial analysis, community activism and political will combined to redefine the possible, leading to a massive increase in global health funding. Worldwide development assistance for health rose from $5.6bn in 1990 to $8.7bn in 1998, and then to $23.8bn in 2007. Likewise, in 2000 the USA funded antiretroviral therapy for a few hundred people around the world. By 2009, the President’s Emergency Plan for Aids Relief (PEPFAR) supported 2.5m people in 24 nations for antiretroviral treatment, as well as funding 539,800 interventions for pregnant women who were HIV positive.
What happened? Global health practitioners, previously “socialized for scarcity” (p.115) had been trying to modify use of what little resources they had, i.e. to optimise “use of a tiny resource pie” (p.115). But now they refocused their efforts on expanding the size of that pie. At the same time, activists mobilised political will to take on the pharmaceutical companies through various methods of struggle: legal, journalistic, public protest, etc. They succeeded in forcing the industry to dramatically reduce prices. In other words, rather than starting from a ‘realist’ or prudential standpoint of knowing what resources and funds were available and working within that remit, global health practitioners and activists started from the ethical standpoint that every person suffering with AIDS deserved treatment, wherever they were and whatever their financial and social circumstances. If resources and funds did not allow that, then they had to figure out a way to change that, i.e. they had to reimagine the possible.
So when we move on from AIDS and think of health more generally, how do we figure out what our ethical starting point should be? Another key chapter, written by Basilico and Kleinman as well as several others, examines the moral roots of global health work. It briefly surveys the contribution of utilitarianism, particularly with regard to cost-effectiveness analysis and disability-adjusted life years (DALYs), before moving on to cosmopolitan models such as human rights and Amartya Sen and Martha Nussbaum’s capabilities approaches. By this point, the authors of previous chapters have already laid their cards on the table in stating their belief that health is a human right. However, this chapter demonstrates how the editors have not let dogma cloud their judgement. They recognise the problems of the human rights model: including the various interpretations of human rights discourses co-opted by opposite sides of the Cold War and the prioritisation of civil and political rights over social and economic rights after the end of the Cold War. Human rights theory’s reference to the individual rather than the community is discussed. This model’s promotion of small interventions rather than broad-based social change is mentioned, with reference to Alain Badiou. Finally, the one-size-fits-all universalism of all cosmopolitan models is discussed.
Here the chapter demonstrates one of the shortfalls of the book, inevitable in a text of this nature. The brief but lucid outlines of theory whet the appetite for a more sustained critical analysis that never materialises. In this case, I would have appreciated a discussion of how the supposed universalism of the human rights approach interacts with the actual diversity of interpretations and implementations, perhaps illustrated with ethnographic evidence. Of course this would have led to a bloated textbook, rather than the concise and readable one that we have. And it is somewhat pointless to chide the authors for what is left out of an already pretty heavy tome. This book does not aim to be exhaustive. It is an introduction, with a recommended reading section at the end of each chapter for those who want to probe further. This chapter finishes by stating its aim to be a “springboard to deeper consideration of the moral roots of engagement in this work” (p.285). A more sustained critical engagement with any topic would also likely lose its balance, which is undesirable in an introductory textbook. The authors have clearly made huge efforts not to unduly favour particular schools of thought. In fact their efforts at balance sometimes tip into what appears to be effortful palliation. The discussion of the failures of structural adjustment with regard to improving the health of developing nations is a case in point.
So the authors start from the ethical standpoint of health equity, health as a human right for all. From here they seek to reimagine the practice of global health. They use the example of AIDS throughout the book to illustrate how this has been done in the past, and so can be done in the future. AIDS is analysed through the prism of healthcare delivery models (especially Partners in Health, set up by Paul Farmer and Jim Yong Kim), of funding, of activism, and importantly, through case studies of those suffering with AIDS. The driving thrust of all this is that “the limited vision of what is currently defined as possible… is not immutable” (p.340), i.e. we should not be constrained by it.
This use of AIDS neatly ties the book together, lending coherence to its narrative, a difficult task in a textbook of this size. It also falls on the right side of the fine balance between perseverative redundancy and passionate reiteration of an important point. However, the lack of other examples of how the possible has been reimagined in global health work did lead me to wonder whether AIDS was being used to link the chapters in this way, or was features simply because the authors could not think of any other examples. The construction of the British NHS and Mexican Seguro Popular are both briefly mentioned, but with little critical engagement, and there are no other examples given from the “golden age of global health”.
Overall though, this is a superb, inspiring book introducing the critical tools of social theory to undergraduates. It has much to offer to postgraduates as well, particularly its revision of concepts. When was the last time I saw the Foucaultian concepts of biopower and governmentality explained in four pages with such clarity? Never. Owing to its breadth of scope, I would also recommend this book to general readers and activists. This kind of balanced analysis combined with an openly partisan normative claim for global health equity is a rare thing that should be read beyond the realms of academia. The authors finish with the simple plea for the “pursuit of a more just, fair society that allows our children, wherever they are born, a decent shot at a decent life” (p.353). If this is how medicine is taught at Harvard I wish I had studied there.Piyush Pushkar is a trainee in psychiatry in Manchester, England. He is also a graduate student of social anthropology, currently writing a dissertation on the origins and implications of health as a human right.
Duke University Press, 2012
Julie Livingston’s Improvising Medicine is a lucid, poignant, and devastating book about the stakes of a growing cancer epidemic in sub-Saharan Africa that is trailing the HIV/AIDS epidemic. This ethnography takes place mainly on the recently established oncology ward of Princess Marina Hospital in Gabarone, Botswana. It follows the labors of Dr. P, the tireless, irascible German oncologist, a staff of dedicated Batswana nurses, and family caregivers as they work to provide both oncological and emotional relief to cancer patients. These patients are often arriving at the ward with late stage tumors. Many of these tumors are themselves extraordinary—eyes bulge out of sockets and breasts fulminate and stink. A historian-ethnographer interested in the body as a moral condition, Livingston does not shy away from carefully examining the ways in which both caretakers and patients strive to maintain humanity and humanness in the face of disfigurement and disgust. She treats the cancer ward both as a microcosm that lays visible some of the fundamental hopes and challenges of life in present-day southern Africa. The cancer ward is also, as she puts it, “a powerfully embodied social and existential space,” where one can “contemplate the meanings, practices, and politics of care.”
The book advances three interwoven arguments. The first is that improvisation is a fundamental aspect of the practice and provision of biomedicine in Africa. In a context where drugs are constantly in and out of stock, where blood transfusion services are erratic, and where vital reagents for pathology diagnoses are missing, the striking unpredictability of what may or may not be available profoundly shapes medical practice.
Secondly, she argues that cancer is a fundamentally social experience. It is something that happens “between people.” Understanding cancer as an illness of rapidly dividing cells without end, is something that is actively created at PMH, and often becomes solidified by the unholy trinity of oncological practice—poisoning, cutting, and burning in an effort to shrink tumors and prolong life. And bodily experiences, such as pain and disfigurement, also emerge as deeply social experiences in a context where families are washing stinking wounds, nurses are taking care of their relatives on the wards, and beds stand close proximity to one another, making it impossible to not hear the chorus of vomiting after a round of chemo.
Thirdly, Livingston argues that cancer is emerging as an epidemic which will shape public health in sub-Saharan Africa. Cancer has historically been largely invisible in Africa, in part because of public health imaginaries that have constructed Africans as “biologically simple,” and the continent as a denizen of infectious disease crises. But especially in southern Africa, the advent of antiretroviral therapy has prolonged life, and has also unleashed an epidemic of HIV related malignancies, particularly cervical cancer and of course Kaposi’s sarcoma. This is a sad irony in which one pharmaceutical intervention, which has been so pivotal in softening and stemming mortality from AIDS, has created a context in which an epidemic of debilitating malignancies is now far more visible.
Livingston begins with the last argument, tracing the history of how cancer in Africa was rendered invisible, while highlighting the ironies and contradictions of imagining Africa as a place where life expectancy is so short that it would make sense to use the continent as a dumping ground for toxic waste, as Larry Summers infamously argued. From there the book takes the reader to the wards. The ontological politics of cancer are discussed, as Livingston asks, to what extent is cancer the same thing in New York and Gabarone? A chapter on the moral intimacies of nursing care and the ways in which allocating resources on PMH’s cancer ward echo larger concerns of Botswana’s state to equitably cut the national cake follows. The problem of pain and palliation emerge as profoundly social and historically situated experiences in the book, as does the politics of triage and prognostication, which make up the last two substantive chapters of the book.
The intimacy, care, intelligence, urgency, and fearlessness of Livingston’s writing and thinking make Improvising Medicine a truly masterful ethnography. Throughout the book, Livingston invites you to feel the human stakes, bodily dilemmas, and deep contradictions of oncology when its logic is ripped down to the studs and cannot be softened with chemo ports, recliners, and smooth jazz. Perhaps nowhere is this more powerful than in the pivot point of the book, the interlude “Amputation Day at Princess Marina Hospital,” in which we follow the oncologist and ethnographer on a particularly brutal day where the dilemmas of keeping limbs at the cost of lives are laid bare.
Livingston is quick to point out that Botswana’s cancer ward is just one possible manifestation of Africa’s emerging cancer crisis, and the book opens a broader research agenda for examining cancer in sub-Saharan Africa.
Since 2010, I have worked at the Uganda Cancer Institute in Kampala, which was established in the 1960s to do cutting edge chemotherapy trials on children with Burkitt’s lymphoma and adults with Kaposi’s sarcoma. Founded as a collaborative effort between the American National Cancer Institute and the Makerere Medical School’s department of surgery, this Institute weathered the storm of Idi Amin’s murderous dictatorship, the vagaries of structural adjustment, and an HIV epidemic. Today approximately 60 beds at the Institute provide public oncology goods to a population catchment of approximately 40 million Africans in the Great Lakes region. The Institute is also in a tremendous state of flux—two new buildings are dramatically reshaping the possibility of increasing cancer care capacity in the country.
Many of the improvisations, existential dilemmas, and bodily states that characterize the PMH cancer ward can also be found on the wards in Uganda. But the politics of care are quite different. The Institute’s history as a cancer research facility, where “Research is Our Resource,” means that for many years the Institute prioritized the treatment of cancers that were embedded in clinical trial research protocols. Today newly trained Ugandan oncologists struggle to meet the demands of their busy clinics, where they primarily manage late stage tumors, while remaining internationally relevant and conducting translational research for an emerging global oncology audience. Ironically, despite the Institute’s rich history, cancer has only come onto the Ugandan government’s radar as more and more politicians succumb to cancer themselves, or find that they are not in a position to shoulder the burden of sending multiple grannies to India for treatment.
Livingston is careful to not romanticize Botswana’s African miracle, but the Batswana’s commitment to social cohesion and equitable allocation does remain astonishing. Reading Livingston’s account of the oncology ward in Zimbabwe at Mpilo hospital, one has a sense that Mugabe’s state consumed itself from the inside out. One is reminded of the theorist Jean-Francois Bayart, who coined the idea of the “politics of the belly,” or the ways in which the symbolic power of eating can connote corruption and graft in African politics. Political power and its relationship to eating and consumption takes on a new and sinister twist when we think about cancer. The Red Pepper, one of Uganda’s tabloid newspapers that occasionally carries vital news, recently published an amazing photo essay of politicians stuffing their faces full of local food at an important meeting. The mouths open in mid-bite, the close ups of banana mash in groundnut sauce, the gigantic bellies—these images captured the vulgarity of a state intent on eating itself to death. The sad fact of the matter is that in many countries, and the U.S. is not exempted here, the politics can be downright malignant themselves. In an African context, it is unclear what sort of impact these dynamics will have on shaping cancer services in the decades to come.
I encourage readers to buy the book now and read it this weekend before the school year starts in earnest, if you have not yet had the pleasure of doing so. In addition to the intelligence and empathy of the writing, Livingston is making major contributions to scholarship on ontological politics, public health in Africa in the wake of structural adjustment, the history of the body, the plasticity of where infectious diseases end and chronic illnesses begin. Improvising Medicine would be indispensable in any global health, medical anthropology, or modern African history course. The book could also be read as the second volume of Livingston’s first work, Debility and the Moral Imagination in Botswana, which I recommend to readers if they are interested in a deeper historical and contemporary contextualization of the moral universe of care beyond the space of the cancer ward itself.
It is my hope that the Improvising Medicine, which highlights the pressing need to take cancer in Africa seriously, will be taken seriously by the broader global health community. There are no easy sociotechnological fixes or financial solutions to the dilemmas Livingston presents here. Improvisation will, no doubt, continue to be a fact of life in under funded public tertiary medical centers throughout sub-Saharan Africa. Perhaps what may be deemed the most immediately relevant to the emerging global oncology community is the fact that the cancer epidemic in Botswana, and indeed in Uganda, is in many ways a pain epidemic, and a sane redistribution of the world’s opiate consumption would greatly improve lives.
And closer to home, for all of us who have been touched by the slow and sad decline of a relative, or the untimely departure of a dear friend, or indeed the revelation of our own mortality, I hope this book challenges us to think a little more carefully about the limitations and double bind of the healing and harming qualities of oncological goods.
Marissa Mika is a historian-ethnographer who uses the lens of medicine, science, and technology studies to understand the ways in which ordinary people cope with social change and negotiate politics in modern Africa. Her current project, Malignant States: Creativity, Crisis, and Cancer in Uganda, traces the political and social history of a cancer research institute in Uganda. A second project on medical waste and occupational safety in African hospitals is in development. Marissa will defend her PhD in the History and Sociology of Science at the University of Pennsylvania in spring 2015, and is currently a visiting researcher at the University of California, Berkeley’s Center for Science, Medicine, and Technology Studies.
The Recent History of “Contagious Shooting” (1982-2006) and more recent events in Ferguson, Missouri by Stephen T. Casper
A version of this post first appeared on Stephen T. Casper’s blog, The Neuro Times.
In the decade since the “Decade of the Brain,” the neurosciences have acquired a spectacular cache in the humanities and social sciences. One need look no further than the work of Nikolas Rose and Joelle M. Abi-Rached, scholars who argue in their striking volume Neuro: The New Brain Sciences and Management of the Mind that governing in the future will occur through the brain.[i] While for contemporary neuroscientists and neurologists such an expansion of a-disciplinary neuroscience might and probably should represent a crisis in terms of the public face of their science and practice[ii], I would suggest that when combined with other disconcerting trends in governance, these developments have wider implications in terms of global civil society, policy, common law systems, jurisprudence, and economics. Such a starting place may seem very far away from Ferguson, Missouri. But I think that isn’t the case at all. And in this long essay, I’ll try to explain why.
Whether people identify with it or not, there are undeniable geneticist qua mechanistic currents now pervasive within media analyses (and hence also public understanding) about how we should manage social, economic, and political decay in urban and rural environments. Much of this discourse justifies both excessive violence against and also the dehumanization of people who, for whatever reason, are identified with the marginal, the poor, the weak, the downtrodden, etc. While it is easy to read part of this brutality as symptomatic of the anti-human nature of neoliberal, global capitalism[iii], I think it far more convincing to describe growing authoritarianism seen in developed societies as symptomatic of a war against particular forms of public liberty and of a decline in trust in institutional governance. The militarization of the constabulary is only the most dramatic recent demonstration of the militarization of much in the civilian sphere, including science, a process that began during and has continued since the Cold War.[iv]
It is surprising, of course, to see the advance of this process even up to neuroscience. But only a cursory knowledge of the history of recent neuroscience makes this a particularly credible claim, not least in crass examples of the way knowledge from the civilian neurosciences was mobilized in torture (as detailed by, for instance, by James Kennaway in Bad Vibrations) or in the deployment of the LRAD (long range acoustic device) against public protests, which has been an ongoing police procedure since 2009. Beyond studies of the neuroscience, such thinking has characterized the work of many renowned scholars, including Sheldon Wolin, who, although speaking of statistics and technocracy rather than neuroscience, has painted similarly glum pictures of the nature of growing “inverted totalitarianism.”[v]Tempting as it may be to describe neuroscience as the ‘liberatory’ stuff of the search for secular selfhood,[vi] in this context it is plausible to infer the emergence of such coercive and illiberal strategies and tactics as marking the defining nature of our cultures and encounters with (and beyond) neurodiscourse and neuroscience.
How so? It is obvious that the rhetoric of this science matters and it is mobilized alongside real force. Consider the implicit association test. On the face of it, this psychological test can only provide a cursory understanding of peoples’ propensities towards prejudice. But the way findings from psychological studies using this test are mobilized in the public sphere is often in the service of an apparatus to explain away, among other things, police brutality (and likely in the future instances of person-to-person violence of the kind that killed Trayvon Martin). Automatic and reflexive racism is understood publicly through the findings of tests like these to be a natural precondition of police force and self-defense. The most obvious policy solution – immediately charging police officers with manslaughter or homicide – would likely carry enough force to preempt such tragic episodes, but the very act of naturalizing such discrimination has increased the sense that such crimes are unavoidable, tragic, and require processes permitting circumvention of the law.
I intend such observations to provide this study of “Contagious Shooting” with the flavor of a perhaps too late cautionary tale, not least because many of the details of this case inevitably call attention to the very real and tragic circumstances that have sparked public protests in Ferguson, Missouri. Little in public analysis has spoken to the violence that has plagued interactions between the civilian constabulary and those who pay their salaries. Similarly, little work in the social studies of science and medicine has focused on science as a rhetorical strategy of police power (although there is some scholarship on lie detection). Furthermore, little real analysis has looked at the enormous historical similarity in tactics adopted by the police and their apologists for managing the rhetoric of accountability (although Michelle Alexander’s The New Jim Crow: Mass Incarceration in the Age of Colorblindness has cast a very wide net in calling attention to the broader issues I’m exploring here).
As historian Roger Smith has suggested, history, and specifically the history of the neurosciences, may be able to check both the utopian optimism and the authoritarian impulses that underlie this new discourse as it pertains to the practice of neuroscience through the elaboration of a politics of skepticism,[vii] but I think it is worth underscoring that there is ample evidence all around for the empirically-minded to see what governing through the brain already looks like in circumstances of increasing authoritarianism and repression. It isn’t a pretty picture. No one, of course, has described the shooting of Michael Brown as reflexive or contagious – at least not at the time this essay was written. I would anticipate that some mechanistic explanation will appear as the results of the autopsy become publicly known.[viii] But even more to the point, the implicit logics that underpin police violence of the type that killed the young man (and many before him), is no less mechanistic and deterministic in its assumptions. Equally, critiques of the protestors’ behavior in Ferguson since that violent date of Brown’s death, mirror similarly dismissive and reductionist tendencies in media analysis. To people familiar with the science and culture wars of the 1980s and 1990s, much of this analysis will sound eerily familiar about debates pertaining to genetics and society. There are, however, differences, not least in that neuroscience calls into question cognitive agency. In the case of genes, such determinism leads to discussions about “destiny” and “potentiality.” In the case of brains, such determinism can justify state-sanctioned slaughter. That, putting it mildly, is a very big difference.
Intentional but reflexive
In February of 1999, four police officers in the Bronx, New York, fired 41 shots at Amadou Diallo. He was killed. In 2004 police shot 120 bullets at Winston Hayes, a suspected drug dealer in Los Angeles. Hayes survived. However, a deputy police office was injured by friendly fire, a further eleven bullets hit police cars, and an additional eleven hit five houses in the neighborhood. One year later police in Los Angeles fired 50 shots at Carl Williams, a suspected drunk driver. In 2006, three police officers in the Bronx shot a pit bull 26 times, and in that same year five officers fired 50 shots at a car filled with unarmed passengers. One of the passengers, Sean Bell, was killed. Experts described all of these cases as examples of “contagious shooting,” a condition described in the New York Times as “gunfire that spreads among officers who believe that they, or their colleagues, are facing a threat.” One that supposedly: “spreads like germs, like laughter, or fear. An officer fires, so his colleagues do, too.”[ix]
The Sean Bell case was one among many similar episodes since 1986 that caused tensions between communities and police officers. Denver, Cleveland, Baltimore, Los Angeles, Cincinnati, and New York had all had similar incidents. The victims were almost exclusively poor and non-white. Typically the police officers, with only a few exceptions, were white. Thus, “contagious shooting” was almost always a category of accident that sprang-up in the context of racial tensions. Activists in many of the neighborhoods often regarded the police as trigger happy, violent, and racist. Community activists, moreover, saw the police as representatives of a civil authority institutionally predisposed to racism.
The Sean Bell killing touched a nerve. Bell had been at his bachelor’s party on the night before his wedding. Images of Bell’s fiancé, her public statements, and her obvious sorrow made for gripping television. Bell, too, came across in early accounts as a young African American trying to make good in a community where too many men were behind bars. Media commentators, activists, and experts thus sought various ways of categorizing and contextualizing the bitter circumstances. Representatives of the political Left gravitated towards assertions of latent or overt racism. The political Right dwelt upon the rarity with which police officers drew their weapons, the difficulties of being in a situation that called for lethal force, and the horrors of having fired. “Contagious shooting” emerged chiefly in accounts that gravitated towards explanations like these.
ABC News was one of the first organizations to report extensively on the Sean Bell killing. They cast Bell as another 23 year-old male victim of a rare but recurring problem for police departments around the country. Carol Liberman, a forensic psychiatrist and assistant clinical professor at UCLA’s Neuropsychiatry Institute, told ABC News: “when a fellow officer starts shooting it sends off an alarm, warning the others that they must be in lethal danger…. Not only is there ostensibly a killer on the loose…[but]…the other officers who become affected by the ‘contagion’ are responsible for panicking, becoming blinded by the outbursts of gunfire, and not restraining themselves enough to assess the situation.” Another law enforcement expert saw the instance in New York as rather restrained. “This type of contagious shooting happens out West,” he said, “It’s a cowboy mentality. They like to shoot out there.”[x]
Expert testimony typically oscillated around this axis of responsibility. While Liberman appealed to an infectious metaphor, she nevertheless maintained that officers were responsible for the discharge of their weapons. However, as the idea of “contagious shooting” became more commonplace, questions about individual responsibility became ever more salient. Increasingly media understanding of the concept hardened around the contradictory notion of a reflexive agency. By the end of January 2007, the Daily News argued: “the shootings would never have started at all unless one of the cops thought he was in imminent danger.”[xi] Of course, fearful police officers had intended to kill armed men. For this reason, the violence was a terrible accident.
The Rhetoric of Contagious Shooting
In January 2007, the New York Police Department, reacting to noxious public opinion, commissioned a report from the RAND Corporation. The report, which cost $500,000, focused on firearms training and contagious shooting.[xii] In an interview with the Daily News, Bernard Rostker, PI on the RAND Report, remarked that, “there is not a lot out there, especially on the question of ‘contagious shooting.’”[xiii]
Underlying these appeals to the accidental nature of these circumstances was concern about the growing perception that the New York Police Department was a racist civil institution. In March 2007, Police Commissioner Raymond Kelly asked RAND for a second report to examine evidence of racial bias in police stop and frisk policies. In a news release, the Associated Press reported that the new RAND report would complement the earlier one by focusing on ways to “reduce the incidence of so-called ‘reflexive’ or ‘contagious’ shooting the phenomenon of officers firing an excessive number of rounds in a chain reaction.” This AP bulletin was the first to describe “contagious shooting” as “reflexive shooting.” It was the first press release to use deterministic language.
That March, a grand jury indicted the officers involved – Marc Cooper, Gescard Isnora, and Michael Oliver. Tensions were extremely high in the community. Reverend Al Sharpton, a community civil rights firebrand in New York City, said that the indictment had not gone far enough. More details of the case also emerged. The event had taken place at the Kalua Cabaret, a topless bar with a history of drug violence and prostitution. The police officers claimed to have heard members of the bachelor party mention guns. The three survivors claimed in court that they had thought the undercover detectives were attempting to steal their car. They had thus tried to use the car to get away from a dangerous situation. Michael Oliver, at whom the driving car was directed, had subsequently shot at the men in the car 31 times. Isnora had fired 11 times. Marc Cooper had fired four times. One of Oliver’s shots had passed through the window of an occupied house. One of Cooper’s had smashed through the window of an occupied train station.[xiv] Oliver and Isnora thus faced charges of manslaughter, with potential 25-year sentences, and Cooper faced a lesser reckless endangerment charge.
Cooper’s attorney, the Washington Post reported, expressed frustration at the decision. “We are outraged,” he stated, “that police officers are being charged for actions taken in the line of duty. That just isn’t right.”[xv] The New York Mayor’s Office, which had from the beginning deemed the force used excessive, did not concur. Christopher Dunn, the associate legal director of the New York Civil Liberties Union, placed the event in a much wider legal context. In an interview with a New York Times reporter, Dunn stated: “While it’s certainly an aberration to be shot [by a police officer] – much less to be shot at 50 times – the Bell shooting touches on something that is no aberration, which is the police being very aggressive with those in the black community.”[xvi]
The first article challenging the growing discourse on the neurologically mechanical nature of “contagious shooting” had appeared earlier in a November 2006 article by William Saletan. Saletan, a libertarian skeptic of the arguments being advanced for “contagious shooting” observed that it was natural to seek mechanical explanations. Yet he noted that it was difficult to verify when “contagious shooting” had been coined. He also found that the majority of journalists had referenced the phenomenon in conjunction with explanations for patterns of shooting on basketball courts. Building upon a commonplace hostility to psychiatric diagnoses, Saletan noted that there was something inevitably self-fulfilling about such behavioral explanations:
Once you start describing a behavioral phenomenon as a predictable sequence of events—”post-traumatic stress disorder,” for example—people start reading it as an excuse. Seven years ago, during the Diallo case, a lawyer for one of the accused officers pointed out that “contagious shooting” was in the New York Police Department patrol guide. “I suspect that this phenomenon may play an active role in this case for my client,” he told reporters.
It was a useful line of legal reasoning. As Saletan pithily put it: “You’re not choosing to kill; you’re catching a disease.” A former Captain of the New York Police Department, Edward Mamet, had told CNN news: “It’s sort of like a Pavlovian response. It’s automatic. It’s not intentional.”[xvii]
On the force of such explanations, Saletan could only sputter: “This mess of metaphors is telling. Nothing can behave like germs, sparks, laughter, fog, instinct, and conditioning all at once. That’s the first clue that “contagious” is being used not to clarify matters, but to confuse them.” He added that the Orwellian point was the fatalistic view that such episodes would happen again. An idea mainstream in American culture at the time was that people killed people – not guns. To Saletan, the black and white legal distinction offered by that commonplace view was becoming unclear: “Contagious shooting blows that argument away. If cops fire reflexively, there’s no moral difference between people and guns. They’re both machines….No responsibility, no freedom.”[xviii]
The Sean Bell slaying remained prominent in media sources well into 2008. The Bell family, including Bell’s former fiancé, had gathered for a candlelight vigil in November of 2007, one year after his death. The Gothamist reported that Bell’s fiancé told a crowd: “I want justice.”[xix] In court, one author suspected, the legal arguments would fall between “fog of war” claims and the 50 bullets without return fire. Thus, in court, “contagious shooting” defined in the New York Police Department’s patrol guide as a “chain reaction of shooting” would be cast in neo-Pavlovian terms, an automatic response. To this proposed neurological explanation, there was no scientific retort. The prosecution could only rely on rhetorical questions about the nature of free will, intentionality, instinct, and hope that jury and judge would understand the Pandora’s Box being opened if “contagious shooting” were permitted to stand as a defense for excessive police force.[xx]
Publicly “contagious shooting” had been all but accepted. Kyle Murphy, a former police officer turned graduate student in journalism at Columbia University, wrote in an opinion editorial that it was obvious that the police officers had felt threatened and that once “contagious shooting took hold it was difficult for the others to stop.”[xxi]These were claims he repeated in a nationally broadcasted interview with National Public Radio – the Public Radio Resource in the United States – days later.[xxii] Whether it was arguments like these that prevailed is unclear – court testimony, records, and decisions for the trial are not publicly available. In any case, by May 2008, all three of the officers walked.[xxiii]
The RAND Report
In June 2008 the RAND Corporation finally published its report. Its 114-pages of text chiefly addressed issues of police officer training and usage of non-lethal weapons. It barely analyzed the incidence of “reflexive shooting.” Christopher Dunn of the New York Civil Liberties Union criticized the “cursory” treatment of the topic. The Report’s lead author, Bernard Rostker, admitted that it had been “nearly impossible to tabulate whether incidents had risen or fallen in recent years”, but he averred in The Sun that, “contagious shooting is a rare event.”[xxiv]
Indeed that rarity was reflected in the pages of the report. Although the report’s authors noted that the NYPD categorized “contagious shooting as intentional reflexive discharges” they also admitted in the executive summary that data on the condition had not been easily located. Nor was there psychological research on decision-making processes that led to firearms discharges among police officers.[xxv] In the four-page chapter devoted to the topic, the authors noted that the phenomenon could be described as a “mass reflexive response” characterized by many “intentional reflexive discharges”, which could be distinguished from accidental discharges:
While it is often discussed as a group phenomenon, a single officer can also intentionally discharge his or her weapon out of fear and without knowing specifically what he or she is shooting instead of carefully considering whether the situation meets the requirements for the use of deadly force. Typically, the officer is reacting to the sight and sound of other officers shooting and starts to shoot. An intentional reflexive discharge may involve as little as a single round being fired…(my emphasis)
According to the RAND Report’s authors, this phenomenon was well-recorded in psychological studies. This was a claim not substantiated by any specific literature. Interestingly of the only two scientific works cited in support of the chapter’s claims, one of the studies addressed the automatic response of individuals to perceive but cognitively fail to process environmental stimuli. The argument suggested through this selective citation was that police officers were unaware of all they perceived in the environment. Intentional reflexive discharges occurred as a result of individual reaction to contexts not cognitively understood.
While the report argued that such episodes should be tracked and that further training to prevent such episodes be pursued, an implicit subtext in the report was that the police officers had been conditioned to automatically respond in these ways. Rare, unfortunate accidents like the Sean Bell slaying might continue to occur. At the same time, that conditioning prepared officers for circumstances where lethal force was appropriate. In other words, such reflexive behavior saved lives, even if it sometimes resulted in excessive over-response to stimuli. Police officers needed to respond mechanically to danger before their minds comprehended the context. Their response was always appropriate, intentional, and reflexive. Any individual behaving oddly risked triggering a mass reflexive response.[xxvi]
Critics responded to these claims in a variety of ways. Most pointed out that such instances of over-reaction seemed to most adversely affect minorities. In the courts, claims of contagious shooting tended to be dismissed across the United States as unsubstantiated – but there were court cases in which contagious shooting was used as a defense. Fundamentally, the challenge arose around the question of intent. No one wanted to argue that the police officers had intentionally shot and killed innocents. Everyone agreed that they had acted intentionally to protect themselves. In an instance like this, recourse to a neurological principle substituted for the harder reality that in preparing police officers to protect people, police officer training could lead to tragic outcomes. Perception without cognition equaled almost complete power without culpability.
Historians of neuroscience can puncture the impulses underlying such rhetoric. Criminologists and lawyers have already challenged the empirical veracity of claims of “contagious shooting.” Yet we should understand that governing through the brain might well mean perceiving without cognition. In common law and jury systems that may well be enough to establish a new common doctrine of the nerves – it is certainly enough to overhaul established conventions in jurisprudence. Against such rhetoric, historians can offer the material, social, and cultural context of scientific knowledge. We can argue that the debates that undergird these claims are not new at all, but represent a long history of questioning easily traced back to antiquity, even through all of the disguises of technology, medicine, philosophy, and theology.
The examples of “contagious shooting” offer much as well to understanding the fury and outrage now on display in Ferguson, Missouri. Ferguson is not simply a story of race; nor, for that matter, is the story of “contagious shooting.” Both make clear, however, that it is very easy for the downtrodden and brutalized to see the agency of their oppressors. The oppressors and their apologists, in fleeing to mechanistic, geneticist, and deterministic rhetoric, seek to absolve themselves of accountability for the exercise of power. They perceive without cognitive awareness of their own culpability in the circumstance. In this, however, the police are no more guilty than are those Americans on the Left and Right who sit silently as prisons fill-up with mainly oppressed minority men. They too perceive without cognitive awareness that they participate in racial apartheid.
Science was always supposed to be an ennobling enterprise. But in matters of race and matters of individual self-interest it has often emerged as a tool of oppression rather than emancipation. The analysts who wrote the RAND Report on reflexive shooting were not bad analysts. Nor were they cynics! The scientists who utilize the implicit association test do not do so out of some overt racist agenda. Just as educated people with modest wealth often fail to realize how well off they are in comparison with their poor neighbors, these analysts have failed often to understand that discourse is practice in the public sphere. It makes no difference whatsoever in media accounts that these tests or these metaphors were meant to relay nuance and subtly. What matters is the way they are used; not what they empirically show. This failure to grasp that distance between science and politics is very great, this inability to see that cultural discourse easily trumps evidence, and this blindness to the fact that the exercise of power requires little evidence at all situates our times as particularly tragic. Ferguson reminds us in the same way that Sean Bell reminded us that there is a real person on the other side of the real or metaphoric gun. It also reminds us that our own silence about these grave matters contributes to the pulling of the trigger. Perhaps that is what we all perceive without understanding. Perhaps that is what it will really mean to govern through the brain.
Stephen T. Casper is an historian who has published extensively on neurology, neuroscience, and issues in critical neuroscience. His books include: The Neurologists: A History of a Medical Specialty in Modern Britain, c. 1789-2000 and The Neurological Patient in History. He also recently published “History and Neuroscience: An Integrative Legacy” in a Focus Section in Isis devoted to “Neurohistory and History of Science”. He blogs at The Neuro Times and can be followed on Twitter @TheNeuroTimes.
[i] Nikolas Rose and Joelle M. Abi-Rached. Neuro: The new brain sciences and the management of the mind. Princeton University Press, 2013.
[ii] See: Sally Satel and Scott O. Lilienfeld. Brainwashed: The seductive appeal of mindless neuroscience. Basic Books, 2013.
[iii] David Harvey. Rebel cities: from the right to the city to the urban revolution. Verso Books, 2012.
[iv] See, for instance, John Krige, American Hegemony and the Postwar Reconstruction of Science in Europe. The MIT Press, 2008. Also see Philip Mirowski, “A History Best Served Cold” in edited by Joel Issac and Duncan Bell, Uncertain Empire: American History and the Idea of the Cold War. Oxford University Press 2012.
[v] Sheldon S. Wolin, Democracy Inc. Managed Democracy and the Specter of Inverted Totalitarianism. Princeton University Press, 2008.
[vi] This is a point that I raise more fully in a forthcoming review in Social Studies of Science of Nicholas Langlitz’s excellent Neuropsychedelia: The Revival of Hallucinogen Research since The Decade of the Brain. University of California Press 2008.
[vii] Roger Smith, Being Human: Historical Knowledge and the Creation of Human Nature. Columbia University Press 2007.
[viii] After I wrote this article, CNN.com published an op/ed about the slaying of Michael Brown. Although it does not mention “reflexive shooting”, it does mention physiological indicators and also training. http://www.cnn.com/2014/08/19/opinion/haberfeld-why-six-bullets-fired/index.html?hpt=op_t1
[ix] Michael Wilson, “Fifty Shots Fired, and the Experts Offer a Theory” New York Times, November 27, 2006.
[x] Marcus Baram, “How common is contagious shooting? Such High-Round Incidents are Relatively Rare in New York Compared to Los Angeles and Denver” ABC News, November 27, 2006.
[xi] Michael Daly, “Gun Barrel of Horror” Daily News (New York), January 25, 2007, 16.
[xii] Cara Buckley, “Police Training and Gun Use to Get Independent Review” New York Times, January 5, 2007, 3.
[xiii] Ernie Naspretto and Alison Gendar, “Study will examine cops’ gun training. Kelly hires 500G Consultants” Daily News (New York), January 5, 2007, 8.
[xiv] Pat Milton, “New York police officers surrender to face charges in 50-shot killing”, Associated Press Worldstream, March 19, 2007.
[xv] Anthony Faiola, “Felony Charges for 2 in Groom’s Killing: Indictment of Three N.Y. Detectives in Shooting is Unsealed” Washington Post, March 20, 2007, A03.
[xvi] Diane Cardwell and Thomas Lueck, “After Bell, Critics Want Mayor to Broaden Focus on Police” The New York Times, March 21, 2007, 1.
[xvii] American Morning, http://transcripts.cnn.com/TRANSCRIPTS/0611/28/ltm.01.html, accessed 4 February 2010.
[xix] Jen Chung, “Gone but not forgotten” Gothamist, November 25, 2007.
[xx] Robert Kolker, “A Bad Night at Club Kalua; In the Sean Bell shooting, 50 bullets and many truths” New York Magazine, March 3, 2008.
[xxi] Kyle K. Murphy, “The Fear Behind the Badge” New York Times, April 27, 2008, 13.
[xxii] Lynn Neary, host, “Talk of the Nation: Sean Bell Verdict May Deepen Mistrust of Police” National Public Radio, April 29, 2008.
[xxiii] Sean Bell Supporters Angry About Detectives’ Acquittal in Wedding Day Killing; http://www.foxnews.com/story/0,2933,352622,00.html
[xxiv] Sarah Garland, “Police Use of Stun Guns May Increase” The Sun June 9, 2008, 4.
[xxv] Bernard D. Rostker, Lawrence M. Hanser, William M. Hix, Carl Jensen, Andrew R. Morral, Greg Ridgeway, Terry L. Schell, Evaluation of the New York City Police Department Firearm Training and Firearm-Discharge Review Process (Santa Monica: RAND Corporation, 2008), p. xxiv
[xxvi] Bernard D. Rostker, Lawrence M. Hanser, William M. Hix, Carl Jensen, Andrew R. Morral, Greg Ridgeway, Terry L. Schell, Evaluation of the New York City Police Department Firearm Training and Firearm-Discharge Review Process (Santa Monica: RAND Corporation, 2008).
Welcome to the August 2014 edition of In the Journals, just in time to kick off the transition from summer back to the start of the academic year. Without further ado…
The technical infrastructures of modern life—energy, communications, transport—stand at the juncture between material orderings of society and collective meaning. Public utilities are both material and symbolic, and both aspects require maintenance—and anthropological understanding. However, recent anthropological approaches building from science studies have tended to pursue “flat“ descriptions that replace mystical or hypostatizing concepts of “social forces“ with material associations and have focused on micrological discipline rather than ritual sites where collective identity is formed. By contrast, I identify an “aporetic relation“ between material ordering and symbolic form as the site of ritual, and hermeneutic, processes by which large-scale political collectives are built up—and infrastructures are shaped to serve collective projects. I analyze examples of contemporary and historical infrastructural politics from India and Scotland to develop insights into how collectivities and states are formed, interpreted, and challenged in symbolic contests over their infrastructures.
Ontological dimensions of encounters between Brazilian biomedical Cartesianism and Amerindian perspectivism come into sharp focus in an intensive course in functional anatomy offered to trainee indigenous health agents in Acre state, Brazil. After presenting the biomedics‘ rationalization of the course, which centered on the supervised dissection of a cadaver, I look at Cashinahua students‘ accounts of their participation in the training and consider the broader implications of this particular engagement between two profoundly different philosophical traditions from the angle of the ontogenesis of meaning. I contextualize the students‘ views of the cadaver through discussion of Cashinahua phenomenology of the body and cumulative personhood. Rather than revealing a confrontation between distinct “cultures,“ as suggested by the term interculturality, analysis supports a focus on the interplay between ontology and epistemology within historically specific ontogenetic processes.
Donna M. Goldstein
New narratives of toxic contamination are expanding and challenging our ethnographic sensibilities. In confronting the contamination left behind from the Cold War period, a range of disciplinary approaches, methods, and writing styles is necessary. Ethnography plays a crucial role here, but it cannot fly solo in these sorts of projects. In this review essay, I compare three books from authors belonging to distinct scholarly traditions, each one dealing with complicated cases of radioactive contamination that began in the Cold War era and that demand rethinking in the contemporary one. Anthropologists have much to learn from approaches pursued in other disciplines, particularly if the end goal is a more holistic portrait of contamination and toxicity.
Lucas Bessire and David Bond
What does ontological anthropology promise, what does it presume, and how does it contribute to the formatting of life in our present? Drawing from our respective fieldwork on how Indigenous alterity is coenvisioned and how the lively materiality of hydrocarbons is recognized, we develop an ethnographic and theoretical critique of ontological anthropology. This essay, then, provides an empirical counterweight to what the ontological turn celebrates of Native worlds and what it rejects of modernity. In it, we examine the methodological and conceptual investments of ontological anthropology. The figure of the ontological as commonly invoked, we argue, often narrows the areas of legitimate concern and widens the scope of acceptable disregard within social research. We chart how this paradigm’s analytical focus on the future redefines the coordinates of the political as well as anthropology’s relation to critique. Finally, we formulate three conceptual theses that encapsulate our criticism and open this discussion to further debate.
A prominent animal rights activist in New Delhi, explaining her relentlessness on behalf of animals, said to me the following: “I only wish there were a slaughterhouse next door. To witness that violence, to hear those screams . . . I would never be able to rest.” She was not alone among animal welfare activists in India in linking the witnessing of violence against an animal to the creation of a profound bond that demanded from her a life of responsibility. I argue in this article that this moment of witnessing constitutes an intimate event in tethering human to nonhuman, expanding ordinary understandings of the self and its possible social relations, potentially blowing the conceit of humanity apart. But I also consider another reading, which is how this act of intimacy exacerbates the species divide as the witness hyper-embodies herself as human, “giving voice” for the animal other which cannot speak. Throughout the article, I consider how posthumanist perspectives might trouble both these interpretations and ask what it would it mean to take seriously the animal activist’s “becoming animal.”
My fieldwork among HIV vaccine researchers, activists, and funders has led me to suggest that humanity—when it was first conceived of in the late eighteenth century—emerged as a plan, a plan for how to establish a future anticipated in the present. The powerful implication of this fieldwork-based suggestion is that what humanity is—or if it is at all—depends on the available humanity plans. I argue in this essay that we are currently seeing the emergence of a new—a biological—humanity plan, and I wish to make visible that—and how—this biological humanity plan has outgrown, conceptually as well as institutionally, older humanity plans. I also hope to make comprehensible the massive—intellectual as well as political—challenge this emergence poses.
Ending the decades-long search for the elusive Higgs particle, physicists at the Conseil Européen pour la Recherche Nucléaire, or CERN, in Switzerland announced the news of its historic discovery on July 4, 2012. In the wake of the recent discovery of the Higgs particle, the article aims to give a critical account of the concept of signature used in contemporary particle physics. Appearing as interlopers in the material world of science, signatures engender a complex movement between fact and value, thing and sign, or reference and meaning. This movement is instructive in explaining how discoveries are made in an experimental science, and also in the more provocative problem of how necessary consequences follow from contextual signs. Drawing on two and a half years of ethnographic fieldwork carried out at the Large Hadron Collider particle accelerator complex and integrating it with medieval theories of the signature, the essay offers a renewed interrogation into the topic of things, signs, and relations and their relevance for anthropology today.
Aisha Beliso-De Jesús
In Santería priesthoods, practitioners are “made” into African diaspora bodies in what is called “making santo.” These embodied epistemologies reveal not only the complex historical practices that have emerged through processes of racialization and enslavement but also how a body logic resituates the formations of diasporic feeling and sensing. I argue that practitioners’ everyday acts redefine the capacities of and for action as part of a spiritual habitus. The various rituals, works, and spiritual acts in Santería thus culminate in a different form of bodily engagement with the world, operating in racial space. This article examines Santería body logics, showing how what I call copresences are activated in somatic racial ontologies. I suggest that these diasporic sensings resituate anthropological universalisms, arguing for a disruption in the debate between mediation and practice in the anthropology of religion. Rather than assuming notions of presence, copresence allows for an intervention that hails Santería’s embodied epistemology as a form of diasporic sensing.
After Lemba South Africans participated in genetic tests that aimed to demonstrate their ancient links to contemporary Jewish populations, American Jews began to visit the Lemba to connect with them on the basis of an assumed shared Judaism. Some Lemba people welcomed and endorsed these visits, but they also maintained their own ideas about the meaning of their “genetic Jewishness” and the terms of their new diasporic relationships, which often contradicted the understandings of visiting Jews. This article privileges the perspectives of Lemba South Africans, and the historical and ethnographic contexts through which Lemba genetic data emerged and circulated, to offer an alternative reading of the social and political significance of DNA. It poses the question: How do divergent genomic knowledges articulate with the politics of belonging and the pursuit of citizenship in South Africa and transnationally? I argue that DNA and diaspora converge to create new sites of political belonging, ones marked by precarious connections that balance on the production of knowledge and its refusal. I introduce the concept of genetic diaspora to theorize how these connections, marked by inequality, are tenuously forged through national, racial, and religious difference that is imagined to be the same. Genetic diaspora offers Lemba South Africans the possibility to produce and circulate their own new knowledge about Jewish history and genetic belonging. This article demonstrates that those implicated in genetic studies transform DNA into a resource that authorizes their own histories and politics of race and religion.
Peter James, Mariana C. Arcaya, Devin M. Parker, Reginald D. Tucker-Seeley, S.V. Subramanian
• Fast-food access has been linked to obesity in low income and black populations.
• Most studies cover small areas and use administrative boundaries to define access.
• Do these populations have greater access to fast-food across the United States?
• Neighborhood poverty was not independently linked to fast-food access.
• Higher proportion black neighborhoods had higher fast-food access.
This paper explores the spatial dynamics of health social movement activism in the context of a specific condition, Attention Deficit Hyperactivity Disorder (ADHD). Deploying qualitative research conducted with Irish ADHD organisations, it examines how place and space affect activist networks and the dilemmas that emerge when local ‘mobilisations’ converge at national and transnational levels. ADHD activism in Ireland has been predominantly localist in orientation, but certain organisations have shifted their activism to the European scale as a means of gaining further political and epistemic recognition for the condition. The paper suggests that health social movement studies would benefit from an engagement with the geographies of inter-scalar relations in analysing organisations׳ action repertoires.
Elena Sautkina, Denise Goodwin, Andy Jones, David Ogilvie, Mark Petticrew, Martin White, and Steven Cummins
This paper explores how system-wide approaches to obesity prevention were ‘theorised’ and translated into practice in the ‘Healthy Towns’ programme implemented in nine areas in England. Semi-structured interviews with 20 informants, purposively selected to represent national and local programme development, management and delivery were undertaken. Results suggest that informants articulated a theoretical understanding of a system-wide approach to obesity prevention, but simplifying this complex task in the context of uncertainty over programme aims and objectives, and absence of a clear direction from the central government, resulted in local programmes relying on traditional multi-component approaches to programme delivery. The development of clear, practical guidance on implementation should form a central part of future system-wide approaches to obesity prevention.
Vissého Adjiwanou and Thomas LeGrand
In this study, we measure gender inequality both at individual level by women׳s household decision-making and at contextual level by permissive gender norms associated with tolerance of violence against women and assess their impact on maternal healthcare services utilisation in rural Africa. We apply multilevel structural equation modelling to Demographic and Health Survey (DHS) data from Ghana, Kenya, Tanzania and Uganda to gain better measure and effect of the gender norms construct. The results show that women in Ghana and Uganda, who live in areas where gender norms are relatively tolerant of violence against women, are less likely to use skilled birth attendants and timely antenatal care. In Tanzania, women who live in this type of environment are less likely to attend four or more antenatal visits. In contrast, the effects of a woman׳s decision-making authority on maternal health service use are less pronounced in the same countries.
Nicola Wright, Melanie Jordan, and Eddie Kane
This article takes mental health and prisons as its two foci. It explores the links between social and structural aspects of the penal setting, the provision of mental healthcare in prisons, and mental health work in this environment. This analysis utilises qualitative interview data from prison-based fieldwork undertaken in Her Majesty׳s Prison Service, England. Two themes are discussed: (1) the desire and practicalities of doing mental health work and (2) prison staff as mental health work allies. Concepts covered include equivalence, training, ownership, informal communication, mental health knowledge, service gatekeepers, case identification, and unmet need. Implications for practice are (1) the mental health knowledge and understanding of prison wing staff could be appraised and developed to improve mental healthcare and address unmet need. Their role as observers and gatekeepers could be considered. (2) The realities of frontline mental health work for clinicians in the penal environment should be embraced and used to produce and implement improved policy and practice guidance, which is in better accord with the actuality of the context – both socially and structurally.
Yasmin Y. Ortiga
This paper investigates the challenges faced by nursing schools within migrant-sending nations, where teachers and school administrators face the task of producing nurse labor, not only for domestic health needs but employers beyond national borders. I situate my research in the Philippines, one of the leading sources of migrant nurse labor in the world. Based on 58 interviews with nursing school instructors and administrators, conducted from 2010 to 2013, I argue that Philippine nursing schools are embedded within a global nursing care chain, where nations lower down the chain must supply nurse labor to wealthier countries higher up the chain. This paper shows how this process forces Filipino nurse educators to negotiate an overloaded curriculum, the influx of aspiring migrants into nursing programs, and erratic labor demand cycles overseas. These issues create problems in defining the professional knowledge needed by Filipino nurses; instilling professional values and standards; and maintaining proper job security. As such, these findings demonstrate how countries like the Philippines bear the burden of ensuring nurses’ employability, where educational institutions constantly adjust curriculum and instruction for the benefit of employers within wealthier societies. My interviews reveal how such adjustments undermine the professional values and standards that define the nursing profession within the country. Such inequality is an outcome of nurse migration that current research has not fully explored.
Michael P. Fisher
Despite the long-standing codification of posttraumatic stress disorder (PTSD) as a mental disorder, the diagnosis is a controversial one whose legitimacy is at times disputed, particularly in U.S. military contexts (e.g., McNally and Frueh 2013; McNally, 2003, 2007). These disputes often manifest in a struggle over prevalence rates. Utilizing data from in-depth interviews and relying on situational analysis methodology (Clarke, 2005), I highlight this struggle in the wake of a decade of U.S.-led war in Afghanistan and Iraq. I focus on the objects of contestation employed by public officials, veterans’ advocates, and researchers to make or refute claims about PTSD prevalence. These objects of contestation include the diagnostic category and criteria; screening tools, procedures, or systems; and the individuals who express symptoms of the disorder. Based on these claims, I make two key interrelated assertions. First, PTSD is viewed by some public officials as an overly generalized or invalid diagnostic category that is often induced in or falsified by veterans or servicemembers. As such, PTSD is perceived by these stakeholders to be over-diagnosed. Compounding these perceptions are beliefs that PTSD is costly and negatively impacts military duty performance, and thus overall manpower. Second, there exist perceptions, largely on the part of veterans’ advocates but also some public officials, that many servicemembers and veterans are not seeking treatment (and thus, a diagnosis) when they experience symptoms of PTSD. Thus, PTSD is perceived by these stakeholders to be under-diagnosed. Paradoxically, some public officials make both claims: that PTSD is over-diagnosed and under-diagnosed. I conclude by exploring the implications of these findings.
Preterm delivery (PTD), defined as delivery prior to 37 weeks gestation, is a key contributor to persistent racial disparities in infant mortality in the United States. Five major funding initiatives were devoted to advancing PTD epidemiology during the 1990s and 2000s. By examining content and rhetorical features of 94 studies conducted under these initiatives, and published between 1993 and 2011, this paper considers how calls for more “contextual” approaches (focusing on social and environmental contexts) interacted with more “conventional” approaches (focusing on individual-level risk factors) to PTD epidemiology during this period. Contextual advocates initially emphasized complex biosocial reasoning to better connect social adversity with embodied outcomes. Yet responses by researchers invested in conventional approaches, as well as in studies published under new initiatives that explicitly claimed to incorporate contextual insights, often reframed this complex reasoning in biologically reductionist terms. Subsequent contextual advocates then focused on developing statistical methods to support research about social and environmental causes of PTD, and this strategy appears to have gained some traction with conventional researchers. These findings call for closer attention to language and power in both social scientific studies of epidemiological knowledge production, as well as among epidemiologists themselves.
Michelle Ko, Kathryn Pitkin Derose, Jack Needleman, Ninez A. Ponce
Prior literature on social capital and health has predominantly focused on health outcomes and individual access to healthcare services. It is not known to what degree, if any, community social capital influences the performance or behaviors of public hospitals, a key source of healthcare for disadvantaged communities in the United States. In this study we developed measures of community bridging social capital – horizontal social networks between heterogeneous groups of similar social position – and linking social capital – vertical networks across the status hierarchy – relevant to public hospitals. We examined associations between social capital, and U.S. urban public hospital closures and conversions to private ownership from 1987 to 2007. We found that higher voting participation was associated with a greater hazard of public hospital closure over time (p < 0.01), whereas the number of business, professional and political organizations per 10,000 residents was associated a greater hazard of conversion (p < 0.05). Additional measures of bridging and linking social capital were not associated with either outcome. Taken together, our findings suggest that, at least historically, horizontal forms of social capital among more privileged groups (e.g., business, professional, and political associations) bear influence on public hospital outcomes. Specific efforts to increase engagement of disadvantaged groups and connect them with decision-makers may be needed to fully realize the potential of linking social capital to influence local healthcare policy promoting social protection.
Lantona Sado, Alma Spaho, and David R. Hotchkiss
Women in Albania receive antenatal care and postnatal care at lower levels than in other countries in Europe. Moreover, there are large socio-economic and regional disparities in maternal health care use. Previous research in low- and middle-income countries has found that women’s status within the household can be a powerful force for improving the health, longevity, and mental and physical capacity of mothers and the well-being of children, but there is very little research on this issue in the Balkans. The aim of this paper is to investigate the influence of women’s empowerment within the household on antenatal and postnatal care utilization in Albania. The research questions are explored through the use of bivariate and multivariate analyses based on nationally representative data from the 2008–09 Albania Demographic and Health Survey. The linkages between women’s empowerment and maternal health care utilization are analyzed using two types of indicators of women’s empowerment: decision making power and attitudes toward domestic violence. The outcome variables are indicators of the utilization of antenatal care and postnatal care. The findings suggest that use of maternal health care services is influenced by women’s roles in decision-making and the attitudes of women towards domestic violence, after controlling for a number of socio-economic and demographic factors which are organized at individual, household, and community level. The study results suggest that policy actions that increase women’s empowerment at home could be effective in helping assure good maternal health.
Julie A. Phillips
The increases in suicide among middle-aged baby boomers (born between 1946 and 1964) in the United States since 1999 suggest a changing epidemiology of suicide. Using data from 1935 to 2010, this paper conducts age-period-cohort analyses to determine the impact of cohorts in shaping temporal patterns of suicide in the United States. The analysis demonstrates that age, period and cohort effects are all important in determining suicide trends. Net of age and period effects, the cohort pattern of suicide rates is U-shaped, with cohorts born between 1915 and 1945 possessing among the very lowest suicide rates. Suicide rates begin to rise with boomers and subsequent cohorts exhibit increasingly higher rates of suicide. The general pattern exists for both men and women but is especially pronounced among males. The average suicide rate over the entire period for males is about 28 per 100,000, 95% CI [27.4, 28.7]. For males born in 1930–34, the suicide rate is estimated to be 17.4 per 100,000, 95% CI [15.9, 18.8]; for males born between 1955 and 1959, the rate is essentially the same as the average for the period while for males born between 1985 and 1989, the suicide rate is estimated to be 37.8 per 100,000, 95% CI [33.1, 43.4]. The results dispute popular claims that boomers exhibit an elevated suicide rate relative to other generations, but boomers do appear to have ushered in new cohort patterns of suicide rates over the life course. These patterns are interpreted within a Durkheimian framework that suggests weakened forms of social integration and regulation among postwar cohorts may be producing increased suicide rates.
In this article I report on an investigation of the pharmaceutical industry’s influence in medical education. Findings are based on fifty semi-structured interviews with medical students in the United States and Canada conducted between 2010 and 2013. Participant responses support the survey-based literature demonstrating that there is clear and pervasive influence of the pharmaceutical industry in medical education. They also challenge the theory that medical students feel entitled to industry gifts and uncritically accept industry presence. I investigate how medical students who are critical of the pharmaceutical industry negotiate its presence in the course of their medical education. Findings suggest that these participants do not simply absorb industry presence, but interpret it and respond in complex ways. Participants were uncomfortable with industry influence throughout their medical training and found multifaceted ways to resist. They struggled with power relations in medical training and the prevailing notion that industry presence is a normal part of medical education. I argue that this pervasive norm of industry presence is located in neoliberal structural transformations within and outside both education and medicine. The idea that industry presence is normal and inevitable represents a challenge for students who are critical of industry.
Ann V. Bell and Elizabeth Hetterly
Existing literature characterizes fatalism as a passive reaction to health in the face of powerlessness and constructs agency as a more activist perspective based in self-efficacy and control. Frequently studied together, researchers extol agency as the appropriate approach to decision-making around health, while discouraging fatalistic outlooks. Despite associating such beliefs with social classes—agency with high socioeconomic status (SES) groups and fatalism with low SES groups—there is little research that compares health beliefs across class groups. By examining the medicalized condition of infertility among women of both high and low SES, this study examines how social class shapes reactions to health and illness. Through 58 in-depth interviews with infertile women in the U.S., we reveal the complexity of fatalism and agency and the reasons behind that complexity. We first examine the commonalities among SES groups and their mutual use of fatalism. We then demonstrate the nuance and continuity between the health beliefs themselves—fatalism can be agentic and agency can be achieved through fatalism. In other words, we disrupt the binary construction of health beliefs, their conflation with social class, and the static application of health beliefs as psychological attributes, ultimately exposing the classist basis of the concepts. Doing so can result in improved patient care and reduced health inequalities.
In recent years, science studies scholars have critically examined several methods used by the pharmaceutical industry to exert control over knowledge about drugs. Complementary literatures on ‘medical neoliberalism’ and ‘neoliberal science’ draw attention to the economic ideas justifying such methods of organizing knowledge, and in so doing suggest that neoliberal thinkers may play an important role in developing them. As yet, the nature of this role remains unexplored. Relying on heretofore-unexamined archival evidence, this article establishes a direct link between the Chicago School of Economics and the mobilization of the pharmaceutical industry in the 1970s. It argues that economists affiliated with the Chicago School of Economics sought to influence pharmaceutical policy and science and constructed institutions to do so. These institutions – most notably the Center for the Study of Drug Development – remain highly influential. This article contributes to a historical understanding of how neoliberal ideas came to assume prominence in pharmaceutical policy, the management of science, and scientific practice.
Policies about physicians’ involvement with pharmaceutical companies spawn contradictory ideas. One set of policies aims to stimulate collaboration between private companies and publicly employed researchers to spur innovation and economic growth, another addresses what is seen as the problem of physicians’ conflicts of interest stemming from industry collaboration. This article explores how these contradictory policies interact with everyday practice in clinical hypertension research in Denmark. I argue that ‘corporate’ and ‘academic’ research is entangled as physicians participate in industry trials to pursue their own research. Building on document analysis, observations of contract research, and interviews with clinician researchers and industry executives, I show how the establishment of industry ‘ties’ can serve as a way for physicians to navigate the constraints of research infrastructures and live up to intergenerational norms that knit the medical collective together. I discuss how this entanglement shapes medical research in ways that may run counter to the aims of medical innovation policies and that conflicts of interest policies do little to address. I conclude that appreciation of the ways in which economic and moral valuations come together is necessary to understand the conditions for medical research in an intertwined public–private research environment.
Janet K. Shim, Katherine Weatherford Darling, Martine D. Lappe, L. Katherine Thomson, Sandra Soo-Jin Lee, Robert A. Hiatt, and Sara L. Ackerman
In this article, we explore current thinking and practices around the logics of difference in gene–environment interaction research in the post-genomic era. We find that scientists conducting gene–environment interaction research continue to invoke well-worn notions of racial difference and diversity, but use them strategically to try to examine other kinds of etiologically significant differences among populations. Scientists do this by seeing populations not as inherently homogeneous or heterogeneous, but rather by actively working to produce homogeneity along some dimensions and heterogeneity along others in their study populations. Thus we argue that homogeneity and heterogeneity are situational properties – properties that scientists seek to achieve in their study populations, the available data, and other aspects of the research situation they are confronting, and then leverage to advance post-genomic science. Pointing to the situatedness of homogeneity and heterogeneity in gene–environment interaction research underscores the work that these properties do and the contingencies that shape decisions about research procedures. Through a focus on the situational production of homogeneity and heterogeneity more broadly, we find that gene–environment interaction research attempts to shift the logic of difference from solely racial terms as explanatory ends unto themselves, to racial and other dimensions of difference that may be important clues to the causes of complex diseases.
Ben W. Brisois
The growth of the field of global health has prompted renewed interest in discursive aspects of North–South biomedical encounters, but analysis of the role of disciplinary identities and writing conventions remains scarce. In this article, I examine ways of framing pesticide problems in 88 peer-reviewed epidemiology papers produced by Northerners and their collaborators studying pesticide-related health impacts in Latin America. I identify prominent geographic frames in which truncated and selective histories of Latin America are used to justify research projects in specific research sites, which nevertheless function rhetorically as generic ‘developing country’ settings. These frames legitimize health sector interventions as solutions to pesticide-related health problems, largely avoiding more politically charged possibilities. In contrast, some epidemiologists appear to be actively pushing the bounds of epidemiology’s traditional journal article genre by engaging with considerations of political power, especially that of the international pesticide industry. I therefore employ a finer-grained analysis to a subsample of 20 papers to explore how the writing conventions of epidemiology interact with portrayals of poverty and pesticides in Latin America. Through analysis of a minor scientific controversy, authorial presence in epidemiology articles, and variance of framing strategies across genres, I show how the tension between ‘objectivity’ and ‘advocacy’ observed in Northern epidemiology and public health is expressed in North–South interaction. I end by discussing implications for postcolonial and socially engaged approaches to science and technology studies, as well as their relevance to the actual practice of global health research. In particular, the complicated interaction of the conflicted traditions of Northern epidemiology with Latin American settings on paper hints at a far more complex interaction in the form of public health programming involving researchers and research participants who differ by nationality, ethnicity, gender, profession, and class.
Brandon Andrew Robinson
Sexual health discourses have become a defining part of many gay men’s sex lives. These discourses have effectively linked gay identity to HIV/AIDS discourses through telling most gay men how to rationally have sex and how to routinely get tested. However, some gay men who bareback – the choice often made not to use a condom – engage in condomless sex despite these larger discourses. Through using Weber’s theories on rationalization, I explicate how sexual health and HIV/AIDS discourses are calculable, efficient systems that are about protecting the public good. I show how this rationalized sexual health system disciplines pleasure and intimacy. Through this disciplining, I illuminate how sexual public health has disenchanted sex, specifically for some gay men, where some of these men who bareback may be attempting to find re-enchantment in this disenchanted sexual world. Through this Weberian framework, barebacking may be seen as an act that can allow for the re-exploration of personability, intimacy, eroticism and love.
Barry J. Gibson and Ninu R. Paul
This article seeks to unpack the relationship between social structure and accounts of illness. Taking dentine hypersensitivity as an example, this article explores the perspective that accounts of illness are sense-making processes that draw on a readily available pool of meaning. This pool of meaning is composed of a series of distinctions that make available a range of different lines of communication and action about such conditions. Such lines of communication are condensed and preserved over time and are often formed around a concept and its counter concept. The study of such processes is referred to as semantic analysis and involves drawing on the tools and techniques of conceptual history. This article goes on to explore how the semantics of dentine hypersensitivity developed. It illustrates how processes of social differentiation led to the concept being separated from the more dominant concept of dentine sensitivity and how it was medicalised, scientised and economised. In short, this study seeks to present the story of how society has developed a specific language for communicating about sensitivity and hypersensitivity in teeth. In doing so, it proposes that accounts of dentine hypersensitivity draw on lines of communication that society has preserved over time.
Elizabeth Quinlan, Roanne Thomas, Shahid Ahmed, Pam Fichter, and Linda Mcmullen
The use of popular expressive arts as antidotes to the pathologies of the parallel processes of lifeworld colonization and cultural impoverishment has been under-theorized. This article enters the void with a project in which breast cancer survivors used collages and installations of everyday objects to solicit their authentic expression of the psycho-social impacts of lymphedema. The article enlists Jurgen Habermas’ communicative action theory to explore the potential of these expressive arts to expand participants’ meaningful engagement with their lifeworlds. The findings point to the unique non-linguistic discursivity of these non-institutional artistic forms as their liberating power to disclose silenced human needs: the images ‘spoke’ for themselves for group members to recognize shared subjectivities. The authenticity claims inherent in the art forms fostered collective reflexivity and spontaneous, affective responses and compelled the group to create new collective understandings of the experience of living with lymphedema. The article contributes theoretical insights regarding the emancipatory potential of aesthetic-expressive rationality, an under-developed area of Habermasian theory of communicative action, and to the burgeoning literature on arts-based methods in social scientific research.
This article examines the professional and public response to the television play Through the Night, which aired on BBC1 in December 1975. One of the first British mass media portrayals of a woman’s experience being treated for breast cancer, this play attracted a large audience and considerable attention from both critics and everyday viewers. My analysis of the play draws on sources documenting expert responses to the play in its production stages, as well as critics’ and viewers’ responses to what the play said about breast cancer treatment in particular, and about Britons’ experiences of medical institutions more broadly. Together, I argue, these sources help us see how Through the Night’s critique of what one expert called ‘the machinery of authoritarian care’ reverberated with and supported the efforts of professionals anxious to improve patient experience, and how it crystallised the concerns of activists and everyday viewers.
Liz Ross, Phil Lyon, and Craig Cathcart
This article examines the ameliorative options facing people with hearing loss in mid-nineteenth-century Britain. As reflected in professional journals of the day, medical understanding of diseases and dysfunctions of the ear was limited, yet there was vigorous assertion and counter-claim as to the cause and treatment of problems. At the time, medicine was largely unregulated and quack practitioners were also able to promote their nostrums and services to a credulous the general public with little chance of a genuine cure for their hearing loss. Using the nineteenth-century British Library Newspapers Archive for 1850, 379 advertisements offering cures for deafness were identified and examined to illustrate the variety of nostrums and devices offered to the public. Individuals with hearing loss were easy prey when even qualified medical practitioners had little understanding of cause or treatment, and when scant legal protection protected them from fraudulent treatment claims or offered redress for their failure.
This paper examines the turn toward the small companion animal that occurred in British veterinary medicine in the twentieth century. The change in species emphasis is usually attributed to post-war socioeconomic factors, however this explanation ignores the extensive small animal treatment that was occurring outwith the veterinary profession in the interwar period. The success of this unqualified practice caused the veterinary profession to rethink attitudes to small animals (dogs initially, later cats) upon the decline of horse practice. This paper argues that a shift toward seeing the small animal as a legitimate veterinary patient was necessary before the specialty could become mainstream in the post-war years, and that this occurred between the wars as a result of the activities of British animal welfare charities, especially the People’s Dispensary for Sick Animals of the Poor.
This paper concerns what I call “the moment of recovery,” the time when, in the 1950s, American cancer campaigns abandoned an earlier tendency to downplay post-operative recovery in their public education programs. This change was signalled by the emergence of new patients groups such as Reach to Recovery (founded 1953), and by a new interest in cancer rehabilitation among physicians, nurses, and manufacturers and sellers of equipment and clothing for patients. My focus is on breast cancer and the nurse-patient-industrial complex that drove the new interest in rehabilitation and recovery, but I also argue that the “moment of recovery” in breast cancer was part of a larger “moment” in cancer more generally. Finally, I seek to distinguish the “moment of recovery” of the 1950s from the discourses around the survivor that have emerged since the 1970s and 1980s, what might be called the “moment of survivorship.”
In contemporary writing Axel Holst and Theodor Frølich are being celebrated as the first to produce an animal model for the experimental production of scurvy. But in their time their research was contested by their peers, most vocally by the polar hero and zoologist Fridtjof Nansen. This paper explores how Axel Holst initially started out as a microbe hunter and worked within a bacteriological framework, before he shifted to performing feeding experiments and came to understand scurvy as a deficiency disease. This radical shift in framework may take part in explaining the controversy around their research. But most importantly, this paper argues, we must understand this in light of the contested status of animal models and modelling work in medical science. In order to analyse this, the paper suggests that we attend to a broad set of approaching and defining ‘models’. Moreover, the paper suggests that we extend our discussion from ‘the animal model’ and what an animal model is, to modelling practices and what models can do, and sometimes fail to do. The paper concludes with arguing that Holst and Frølich in fact did not develop an animal model, i.e. a shared example upon which scientists base their work.
translated by Stephen Adam Schwartz. Harvard University Press, 2014. 392 pp.
How is what is “in” our minds, as thought, also something that we share, communicate, and can understand? This question, however posed, must be fundamental for any anthropological approach to mental life. In the course of our research we have to ask ourselves, at least implicitly, what we are doing—mentally—when we interact with others, and how on this basis we can claim to share, and know, another’s experience. In relation to anthropological fieldwork, the cognitivist common sense that makes mental processes the outgrowth of an individual capacity to think (located in modules or states of the brain) raises more questions than it can answer, rendering illegible both the shared worldly context of speech and thought, and the sense which we, collectively, can make not only of what is present to our immediate perception but also of times past and future, distant cultures with alien epistemologies, and even illusions, hallucinations, and compulsions. In his recently-translated The Institutions of Meaning, the French philosopher Vincent Descombes seeks to understand the mind, instead, through a linguistic and interactional account of intention, formulating a challenge to reductive, materialist accounts of mental mechanism and providing an original pathway to the mind through social institutions of shared meaning and exchanges of words and things (often highly unequal ones). In a significant way, this book returns “the mind” to anthropology as a proper object of social research—or, perhaps better, recovers the anthropological dimension integral to any conception of the mind.
The Institutions of Meaning (originally published in French in 2001 as Les Institutions du sens) is a kind of sequel to Descombes’ earlier book, The Mind’s Provisions: A Critique of Cognitivism, in which he argued on linguistic and phenomenological grounds that mental processes, whatever they are, neither happen inside “a” mind nor are they best described as “representations”—an argument which directly opposed the atomistic and additive language of contemporary cognitive philosophy. In a clear and stylish translation by Stephen Adam Schwartz, The Institutions of Meaning, which is subtitled “A Defense of Anthropological Holism,” sets out to provide a different philosophical account of mind, one that roots cognition in pre-existing contexts of exchange and interaction. This book does not directly address formulations developed in psychology or the natural sciences for understanding the mind—it speaks, instead, primarily to other philosophers’ deployments of mentalistic and materialistic notions of cognitive processes, and challenges them with an expanded concept of mind and meaning built, innovatively, from French structuralist anthropology (which Descombes reminds us was always in part an investigation into mental structures). But if this book does not make a direct contribution to the “collaborative turn” that links the human and the natural sciences, as this was defined recently here on Somatosphere, it still has much to say about scientific thought about the mind, insofar as that thought is conducted in terms that are also embedded in social institutions of meaning.
Descombes is a leading figure in philosophy in France—he is Professor at the Ecole des Hautes Etudes en Sciences Sociales in Paris—and he was trained in much the same tradition as the figures whom most Americans might associate with “French Philosophy,” such as Derrida and Foucault. However, unlike these “Continental” thinkers, Descombes is equally influenced by, and contributes to, the philosophy of mind that has developed as part of the analytic tradition of Anglo-American philosophy. In fact, Descombes practices philosophy in the analytic style, and explicitly aims to address the challenges posed by this philosophy, which expels as both non-empirical and non-philosophical much of the metaphysical baggage of the philosophical tradition, and attempts to rebuild philosophy starting from ordinary language and common sense.
Yet the thrust of Descombes’ work as a whole is against the Cartesian presuppositions which remain internal, as “common sense,” to much Western epistemology and ontology. He argues against any dogmatic adherence to principles that causes must come before effects, and parts before wholes, and matter before mind or spirit. Constructively, he seeks to find philosophical, and analytically-acceptable, means and terms for making sense of the anthropological dicta of the holism of social relations: that societies come before individuals; that meaning emerges from structured relations between signs and not from relations of resemblance between words and things; and that mind and meaning inhere in contexts and in interactions, and not “in” material objects, symbols, or even inside human brains. To defend such holistic propositions, he presents a sustained and excellent critique of the notion that breaking things down into elements clarifies their relations. Insofar as this cuts against our common, “scientific” common sense, and instead builds from conceptions of mind and spirit that owe much to Hegel and Husserl, Descombes’ philosophy of mind can only be “semi-analytic.” Indeed, he explicitly grants himself license to employ the resources that exist in French and German for speaking, in one breath, of mind, spirit, and idea (senses that coexist in the words esprit and Geist). He does not pun on these multiple senses, however, but rather aims to describe a real, human and social, totality to which “mind,” in this expanded sense, may refer.
The first half of The Institutions of Meaning focuses on the notion of intention, which is in modern philosophy the defining attribute of mental phenomena. We say, Descombes stipulates, that something is mental when some thing is related to in a way which puts it “under a description”—when it is perceived, thought of, loved, sought—and this only for a particular subject. The definitional relation established here between subjective thought and its object raises the problem of how to bridge the mental act with the real world—how do language, and thought, refer to, and can they affect, their objects? In an aside relevant to anthropological concerns Descombes discusses, as unsatisfactory, various attempts to construct a wider “intentional history” which could, through the concepts of abstraction or discourse, account for the power of ideas in material and social life. He moves from Kojève’s Hegelian thoughts on the power of abstraction to affect real individuals, to Lacan’s aphorism that the “symbol is the murder of the thing,” to, finally, a refreshing and skeptical take on Foucault’s and Hacking’s accounts of the power of discourse. All of these attempts at an “intentional history” have failed, for Descombes, because their impersonal descriptions of an “order of discourse” (Foucault) require—but give only scant account of—a real context of people talking, acting, and behaving intentionally in order to become plausible as descriptions of interaction between the mental and the real (a condition that Hacking’s work, with its doctors inciting speech from patients, in part meets). In order to bridge, and thus move beyond, the dichotomy between the world of instituted and abstracted meanings, on the one hand, and individual mental facts and real things, on the other, Descombes proceeds to pay close attention to the social as a realm of instituted roles and meanings, related systematically in such a way that some actions and descriptions depend on others and thus, in their instituted relation, link the linguistic context to the real one of thought, interaction, and reference.
That is, Descombes argues (following Pierce and Wittgenstein, among others) that there is always a real relation of reference and patterned interaction which comes with the intentional relation—in the intentional action of even the most private thought, something is intended in the worldly context, and this takes intention out of the realm of the purely mental into a world of social relations and conventional, instituted meanings which can bear upon subjects, personally or impersonally as the case may be. This assertion is clarified in his analysis of a concept from “philosophical grammar,” the “intentional passive” (pp. 66ff.) Though not marked in natural grammar in either French or English, the intentional passive, once defined philosophically, helps explain how one can reverse the description of an intentional or mental act such as “Romeo loves Juliet” and yet still arrive at a properly constituted sentence in which the grammatical object Juliet has become the subject of an intentional predicate: Juliet is loved by Romeo. This perfectly normal linguistic feat, seen philosophically, demands some account of how a mental act can be said to bear on another subject as an “intentional passion”: some state that, for that subject, truly is. Though it need not, of course, affect her at all personally, being loved must affect Juliet in some way insofar as she is known through the descriptions of her.
The intentional verb to love, like all words, is part of a system of verbs and nouns, with various functions, and is internally related to them; meanwhile, grammar is linked to social institutions that set apart certain words and make them refer in a special way. Take, for instance, the institution of proper names. That is, whatever the impact on Juliet, Romeo really loves a specifiable person who is called by that name. His thoughts have, potentially, a real effect in the world, but only in virtue of their prior connection to other words, which are connected institutionally to specifiable contexts, and, to continue the argument, also to a situation in which it is a meaningful thing for a young man to love and seek to be loved. This is what Descombes comes to mean by “institutions of meaning”—that there are conventions of which words and signs are the vehicles, and these conventions are not only linguistic, but social and impersonal, albeit lived very personally. The two levels, of brute reality and mere meaning, which other philosophies might want to keep separate, are here united in a quite pragmatic and describable way, which becomes clearer as Descombes works through his examples.
Indeed, Descombes spends a great deal of time constructing examples that complicate and expand the notion of an intentional phenomenon. What does it mean to say that someone is looking for someone else—say a sheriff for a horse thief—and to describe that action as intentional, and therefore mental? “Looking for” seems like a very physical activity—you might look here, or there, or anywhere, but not inside your head! Yet for all its real-world physicality, the action of “looking” also comprehends a number of mental attitudes and suppositions, which problematize any direct notion of reference: you can look for a horse thief even if, in actual fact, one does not exist (a mistake has been made; or the horse is being hid by its owner for other reasons, in which case one “finds” the horse thief when one “understands” the owner’s motives for hiding his own horse—note how densely mental the example becomes!). Moreover, whatever your mental intention at any one point in time, we say that you can find without looking. What, then, is the relation between these real and mental events, and how does intention bear upon its object, which may not even exist, or which may not be intended in the first place?
In another of Descombes’ examples, “expecting” raises the related problem of the continuity of mental acts. What is it to say that I am expecting someone to show up at my house at a given hour? How do I describe that mental fact of “expecting” which may, in fact, not be an idea I am consciously entertaining at any particular moment during the time I am, in fact, doing just that? I may be avidly knitting, or entirely absorbed in a book, and all the while expecting my visitor. And did I not expect after all, if my visitor failed to show up?
Perhaps unsurprisingly, Descombes’ answers to all of these problems revolve on his specification of a holistic relation between the mental act and previously instituted conventions and shared meanings: the search for the horse thief presupposes the institution of property and the fact of a missing horse, and those make possible the mental act of intending to find a thief; the institution of the appointment explains the expectation of a visit, which is surely a mental act even if it is not a consciously or continuously held idea. Finally, the power of different words to refer to the same things or to different aspects of the same things, without disturbing their apparently real identity and separateness, allows us to evade the apparent “holistic paradox” of institutions and relations preceding their objects, and existing independently from the reality of the things related. For we can understand the parts of things which appear, really or irreally, in a given description as the aspect of them which is relevant at that time, or “under that description”. If the Sheriff thought that Mr. Smith was the horse thief and hence looked for him as such, the Sheriff and Mr. Smith are put in a real relation and transformed by it, even if Mr. Smith was in fact neither a thief nor findable—it is not necessary that he be a horse thief for this relation to hold, nor for him to be mistaken for one; it is only necessary that he be, in fact, Mr. Smith, a fact secured by the social institution of proper names.
Richard Rorty has highlighted this last aspect of Descombes’ philosophy: he refuses the “general illusion of metaphysics” that things must have one, singular identity, and understands instead that we get at them only through their multiple descriptions (which change, as do the things themselves). Action under a description admits the priority of relations while it also permits of change, discovery, and partiality. As Descombes puts it here, “We will say that looking for is necessarily ‘under a description’ (secondum quid) but that an encounter is necessarily an encounter with an object tout court (simpliciter). . . . What is at issue is the aspect under which what is looked for is looked for, and the aspect under which it is found. The found object is necessarily richer than the object sought. . . . Oedipus is looking for Laius’s murderer. When he finds him, he also finds someone he was not looking for, namely Oedipus himself” (p. 85).
But what kind of holism does this understanding of intentions and institutions entail? In answer to this question, Descombes engages with structural anthropology in order to define and defend a notion of structure and differentiation which is far from analytic philosophy’s previous accounts of wholes as sets, classes, and collections. What Descombes calls “collectivist holism” would hold—and he has examples of this point being made—that a whole can only be made up of parts which are similar in some logical way: in the way that all members of the same team make up the whole, any collection or set of things thus constitutes its own totality, logically (the paradigmatic logical statement of this position, “all bachelors are unmarried” describes a collection, and hence this position is “collectivist”). Instead, Descombes defines a whole as the interdependent totality of differentiated parts or roles. “Far from receiving from the system the same characteristic trait, they will receive different positions” (p. 117, italics his), he writes, and thus his holism demands a logic not of singular relations of identity, but rather polyadic relations.
Reciprocal but formally non-reversible relations between actors described in distinct social roles (e.g., murderer-victim; donor-donee; father-son) are key to the second half of this book, to the working out of the grammar of anthropological holism. Thus, the structural anthropology of the gift gets a chapter of its own (Ch. 9), where Descombes explores how key anthropologists described such differentiated and reciprocal roles in exchange, kinship, and social order. Here, Descombes extends his core argument that both the object and the “regulative principle” (a term he takes from Lévi-Strauss) of mental life must be located in exterior, public realm of actual human actors and their social relations, adding that these relations must be (following Peirce) at least triadic. That is, a triadic relation is set up when you have a proposition in which someone accomplishes something bearing upon another subject via an object, such that I give you a thing, and I am a giver, you a receiver, the thing a thing given. This cannot be reduced into a purely dyadic relation (donor-donee) without evacuating the specificity of the relation: “in every proposition concerning a verb of giving, one will have a link to the thing and a link between people, and these two will be dissociable” (p. 251). Further, intentional statements are always, in principle, triadic, for “the description of an intentional action is a description of the undertaking of an action at a distance by means of a local action, with the result that its logical form must comprise a multiplicity equal to at least three” (p. 230, italics his).
Descombes’ philosophical interest in description motivates his turn to anthropology, here, and he specifically seeks to reclaim the explanatory force of the ethnographic descriptiveness of Marcel Mauss, whose texts are densely involved in particulars and in the language of their formulation. For instance, Descombes returns to the complex, polyadic reality that is captured by Mauss’s use of an untranslated “indigenous” term hau—the “spirit of the gift” or esprit de la chose donée—to describe how a social rule of reciprocity in Maori gift-exchange is more or less self-consciously expressed as an interpersonal force, as a spirit (esprit) or social intention which links separated, individual actions and projects others across space and time. Contrasted with Mauss’s ethnographic description of the spirit of the gift, Lévi-Strauss’s later attempt to mathematize and abstract gift-exchange into a balanced system of reciprocity, reducible to binary operations—a general symbolic logic of contrasts—is said here to be, in a curious way, entirely unsocial, because it evacuates the content of the thought, the sense of a spirit animating the exchange, the tertium quid which grants direction, meaning, and (potentially) completeness to the relations established via the gift. Ultimately, Descombes’ effort to put intention back into structural accounts of exchange leads him to a useful, and quite faithful, reading of the later development of structural anthropology and in particular Louis Dumont’s “holistic” emphasis on complementarity, differentiation, and hierarchy in exchange relations (I must pass over here the careful work which Descombes does to defend his own position both against charges of “structural causality” and “the myth of the collective individual”).
In the course of his critique of Lévi-Strauss Descombes becomes, uniquely in this volume, ethnographic—that is, he writes about interactions and exchanges which he himself has observed. He offers, in a skillful, writerly turn (pp. 265-66), a response to Lévi-Strauss’s famous example of reciprocity in the exchange of wine in restaurants in the South of France. Rather than the silent and mutual ritual exchange of equivalent amounts of wine between strangers, in order to form the minimal kernel of a relation and make the anonymous context of a roadside hotel tolerable, Descombes describes anxious and risky negotiations over such exchanges, fraught with class content and uneven demands for return, in which the fact of exchange is subordinated to the uneasy question of who should go first (one settled in his example entirely contingently, but opening to questions of value and hierarchy more fully worked out by Dumont). All of this is pursued to buttress his philosophical argument that the only way to capture the reality of the mental is through examination of contexts of interlocution and sense-making, that these contexts are deeply intentional and intensely personal as well as being shaped by a prior world of established and conventional roles and meanings, and that rather than being logically contradictory these two aspects are mutually constitutive within a structure of unequal and differentiated positions.
This book concludes by returning to the individual mind, in its interiority and separateness, and to a philosophical version of the anthropological methodological quandary: how can we claim to know the intentions of others, widely separated from us by language, culture, and custom? Descombes’ last question is, thus: is it possible to say that two separate minds can, in their interiority, think the same thought? If they are linked by social institutions, governed by rules, and situated in a world, he answers, it is. One of the last philosophical examples in the book has to do with the thought of “having an appointment,” mediated by institutions as diverse as calendars and routines of mutual visiting. In this situation, Descombes argues, two people who are thinking about their mutual appointment are not, indeed, having identical thoughts—B is thinking that she must meet A, and A is thinking of her meeting with B—but “it is nevertheless acceptable to speak about the same thought if we take into account the fact that two complementary thoughts are involved” (p. 330, italics his). And this thought is a social one, possessed equally by two minds individually, which puts them in complementary—and likely hierarchical—relation as a function of their common thought. Thus Descombes manages to bring into communication two minds, without mechanism, and without determining in advance the content of their thought, and without the need to impose on their thoughts a given form or language. What is necessary here is simply the anthropological context in which any two people might have an appointment, which thus puts their separate thoughts in a complementary relation and makes them part of the same whole.
The “anthropological holism” of Descombes’ subtitle, then, is a structural one, which he is at pains to remind us has always also meant, in France, an anthropology of the mental, of l’esprit and la pensée. However, this comes with the important caveat that he seeks to preserve both the autonomy of the speaking subject, and the particularity and agonism of social interactions. Descombes cites, in passing, a “profound remark” made by Samuel Butler: “It takes two people to say a thing—a sayee as well as a sayer. . . . A may have spoken, but if B has not heard, there has been nothing said, and he must speak again” (quoted on p. 312). This mediated relation between what Descombes calls “two freedoms”—the freedom held by the sayer and sayee, individually, to speak, to listen, to repeat, to ignore, to insist, or to doubt—has a triadic structure in which the saying, the said, and the hearing or interpretation are each equally necessary, and none can, in advance, determine the outcome. Not only are the social institutions which give words sense important in this account, but so is the fact of their shared “mental” possession and their use in the thought and action through which linguistic and social structures are worked out.
All of this, of course, has implications which have more to do with matters of mutual understanding and interaction than they do with cognitive operations as such, in which latter much more than propositions are involved. And it could be seen as unnecessary to take this detour through an abstracted, philosophical and logical approach to the mind to find ourselves, simply, back at the scene of social interaction—where anthropologists were to begin with. But Descombes is not recommending a simple, common-sense turn to a “real” world of interactions—rather, it is the institutions of meaning that matter to him, and it is the insight into their systematic structuring as the “historical and social context of the human mind” (p. 261) which is most important here. Further, I think this idea of the mind is one which makes sense of some fundamental problems for any anthropology of mental life (which are also problems for the human sciences that take “the” mind as their object): how do we return from the separateness of individual minds to the common context in which we come to know them? It is Descombes’ achievement to have shown that the reduction of mental processes to associations or assemblies of interacting parts is no answer to this question, which demands instead an account of the plurality and holism of the meaningful relations—including those of kinship, class, power—which are in already at play in any intentional context, any situation of human interaction.
Descombes ultimately allies himself with anthropological and philosophical writers who “want to maintain that the social cannot be reduced to the nonsocial” (p. 295). In this, his work stands at some remove from current epistemological and ontological debates in the anthropology of science and medicine and science and technology studies, debates which while not reductive are oriented more toward understanding associations and interactions than invested in describing institutions (or “total social phenomena”) which could give such relations order or form. But Descombes doesn’t merely assert the priority of the social. Rather, he guides us back to the social in a way which renews classical anthropological holism and totality, using it to understand problems of intention and action (a faithful Maussian might add, “again”—and indeed, Descombes invokes “institutions, in Mauss’s sense” on the very last page of this book). Descombes starts from systematic relations internal to language (and their use in thought), moves through their deployment in contexts of reference, to arrive at the world of interaction and “institutions of meaning” in which any human mind must be set, to be able to operate. This structural, holistic pathway necessities abandoning Cartesian notions of causality, reworking ontological claims about individuals, and interrogating the reality of social facts (historic and ongoing challenges for anthropological theory, too). Returning, by this pathway, to dynamic and unequal interactions, social norms and imperatives, and the structural contradictions to which these can give rise, might help us better understand the very real force of social institutions in the situations in which human beings, together, speak and act with consequences beyond themselves and beyond their immediate context—including mental consequences. It may not be a paradox but a finding that we end up needing a holistic conception of the social to get to the mind.
Leo Coleman is Associate Professor of Comparative Studies at the Ohio State University. A cultural anthropologist by training, he is the editor of Food: Ethnographic Encounters(Berg, 2011), and has published several articles on ethnographic method and on urbanism, infrastructure, and legal knowledge in India and the British empire. He is working on a historical ethnography of electrification and state power in twentieth-century Delhi, India.
 The Mind’s Provisions: A Critique of Cognitivism, Stephen Adam Schwartz, trans., Princeton University Press 2001; originally published as La Denrée Mentale, Minuit, 1995).
 Richard Rorty, “The Brain as Hardware, Culture as Software,” Inquiry 47:3 (2004), 235.
Pesticides: can’t live with them, can’t live without them
In Sri Lanka, producers of the illicit liquor kasippu sometimes suspend a bottle of pesticide above the vat during the fermentation process. It is believed the kasippu will absorb the potency of the pesticide and add to its strength, increasing drinkers’ intoxication and pleasure. But there is also a danger the pesticide will fall in, and if so the batch will be poisoned and mass injuries and even deaths ensue.
Why do kasippu drinkers take this risk? Kasippu, a cheap spirit favoured by those on low incomes, is mostly drunk by agricultural smallholders and daily-waged farm labourers, for whom pesticides (a label including insecticides, weedicides, fungicides, etc.) form an integral part of everyday life. Sri Lankan farmers make heavy use of agrochemicals, applying products in large doses throughout the growing season. Faced with ever-increasing market competition, they are required to use greater amounts just to stay in the game—placing them on an ‘agrochemical treadmill’ propelling greater investment in pesticides for no greater return. Large upfront investments in agrochemicals at the start of the season do represent a considerable risk if harvests should fail, which, due to the unpredictability of Sri Lanka’s monsoons in recent years, they often do. Although Sri Lanka hasn’t witnessed the same scale of debt-driven ‘farmer suicides’ as India, the country has reported some of the world’s highest suicide rates.
Even if pesticide debts contribute only marginally to Sri Lanka’s suicide epidemic, pesticides themselves have still been the most popular method of self-harm in country, as indeed they are across many developing nations. It is this fact more than anything that pushed Sri Lanka’s suicide rate up so high, as the spread of pesticides in the island since the 1970s transformed an already-existing cultural practice of self-harm into a highly lethal practice. When in the mid-1990s the most toxic compounds were banned, suicide rates fell by half.
Besides intentional pesticide poisoning, farmers also run the risk of occupational pesticide poisoning and associated acute and chronic health effects. Hospitalisations caused by accidental inhalation are common, and long-term routine exposure can lead to a range of chronic illnesses. Since the 1990s a growing epidemic of fatal ‘kidney disease of unknown aetiology’ (CKDu) in Sri Lanka’s rural North Central Province has been linked to pesticide spraying, and/or contamination of water sources. Estimates have placed the fatality rate of CKDu at between three and eight deaths per day. On the back of this, the Sri Lankan government has issued further pesticide bans, although not without controversy. For example, a recent study suggested that glyphosate, a weedicide more commonly known as RoundUp, when mixed with hard water and other metals, was to blame for the problem. The Sri Lankan President immediately issued a ban on glyphosate, only to retract it a few months later after the European Glyphosate Task Force, a coalition of pesticide companies, questioned the evidence base.
Thus, on the one hand, pesticides have contributed towards economic and social development by promoting farming, reducing food prices, and opening previously hostile environments to cultivation. On the other hand, pesticides have led to economic dependencies and a wide range of health complaints and environmental problems. Although accepting pesticides as ‘dangerous things,’ farmers in Sri Lanka, stuck on an agrochemical treadmill, are unwilling or unable to give them up. Even the President was apparently unable to enforce a ban on glysophate, reversing a personal directive to the bemusement of critics. The ambivalent status of pesticides as objects that people can’t seem to live with, but also can’t seem to live without, is thus well-established in the Sri Lankan psyche. When viewed in this way, kasippu fermentation techniques come to make sense as a locally-grounded practice through which farmers can take control of pesticides’ ‘known and unknown’ effects.
Pesticide roulette and Schrödinger’s cat
One view onto this is to think in terms of risk, which as a sociological and anthropological subject has attracted significant levels of inquiry. Kasippu fermentation techniques can be understood as a kind of ‘pesticide roulette’ through which the benefits and dangers of agrochemicals in farmers’ lives and livelihoods are managed through a calculative process. Swallowing liquor fortified by the sheer presence of a substance that holds the drinkers’ economic and health wellbeing in its hands, but which might also contain lethal traces of that substance, is tantamount to inviting fate to play dice. To drink kasippu only to enjoy the rewards of drunkenness and avoid self-poisoning is to speculate. To imbibe and survive is a good sign. How the risks of pesticides are imagined and ranged against their potential benefits, and how different groups work these calculations within and between translocal contexts, is a fascinating question.
Another view is in terms of ambivalence—the sense of anxiety caused by a failure to classify something—that as a topic has received much less theoretical elaboration. In Modernity and Ambivalence, Zygmunt Bauman argues that ambivalence is a necessary condition of modernity. The project of modernity, according to Bauman, can be defined as an attempt to impose structure on the world through a system of classifications that ultimately serve in the interests of power—to classify, to decide ‘what is and what is not,’ is to rule. Thus ‘modern times,’ Bauman argues, constitute ‘an era of particularly bitter and relentless war against ambivalence.’ As a practice concerned with classification, pesticide roulette places things on a knife-edge, where the proper definition of pesticides—as objects that benefit or harm—is unknown until the kasippu is drunk. It is in terms of ambivalence that pesticides might be more fully understood, as calculations of risk can only be made once agreement has been reached about how an object of ambivalence ought to be classified. Like Schrödinger’s cat, we only know what’s in the bottle if we open it up.
Pesticides are not alone in their ambivalence, and pesticide roulette is just one example of how people around the world who are faced with ‘ambivalent objects’—those commodities and industries thought essential for human survival whilst also posing considerable potential harm—negotiate the dissonances they create. Popular culture is full of ruminations on the socially, ethically, and politically disorientating pace of scientific, medical, and technological advance that promise revolutions in human health and wellbeing whilst generating considerable, even apocalyptic, risks to people and planet. Reflecting the sheer importance of global food demands, many of these belong to the agricultural sphere. The potentials of organic farming notwithstanding, genetically modified crops present themselves as the only alternative to pesticides—even as critics argue that ‘frankenfoods’ could end up creating terrifying hybrids of plants, animals, and insects and do as much harm as chemicals. Pesticides and GMOs are themselves only a subset of a wider class of ambivalent objects. These include nanotechnologies (which might revolutionise medical care, or turn the world into grey goo); psychopharmaceuticals (which might elevate the mental health of developing nations, or co-opt millions into capitalism’s psycho-fictions); and the whole range of alternative energy sources (which might save us from environmental catastrophe, or simply pollute in a whole range of indirect ways).
Ambivalent commodities and technologies embody the conditions of modernity that produce them. Most people agree that but for a few early products, pesticides as we know them have only been around for 70 years or so. When in 1962 Rachel Carson published the seminal Silent Spring, a book charting the human and environmental devastation wrought by pesticides, she began by describing how the Holocaust produced much of the science behind them, when it was realised that chemicals used to kill people could also kill insects. No less significant is the fact that pesticides were born during the turbulent years of World War II, and revolutionised farming at the beginning of the post-war period, becoming the cornerstone of an agroindustry that fed the rapidly growing population of the modern world. Pesticides are not only the first of the ambivalent objects filling the world around us, but a condition of modernity. Pesticides are necessarily ambivalent; they provide objects against which we can range our values and opinions of modernity, even as they create the very conditions that allow us to ask those questions.
Departure points for a study of pesticides
As pesticides criss-cross the planet from points of manufacture to points of use, they pass through multiple contexts that shape responses to ambivalence and create new forms of ambivalence in their wake. Exploratory ethnographic fieldwork conducted in Sri Lanka points towards four inter-related sets of issues that have bearing on how this unfolds. The first set concerns how pesticides’ health effects are conceptualised by homeopathic and allopathic medical systems, including how they position human bodies vis-à-vis agrochemical landscapes. The second set escalates pesticides’ effects to the level of populations, aggregating them with changing concerns of ‘security,’ including food security, health security, and national security. The third set illuminates the ideological assumptions underpinning these problems and the practical interventions they suggest, including tropes of pesticide ‘safe use’ and ‘safe storage.’ The fourth set escalates further still to the level of global health governance, revealing how debates concerning pesticides are buffeted by debates around ambivalent objects and associated non-communicable diseases more widely.
The first set of issues thus concerns pesticides’ health and environmental benefits and risks in the most fundamental sense. In the decades’ worth of arguments stressing their ‘pros’ and ‘cons,’ this is a space where the vast majority of debates concerning pesticides have taken place. Directing these debates are grand traditions of medical and scientific inquiry, from the allopathic biomedical through to the homeopathic Ayurveda, as well as newer cross-disciplines of environmental science and green politics. Far from existing as a field of detached scientific endeavour, pesticides excite passions. Debates on either side have drawn as much from emotional rhetoric as rationale argument, leading to suspicion, misunderstanding, and antagonism between different lobbies. In Sri Lanka, things aren’t much different. CKDu generates lively arguments between camps, often spilling over into academic and political spats. How commentators evaluate and employ the evidence often says as much about departmental affiliation, old boy networks, and views on the current regime.
Yet health traditions themselves are not always so far apart as might be assumed, and homeopathic and allopathic practitioners get together on a range of subjects. Both are concerned that pesticides affect human behaviour at an emotional level, fuelling the suicide rate by heightening levels of impulsivity in the population. How they imagine such connections links bodies and environment in intriguing ways. Margret Trawick’s description of the Ayurvedic understanding of the body as ‘a landscape, an open field with all the processes flowing visibly, at or near the surface,’ is implied in the chains established between crops, bodies, and minds investigated by biomedical health researchers. Sri Lankan Ayurvedic doctors suggest that the island’s suicide rate went up when pesticides entered the food chain, making minds and bodies ‘hot’ and leading to emotional outbursts including suicide. Building a similar causal narrative, allopathic health researchers are investigating correlations between body absorption of pesticides and impulsive suicidal acts.
The second arena escalates these concerns to the level of populations. Since ‘9/11’ fears over bioterrorism and the release of diseases like smallpox, animal-human transmission of influenza strains and resulting pandemics, and the effects of climate change and extreme weather events, have combined to create a nexus of ‘national security’ threats converging on health and environment dangers. The role of pesticides in these debates is, as ever, paradoxical. The Green Revolution was so-called because intensive farming methods including agrochemical use promised ‘food security.’ The use of pesticides to control mosquito-borne diseases like malaria, and, an increasing concern in urban South Asia, dengue, represents a source of ‘health security.’ But the crisis represented by CKDu and the pesticides said to cause it are explained in terms of a threat to ‘national security.’ When another research report indicated high levels of arsenic in rice was responsible for CKDu, the government allegedly blocked publication. According to the director of the national kidney unit, the thought of the ‘everyday plate of rice and curry’ suddenly becoming a major health risk was simply too much – people would revolt. Thus pesticides have transformed from nation-builder to nation-protector to nation-destroyer.
In its satirical cartoon depictions of modern-day crises facing the nation, the Sri Lankan Daily Mirror captures elements of these debates. In Figure 1, we see Sri Lanka’s troublesome relationship with India cast in terms of bird flu, from where it may spread. On the same theme, in Figure 2, in an image reminiscent of those of civil war that until recently filled Sri Lankan newspapers and TV broadcasts, we see a white-coated doctor gearing up to blitz a flock of infected birds. In Figure 3, threats posed by mosquito-borne diseases align with threats from industrial action in the health sector. Finally, in Figure 4, a sorrowful image of the island itself, recovering from a kidney transplant operation on World Kidney Day.
From their effects upon people, planet, populations, and peace, the third set of issues encompasses the solutions that governments, health NGOs, and academics advocate. One of the most common problems cited by people on all sides of the debate concerns the behaviour of individual farmers in their agrochemical practices. On one side, we find the anti-pesticide NGO Pesticide Action Network Asia Pacific (PAN AP) stressing how farmers in the region are unable to afford the necessary protective clothing and equipment, which is anyway too hot and cumbersome to use in a tropical climate. On the other side, we find Syngenta AG, a major pesticide producer, promoting a range of guides in local languages that seek to convey the importance of ‘following the guidelines’ of safe use. A third dimension here is provided by poisoning treatment and prevention organisations like the South Asia Clinical Toxicology Research Collaboration (SACTRC), which argues most suicides by pesticides are committed by impulsive self-harm and so is trialling a lock-up box intervention that seeks to limit access to pesticides in the home.
Within these approaches, we find particular theories of human behaviour and risk evaluation that underpin pesticide interventions, as they aspire to create ‘responsible’ farming practices. This includes how concepts of culture are worked to explain South Asians’ apparent lack of risk sensibility and presence of impulsivity, as well as reflecting interventionists’ ‘Euro-American’ understandings of ‘investment and return’ in farming technologies, particular gender and age divisions of (farm) labour, and globalised notions of risk and reward. At stake here seems to be the creation of an ‘agrochemical citizenship’ to be promoted as a lasting solution to pesticide injuries and deaths in the region. The problem thus confronted is one that has troubled Sri Lanka for some time. In the late 19th century, British colonialists attributed then high rates of homicide to the impulsive character of the Ceylonese, whom they argued were prone to ‘sudden anger.’ As with pesticides today, the British banned open knives with the hope that folding knives would replace them, giving time for the victim to escape while the attacker fumbled with the blade. In addition to this, the colonialists set out to teach boxing to village youth, with the intention of inculcating a sense of ‘fair play’ and ‘self-control’—a foreshadowing of the 21st century pesticide safe storage discussion that was to come.
Finally, we arrive at the fourth set of issues: linkages between theoretical research and the world of policy and practice in the global health governance (GHG) of ‘ambivalent objects.’ At global level, arguments in favour of and against agrochemicals draw from a range of positions concerning the responsibilities of different actors to limit their risks and promote their rewards. These arguments change across the local contexts through which pesticides pass, and in relation to the health and environmental benefits or problems they may cause. Pesticide regulations limiting toxicity and wider human and environmental impacts are of a different order from regulations which respond to flagrant misuse or intentional poisoning and suicide. Whilst for many people the former may be an ethical and moral responsibility of the pesticide industry, the latter could be construed as the responsibility of individuals solely, or perhaps of the state. Thus, on one level, global health debates concerning pesticides are similar to those concerning tobacco, sugar, salt, and trans fats—companies and consumers each have a duty to behave in a more responsible way. On another level, many pesticides are not expected to make it to the dinner table at all, having disintegrated, been washed off, or otherwise removed at an earlier stage. Put another way, tobacco companies and food manufacturers exist more in the public’s mind than pesticide companies ever have, or likely ever will.
These four sets of issues – bodies and landscapes, nations and threats, chemicals and citizenships, and the complexities of governance – sketch a framework for the study of pesticides and their ambivalences. These are just some of the issues I will be exploring over the next three years, as I trace pesticide products from points of manufacture to points of use, within and between Europe and South Asia. The immediate problem is how pesticides are to be understood in social, ethical, and political terms at local and global levels. The wider significance is how processes attendant to globalisation create ambivalent objects, both as a function and as a condition of modern worlds, which are increasingly filling the world around us.
Tom Widger has conducted ethnographic fieldwork in Sri Lanka for the past 10 years. His first book, Suicide in Sri Lanka: The Anthropology of an Epidemic, will be published later this year. He was recently awarded a Wellcome Trust Society & Ethics Research Fellowship, for the project ‘Pesticides and global health: an ethnographic study of agrochemical lives.’ Find out more at http://www.tom-widger.com/pesticides-and-global-health.html. @tomwidger
 For a case history of this practice see: Dias, S.R. (2009) ‘A novel mode of paraquat poisoning’ Ceylon Medical Journal 54(2): 69-70.
 The concept of ‘agrochemical treadmill’ is elaborated in: Dowdall, M.D. & R.J. Klotz (2014) Pesticides and Global Health: Understanding Agrochemical Dependence and Investing in Sustainable Solutions Walnut Creek, CA: Left Coast Press.
 At the time of writing Sri Lanka’s north and east was suffering from an extended drought: http://www.irinnews.org/report/99884/drought-begins-to-bite-in-sri-lanka.
 For a critique of the ‘farmer suicide’ thesis, see: Münster, D. (2012) ‘Farmers’ Suicides and the State in India: Conceptual and ethnographic notes from Wayanad, Kerala’ Contributions to Indian Sociology 46(1&2): 181-208.
 Eddleston, M. & M.R. Phillips (2004) ‘Self-poisoning with pesticides’ British Medical Journal 328: 42-44
 Widger, T. (2014) ‘Reading Sri Lanka’s Suicide Rate’ Modern Asian Studies 48(3): 791-825.
 International Water Management Institute (2014) Review of Literature on Chronic Kidney Disease of Unknown Etiology (CKDu) in Sri Lanka Available from: http://www.iwmi.cgiar.org/2014/05/review-literature-chronic-kidney-disease-unknown-etiology-ckdu-sri-lanka/.
 Jayasumana, C., S. Gunatilake, & P. Senanayake (2014) ‘Glyphosate, hard water and nephrotoxic metals: are they the culprits behind the epidemic of chronic kidney disease of unknown etiology in sri lanka?’ International journal of environmental research and public health 11(2): 2125-2147.
 For a review see: Caplan, P. (ed) (2000) Risk Revisited Pluto Press.
 Bauman, Z. (1990) Modernity and Ambivalence John Wiley & Sons.
 Kirmayer, L.J., & H. Minas (2000) ‘The future of cultural psychiatry: an international perspective’ Canadian Journal of Psychiatry 45(5): 438-446.
 Carson, R. (1962) Silent Spring Boston: Houghton Mifflin Company.
 Trawick, M. (1992) ‘Death and nurturance in Indian systems of healing’ In: C. Leslie (ed) Paths to Asian Medical Knowledge London: University of California Press, pp. 129-159
 Author’s ethnographic observations.
 Collier, S.J., A. Lakoff, & P. Rabinow (2004) ‘Biosecurity: towards an anthropology of the contemporary’ Anthropology Today 20(5): 3-7.
 Widger, T. (2012) ‘Suffering, frustration, and anger: Class, gender and history in Sri Lankan suicide stories’ Culture, Medicine, and Psychiatry 36(2): 225-244.
On July 3 of this year, the face became an “organ”. Changes to US Federal health policy came into effect, moving face transplantation into the jurisdiction of medical procedures governed and administrated by the agencies that oversee the US national transplant system – the Organ Procurement and Transplant Network (OPTN) and the United Network for Organ Sharing (UNOS). This policy introduced into the world a new type of thing: the “VCA organ”. The term refers to vascularized composite allografts, complete sections of tissue that are procured for transplantation. The most common VCA procedures are face transplantation and hand transplantation. My research to date has examined how the former has introduced new institutional and epistemic understandings and practices into world of biomedicine. In my book On Face Transplantation: Life and Ethics in Experimental Biomedicine (Palgrave Macmillan 2014), I argue that what is being remade in face transplantation is not only the lives of patients, but also the very ways in which state institutions, surgeons, and families make sense of rights, claims for inclusion, and life itself in the contemporary world.
In this post I want to shift focus a little to think about how the ontological status of body parts in technomedicine are shaped vis-à-vis regulatory practice. One of the most well known examinations of ontology in medicine is Ann Marie Mol’s The Body Multiple (Duke 2003), in which the author masterfully demonstrates how “medicine enacts the objects of its concern and treatment,” that is, how it “attunes to, interacts with, and shapes its objects in its various and varied practices” (vii). While it isn’t yet possible to show in detail how the face for transplantation in enacted in light of this policy change, its new status as a VCA organ has been cause for deliberation by the agencies that until now have been responsible for administrating the procurement and allotment of body parts such as the heart, kidney, and liver.
Recently I have been reading through the minutes of the OPTN VCA Committee, which was established to review agency policy in light of the aforementioned changes to the Federal health law. This has made me consider whether something is missing from those hospital-based accounts of ontology and medicine. Are we leaving anything out if we begin our analysis in the present by looking at how the body is experienced and enacted in and through clinical practice? The deliberations of the VCA committee suggest that we should take more notice of the background work that implicitly shapes the clinical space – that we should examine how ontology in medicine is constituted in/by practice and policy.
In this short post, I want to examine this idea. The changes to national transplant law and the redefinition of an organ to include VCAs mean that the face for transplantation now has a rather peculiar ontological status. It is never just a face and never fully an organ; it is only an organ once it is removed from the donor and transplanted to the recipient, at which point it straightaway becomes a face; as a VCA the face extends past the immediate area of the face to include veins, nerves and extra tissue that would aid operative outcomes. The ontological status of the face in this form of medicine is thus both fluid and fractured. This echoes Mol’s account of how medicine shapes its objects. Let’s have a look then, at how such shaping is mediated by policy and broader sociopolitical concerns.
The Federal changes to the definition of an “organ” sought to standardize clinical practice for VCA procedures and, in doing so:
…ensure equitable access for those awaiting VCA transplantation, [as] there is a need to provide for consistency in allocation processes and reliable outcomes reporting on a nationwide basis. Appropriate Federal oversight of a national allocation system can increase safety of such transplants and provides equitable and consistent national access to such transplants while also conveying to the public that donation for such purpose will serve an essential medical need, (OPTN, Notice of proposed rulemaking).
Contained within the above is an implicit understanding of what both VCA procedures and the US state are about: ensuring equitable, safe and essential biomedicine. In making the face an organ, the Federal government has nationalized face transplantation in two interrelated ways: by standardizing disparate practices and by encoding them with values of what it stood for. From the get go, then, we see that normative sociopolitical concerns have been embroiled in the shifting status of the face for transplantation.
The piece of law that governs organ transplantation in the USA is referred to in short as the OPTN Final Rule. The modifications to this law were made in late 2013 and required the national transplant agency to develop policies for VCA transplant before July 3. Following amendments to the Final Rule, now “Organ means a human kidney, liver, heart, lung, pancreas, intestine (including the esophagus, stomach, small and/or large intestine, or any portion of the gastrointestinal tract) or vascularized composite allograft.” Accompanying the classification of VCAs as an organ are nine criteria. For a graft to be considered a VCA, it must be something:
- That is vascularized and requires blood flow by surgical connection of blood vessels to function after transplantation;
- Containing multiple tissue types;
- Recovered from a human donor as an anatomical/structural unit;
- Transplanted into a human recipient as an anatomical/structural unit;
- Minimally manipulated (i.e., processing that does not alter the original relevant characteristics of the organ relating to the organ’s utility for reconstruction, repair, or replacement);
- For homologous use (the replacement or supplementation of a recipient’s organ with an organ that performs the same basic function or functions in the recipient as in the donor);
- Not combined with another article such as a device;
- Susceptible to ischemia and, therefore, only stored temporarily and not cryopreserved; and
- Susceptible to allograft rejection, generally requiring immunosuppression that may increase infectious disease risk to the recipient, (OPTN Policy Notice 7-1-2014).
The role of the VCA Committee was to assess OPTN policy in light of the new status of composite allografts as organs, making suggestions as to additions to and deletions from previous guidelines. In making policy suggestions to the agency’s board of directors, it was able and required to engage with the interpretive flexibility of the above nine criteria. Until July 3, there were no formal guidelines for performing the procedure, and the three active teams that since 2008 have completed seven such operations did so with the oversight of their respective hospital IRBs. The protocols established and used by these individual teams brought together longstanding organ transplant guidelines with specific measures developed to ensure the success of the operation, such as more rigorous candidate selection to minimize the risks and increase the benefits of the operation (Taylor-Alexander 2014). And while these teams had been gaining “extra” consent from donor families for the use of VCAs from the face, there was no national mandate for them to do.
How Committee members understood the new definition of a VCA organ, and its ramifications for clinical practice, was mediated by their own backgrounds and what they considered to be broader sociopolitical concerns. During six months of contemplations and information gathering, VCA committee members came to tackle a number of related issues that emerged with the introduction of this new kind of organ. These ranged from: ‘what kinds of VCA should be regulated by the OPTN?’ and ‘how should consent for procurement be obtained?’ to concerns that people would be less likely to go on the organ donor registry if they thought it possible that their face or hands would be transplanted. Reading over the meeting minutes, it is possible to see how these issues were settled in tandem; in the process questions of knowledge were coproduced with questions of politics, of social order.
For the purpose of this short post, I will take a look at the above three questions to show how the Committee worked within a broader frame that paralleled federal concerns with equity, safety and public regard for biomedicine. In its first meeting, a teleconference on January 22, the issue of what VCAs should be regulated by the OPTN was raised alongside the question of what exactly a VCA is: Is the recovery of extra vessels/tissue/nerves for the purpose of an enhanced outcome allowed? Members debated whether to employ an encompassing definition with broad guidelines for all composite allografts or to produce specific measures for each kind of VCA – i.e. separate protocols for face, hand, limb, etc. The Committee Chair, UCLA transplant specialist Dr Suzanne McDiarmid, emphasized that one of her aims was to “move relatively quickly into discussing specific elements necessary to better facilitate, and thereby maximize VCA procurements…” She recommended that the Committee therefore focus on face and hand transplantation, as they are the most common VCA procedures performed.
In subsequent meetings, the Committee made a number of policy decisions that simultaneously introduced standardized clinical practice while stabilizing the meaning of Vascularized Composite Allograft. Additional informed consent procedures for harvesting faces and hands for transplant was made a requirement, while the Committee thought it reasonable to work with the same framework established for solid organ procurement when deciding what exactly could be taken from a donor body under the label of VCA. The issue of access was addressed by producing national waiting lists and, in the future, recipients will be allocated organs through updated OPTN/UNOS software, which uses an algorithm to rank patients based on criteria such as patient need. While this bureaucratization of face (and other VCA) transplantation is yet to be explored on a clinical scale, I think it tells a story about how policy influences medical practice and thus the ontology of the body.
The nine criteria that define VCA organs were implemented to secure the status of medicine and the values of the US state as equitable and necessary organizations that exist to protect the health and safety of the population. These policies were introduced on the back of the emergence of new types of medical procedures – face and hand transplantation – which arguably introduced public concern about the limits of biomedicine and the role of the state vis-à-vis the bodies of citizens. The resulting changes at the level of OPTN/UNOS policy have standardized and altered how the face for face transplantation will exist in the clinical space.
Unlike solid organs – kidneys, hearts and livers – the face is not considered an organ until it is harvested and transplanted for therapeutic purposes. There are a number of clinical practices that are necessary for this to take place: how the face is enacted, how it exists in networks of clinical practice is mediated by its new classificatory status. A number of practices must be put in place for this to be possible. Alongside new procedures for informed consent and allocation, how the face is treated in the clinical space has also been standardized. It must be labeled in a new way, travel accompanied by paperwork, not be combined with “another article or device”, and used solely for replacing a person’s body part. (If the procedure does not conform with the last two criteria, it would likely fall under the regulatory authority of the FDA.) What the face is, how it is understood and constituted and the clinical arena, has thus been altered through the implementation of new regulatory policy.
In this short post I have aimed to draw attention to the role of medical policy in the making of clinical practice. In debasing established practices and calling into questions longstanding accounts of what society stands for, emerging technomedical fields often become the site of intense scrutiny and political oversight. The result is what Sheila Jasanoff has termed “constitutional moments,” instances of sociotechnical work that reorder both the social and natural world – medicine and its objects, in this case. Examining the background work that goes into the shaping of clinical practice in such a way, I suggest, is important because it allows us to better grasp how emerging technomedical fields become imbued with understandings of what a nation stands for. “How the Face Became an Organ” is thus a story of how the classification and enactment of the body in biomedicine is shaped vis-à-vis particular conceptions of how the US state should act vis-à-vis its citizens.
Samuel Taylor-Alexander is currently a Visiting Scholar in the Department of Anthropology, University of Copenhagen. He wrote his PhD at the ANU and was a doctoral fellow in the STS program at Harvard University. Samuel is the author of On Face Transplantation: Life and Ethics in Experimental Biomedicine (Palgrave Macmillan 2014). His research seeks to understand how national imaginaries shape everyday and experimental medical practice.
Premise and Summary
This is a very provisional text, part of a broader book-length research (forthcoming from Palgrave in 2015) on ‘political epistemology’, a construct I use to investigate the coproduction of epistemological facts and socio-political values in the history of the life-sciences (e.g.: how certain views of heredity, development, nature/nurture potentially favor certain political values and conversely, how socio-political contexts/pressures have shaped the epistemic construction of key notions in biology such as the gene, the brain, human nature, and so on).
In the spirit of a (developing) political epistemology analysis, this paper aims to problematize the socio-political implications of a return to a neo-Lamarckian framework and to examine a possible unforeseen aspect of the notion of local biologies in policy/public health discourses as a consequence of the recent rise of epigenetic research. Epigenetics, as is well known, is a burgeoning discipline in molecular biology that investigates changes in gene expression that do not imply alterations of DNA sequences. These changes (for instance, methylation) are often driven by environmental inputs (included social interactions for the human species) and are believed to be in some cases stable enough to be transmitted trans-generationally even in higher organisms, humans included.
Epigenetics can be considered the most advanced example of the new postgenomic and context-dependent view of the gene that is making its way into contemporary biology (Stotz, 2008; Griffiths and Stotz, 2013; Keller, 2012, 2014; Meloni, 2013b; 2014a, b; Meloni & Testa, 2014).
In this piece, I ask whether the social, environmental, and contextual shaping of genetic expression which is implied by epigenetics may give rise, in the wider society, to a public rhetoric that identifies local groups/populations with different epigenetic marks (reflecting for instance their disadvantageous conditions over history) and how these potentially vulnerable/risky sub-populations may become the target of a new (postgenomic) biopolitical intervention.
I ask (rather provocatively, I can see that): 1) whether there are any dark unforeseen implications of epigenetics remaking the notion of local biologies and 2) what emancipatory potential (if any) was implied in the notions of universal human nature and universalistic biology that were elaborated after 1945, and have been progressively destabilized since the 1990s.
The fortunes of local biologies and their epigenetic remaking today
The concept of ‘local biologies’ has enjoyed a deserved success since it was coined in the early 1990s by Margaret Lock (1993), as a very healthy antidote to the abstract body of genetics and biomedicine, on one hand, and the disembodied body of social constructionism, on the other. When Lock first wrote about local biologies, the wave of epigenetics studies was still to come and her concept was a result of anthropological observations, not biological measurement, of the continuous exchange between the social and the biological in the production and reproduction of bodies in situated socio-cultural contexts (Lock, 2012).
“Recognition of the embodiment of an historicized biology” (Lock, 2001) suggested a more sophisticated conceptual move than the actual realization, which took place only after the 2000s, that biological signatures of socio-environmental exposures can literally leave marks on the genome, acting as a sort of bio-markers of social position and local contexts.
It is far from me to claim that the current explosion of epigenetics studies of social position is a mere actualization, for the molecular age, of the notion of local biologies. I am aware that Lock has expressed skepticism at the reductionist implications of epigenetics (2005, 2013). Nonetheless, as Jörg Niewöhner has pointed out (2011), it seems fair to recognize that researchers in epigenetics are the first ones who see their research as being practiced under some sort of local biology paradigm. After all, what they are trying to achieve, as Niewöhner claims, is to explore the hypothesis that “gene expression may be connected in significant ways to local cultural practices” (2011).
The point I am trying to make is that epigenetics asks questions which are in a sense possible only in a genuine local biologies approach and which, when the concept was first coined by Lock in the early 1990s, were rather taboo, or even impossible to imagine. These are questions such as: do manual workers have different gene expression compared to non-manual ones? Do the poor have different patterns of methylation than the rich? Are distinct patterns visible across other differences: The psychologically traumatized versus the simply melancholic? The Black versus the White? The obese versus the slim?
For technological and conceptual reasons, all of these questions are now becoming possible to ask and are actually on the rise in the burgeoning field of social epigenetics. Is this a molecular translation of local biologies? Or is this a development to which the notion of local biologies may actually bring a serious critique?
Taking just one example of the recent wave of social epigenetics research, a study by Dagmara McGuinness and colleagues (2012), addresses the correlation between socio-economic status (SES) and methylation patterns in socio-economically deprived and affluent areas of the Scottish city of Glasgow. McGuinness and her colleagues found aberrant levels of methylation in “the most deprived group of participants, when compared with the least deprived” (2012: 157). Manual workers have also been found to have “24% lower DNA methylation content than non-manual”. What seems to emerge from this study is a sort of new social cartography of the city of Glasgow, one based on (dichotomous) differences in the biology of its members (affluent vs. deprived; manual vs. non-manual workers). Epigenetic marks, in this case methylation patterns, act as a sort of “bio-dosimeter” (ibid., 157) assessing the impact of social adversity (past and present) on lifestyle and disease susceptibility (see for a broader reflection: Landecker and Panofsky, 2013).
To the extent that it is not only present social hardship which social epigenetics associates with aberrant patterns of methylation, but also, it is claimed, the transgenerational inheritance of unfavorable environments (“you are what your grandma ate,” as the new epigenetic slogan says), epigenetics is increasingly identified as the missing mechanism to explain niches of neglect and social hardship within specific populations/areas/social classes. And the city of Glasgow of course was an excellent target for such a preliminary exploration given its quite exceptional level “of health inequality not fully explained by conventional risk factors for disease” (McGuinness et al., 2012).
In other words, what emerges with epigenetic research is that my parents or grandparents didn’t only pass on to me a bunch of genes, but also their various misbehaviors (the negative effects of smoking for instance, see Pembrey et al., 2006) or misfortunes. And notice that the distinction between misbehaviors and misfortunes become increasingly blurred in an epigenetic framework (Loi et al., 2013). For instance, they passed on their own exposure to poor nutrition (Hejimans et al., 2008), or, as in the works of Michael Meaney’s group on rats, even the effects of inadequate mothering (see Weaver et al., 2004). Marx’s dictum that “the tradition of all dead generations weighs like a nightmare on the brains of the living” may find a novel epigenetic incarnation in scenarios like the Dutch Hunger Famine or Marcus Pembrey’s studies on transgenerational effects of food availability in North Sweden.
In sum, specific social-environmental experiences become transgenerationally imprinted and embedded in locally defined populations. A certain sort of “inertia” is inscribed and reproduced amongst certain social groups.
How far are we here from the Lamarckian notion of ‘race memory’ that Boasian anthropology fought against? Are we witnessing the beginning of a postgenomic form of classification of ‘kinds of people’ based on novel (non-genetic) biological grounds? What if the emphasis is mostly placed on the perpetuation of harmful environments from generation after generation in specific groups?
To sum up once again: epigenetics, along with related discoveries in molecular biology, may certainly contribute to “undermin[ing] the notion of biology as a universal standard against which human difference may be adequately accounted for” (Lock & Nguyen, 2010: 109). In promoting a view of the “embedded body” (Niewöhner, 2011), epigenetics can be considered an ally (with due anthropological corrections) of the local biologies construct.
However, these findings may also be taken up and circulated in the broader society in a way which differs fundamentally from the original notion of local biologies. Evidence for the existence of social groups with different biological signatures may have more unpredictable effects than merely critiquing the persistent belief in the “universal applicability of biomedical knowledge and technologies” (Lock & Nguyen, 2010: 361). It is the same idea of a universal human biology/human nature that might be challenged by this return to the idea of some sort of Lamarckian inheritance and transgenerational transmission of “local exposures”. And, it has to be remembered, this idea of a universal human biology/human nature was developed after 1945 for well-defined political reasons.
Why a notion of universal human nature was constructed after 1945
After the trauma of eugenics and Nazism at the end of WWII, biological explanations in the social arena were totally discredited. In the period immediately after 1945, public writings by evolutionists on the social implications of biology tended to be rather moderate (or self-restrained): the place of culture and society had to be entirely recognized, no invasion of fields was possible, boundaries between biology and human behaviours were respected (see Dobzhansky & Montagu, 1947: “man has escaped from the bondage of the physical and the biological”).
Biological speculations on the “inequality of men” (Haldane, 1932), which had been rather common even amongst leftist biologists before 1945, were now increasingly silenced. It is not difficult to see why biology in human affairs had such a bad name after 1945 and why biology was used in such a cautious way in public affairs immediately after WWII. In the aftermath of the Nazi catastrophe (Nazism is ‘applied biology’ was after all a very sad leitmotiv of the German regime), the complicity of American as well as European eugenicists, not only in sterilization policies in their own countries, but also in building the Nazi’s murderous program, were evident and scandalous. The explosive effects of biology in the public arena were to be neutralized and its bad name cleaned.
The efforts of people like Ashley Montagu in writing the UNESCO statement on race (published as The Race Question in 1950) were to deflate and de-emphasize the role of biology in defining race. The Race Question emphasizes the universality and the “likeness” of human beings as much more important than their supposed differences. Confucius’ dictum that “Men’s nature are alike; it is their habits that carry them far apart” is quoted in point 9. Biological studies are said in the statement to “lend support to the ethic of universal brotherhood” (UNESCO, 1950, 14).
There were only two possible ways of making sense of post-1945 biology in public affairs. 1) One was to deny that biology had anything to do with human affairs in any specific way. This was the road taken by culturalism, which remained mainstream until the 1970s. 2) The second was to claim that biology had much to do with human affairs, but in the same measure for everyone and everywhere, black-boxing any local differences.
After the emergence of sociobiology in 1975 the latter approach was taken by evolutionary psychologists and the proponents of many varieties of universal nativism (ranging from Steven Pinker to Marc Hauser) which gained ascendancy in the 1980s and 1990s in studies of language or morality. These studies argued that there is a universal human nature hardwired in our biology or our brain that constrains the limits of its (superficial) cultural variation (see for a critique, Meloni, 2013a).
Many discoveries contributed to this universalistic trend, although it is impossible to tell the whole history here. These range from paleoanthropology (the “Out of Africa” theory), to Crick’s dogma of molecular biology (1958) which undermined any possible influence of the environment on genetic information, reinforcing that “encapsulation” of the genetic material (Gottlieb, 2000) already anticipated in August Weismann’s separation of the germline from the soma.
Emphasizing strongly that biology is about a universal human nature shared by all human beings which has remained unchanged since the Pleistocene (as later evolutionary psychologists would claim) was the best insurance policy against the possible resurgence of dangerous ideas in biology. As Tim Ingold writes: “the appeal to an essentialist [and universalist] concept of human nature” was the only way to reconcile evolution with “the new-found commitment to universal human rights” (2006).
I can see the paradox in my claim that sociobiology and evolutionary psychologists partly played a role on the egalitarian side of post-1945 biology. Politics and epistemology are often in a complex relationship, which is never a one-to-one connection. For instance, if one looks at a broader historical context, the associations between Lamarckism and racism are evident (Stocking, 1968; Bowler, 1983), while the links between classic gene-centrism/Neo-Darwinism and egalitarianism are less rare that one might think.
In this sense, the case of Soviet eugenics and the writings of now forgotten Soviet geneticist Yuri Filipchenko are very telling (Graham, 1978). Filipchenko attacked Lamarckism in the name of the Soviet Revolution claiming that if Lamarckism not Mendelism was true “all socially or physically deprived groups, races, and classes of people-such as the proletariat and peasantry and the nonwhite races-would have inherited the debilitating effects of having lived for centuries under deprived conditions. Far from promising rapid social reform, the inheritance of acquired characteristics would mean that the upper classes are not only socially and economically advantaged, but genetically privileged as well, a result of centuries of living in a beneficial environment” (Graham, 1978, my italics).
As we know, this argument was to be dramatically defeated in the Lysenkoist USSR. Nonetheless, to the extent that epigenetics is a sort of return to Lamarckian research, Filipchenko’s argument might deserve a second look in our postgenomic age.
Remaking social classes in the postgenomic era
Social historians like Michael Katz have recently warned that we must pay attention to the present resurgence of biological definitions of the poor (2013) fearing a return to a biologically-based class racism. As Katz claims, “in the late eighteenth and early nineteenth centuries, a harsh new idea of poverty and poor people as different and inferior” took place, what he calls “The Biological Inferiority of the Undeserving Poor”, part of a broader process that made the poor a separate and dangerous kind.
It is too early to say if epigenetic studies of different methylation patterns between poorest and richest areas will be used to offer a revival to such ideas, as Katz himself and many other in social policy fear, and as Filipchenko thought in the 1930s. However, fracturing the universal view of human nature into potentially differentiated sub-groups of risky and vulnerable populations identifiable by different epigenetic biomarkers, because of their persisting exposure to bad environments, may open a Pandora’s box whose political consequences (such as new stigmas associated with race and class) will not necessarily be in the hands of scientists.
This box was thought to have been firmly closed decades ago by biology (with hard-heredity) and anthropology by severing any equivocal link between biological and socio-cultural processes, (Kroeber 1917, see Stocking 1968). But the new epigenetic configuration will be again a moment of equi-vocity, where the different voices of biological and socio-cultural disciplines will become more and more indistinguishable (as in the Latin root of aequivocus). This undoubtedly presents new challenges for the social sciences. In hindsight, the challenges posed by the notion of local biologies may look like just the beginning of a more profound paradigm-change.
Maurizio Meloni is a social theorist working on the history and political implications of the life-sciences, neuroscience and epigenetics in particular. He has published in journals such as Frontiers in Human Neuroscience, Sociology, Economy and Society, The Sociological Review, Subjectivity, Telos, History of the Human Sciences, BioSocieties, in the edited volume Neurocultures (2011) and in a collection on neuroscience and political theory (Routledge, 2012). He is currently preparing a book on biology and social theory in a postgenomic age. After two consecutive Marie Curie Fellowships at the University of Nottingham, he is now affiliated (as Honorary Senior Lecturer) with the College of Social Sciences and International Studies (Egenis), University of Exeter, UK. For 2014-2015 he is a Member of the Institute for Advanced Study (School of Social Science), Princeton, USA, where he has been awarded a fellowship for his research on sociology and epigenetics. Please send correspondence to: email@example.com
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Katz, M. 2013. (2nd edition) The Undeserving Poor: America’s Enduring Confrontation with Poverty. Oxford: OUP. Excerpts online at http://www.socwork.net/sws/article/view/359/709
Keller, E. F. 2012. Genes, genomes, and genomics. Biol Theory 6, 132–140.
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 This a slightly revised version of a text presented at the workshop “Embodied Being, Environing World: Local Biologies and Local Ecologies in Global Health”, organized by Alex Nading, Vinh-Kim Nguyen, and Nathanaël Cretin and supported by the Chair in Anthropology and Global Health in the Collège d’études mondiales and the Fondation Maison des sciences de l’homme, Paris, France on June 5 and 6, 2014. The text has been mostly left as originally presented, and therefore reflects an oral style of presentation, with no ambition of peer-reviewed accuracy. Thanks to Des Fitzgerald for kindly commenting on a first iteration of this text.
 As Lock (2012) writes: “my conclusion after several years of fieldwork, that biological difference must be implicated in the menopausal transition, was inferred from a robust statistical study fully complemented by intense qualitative research, based on symptom reporting of middle-aged women. The idea of local biologies was the result of intense, informant-centered research about subjectively experienced bodily happenings. It was not possible for me to measure biological difference, nor did I seriously entertain the idea, although this has since been carried out”.
 As Niewöhner claims: “the researchers in Szyf’s lab have been the first group of molecular biologists that I have encountered who appreciated the point of the notion of local biology. Trying to incorporate ‘social life’ into molecular analyses makes immediately plausible that even something seemingly hard-wired such as gene expression may be connected in significant ways to local cultural practices”.
 A further intermediate point between (environmental) epigenetics and local biologies is introduced by Niewöhner with his idea of a “customary biology, that is, a biology that is based on custom understood as time-honored, habituated forms of living everyday life situated in a specific environment…. a biology based on patterns of practice and regularities rather than ‘natural’ laws” (2011)
 The anthropologist Chris Kuzawa (2005) often uses the notion of “intergenerational phenotypic inertia” in his brilliant epigenetic/developmentalist studies on health inequalities, and while he means something more specific, there is clearly a nexus between an epigenetic paradigm and certain ideas about the persistence and continuous movement of past experiences.
Writing in The Lancet, Richard Horton called historians of medicine “invisible, inaudible, and … inconsequential”. Historian of medicine Carsten Timmermann responds. This piece is being simultaneously cross-posted at The H Word, a history of science blog hosted by The Guardian.
In a comment published in the medical journal The Lancet, ‘The moribund body of medical history’ the journal’s Editor in Chief, Richard Horton, deplores what he sees as a terminal decline in the study of the history of medicine. I and many other colleagues who engage with the history of medicine every day, were rather surprised by his obituary for a field of inquiry that we feel is very much alive and not moribund at all.
We historians of medicine, Horton argues, with reference to Owsei Temkin, one of the founding fathers of the social and cultural history of medicine, should be interested in the political and economic conditions that shaped medical advances and not only chronicle them. We should study the thoughts and perceptions of scientists, doctors, nurses, patients. We should connect with the present when we study developments in the past and concern ourselves with the transformation of medicine into a business, study the consequences of medical research becoming commercialised. Horton writes,
“The historian’s task is to strengthen our ability to resist the adverse trends and demands of our age.”
Yes, I thought, and this is exactly what most of us are doing. Great to get some recognition from the editor of one of the world’s leading medical journals (a journal, by the way, with a very distinguished history).
Imagine how dismayed I was to read the next sentence, in which Horton suggests that “the vast majority of medical historians have abandoned any pretence to such ambitions”. Today’s historians of medicine, he suggests, “have nothing to say about important issues of the past as they might relate to the present. They are invisible, inaudible, and, as a result, inconsequential.” Horton lists a number of books that he feels exemplify that great yet moribund tradition in the history of medicine, most of them classics in the field, but with one exception all published before 2000.
I find Horton’s argument puzzling and somewhat worrying. If I look at the book shelf above my head, I see a whole row of recent books that fit Horton’s criteria for good medical history. For instance, I see Broken Hearts, a recent book by David Jones about the history of heart disease and cardiac surgery, which deals with issues such as decision making in modern medicine and how doctors and patients handle uncertainty. Jones discusses the ways in which complications remain invisible in evidence-based medicine and the difficulty of implementing informed consent in clinical practice. Now if that’s not relevant to medicine’s present, I don’t know.
I also see Jeremy Greene’s Prescribing by Numbers, which discusses how pharmaceutical marketing has shaped understandings of chronic disease in concert with medical research. In my own book on the history of lung cancer (I have several reference copies left and thus it’s very visible on the shelf), I address claims that lung cancer remains so deadly because it carries a stigma due to its association with smoking. Or take other books published in the past ten years on the history of cancer alone, such as those by Ilana Löwy, Barron Lerner or Robert Aronowitz, or Peter Keating and Alberto Cambrosio. These and many, many others invite readers to engage in a dialogue with the past to understand the present of medicine and draw attention to historical alternatives that are difficult to conceive without such dialogue.
There are different ways of engaging with the past to explain the present, and no historian I know wants to be accused of being ‘whiggish’, a term often used to label histories that depict the past as a linear story of progress out of the dark ages towards an enlightened present. To us the past is as complex as the present, and the present as confused as the past. Also, good history does not have to deal with very recent developments, and this is not what Temkin had in mind either, as contributors to a debate on Twitter about Horton’s comments pointed out. But historians should not take the attention of their audience for granted. And our audience lives in the present.
It would pain me if the books on my shelf and other recent books, which seem to do exactly what Horton is calling for, were to remain “invisible, inaudible, and, as a result, inconsequential”. Why don’t these books get noticed by smart and well-informed people with a declared interest in the history of medicine, like Richard Horton, to the same degree as mass-market books like Siddhartha Mukerjee’s interesting but flawed and, dare I say it, somewhat whiggish Emperor of all Maladies?
In fact, I don’t think that these books are invisible. They do get noticed and are widely discussed by other historians and scholars in social studies of science and medicine. Part of the problem may well be, in fact, that there are so many of us now (look at the number of cancer historians alone!) that we are quite happy to talk to each other rather than engage with doctors and scientists.
Perhaps more of us should try and leave our comfort zone more often, and talk to scientists and doctors as well as other audiences: if Mukherjee has shown one thing, it is that history of medicine can persuade a lot of people to buy a book of more than 400 pages! In the US, the AAHM’s Clio Initiative may well be a significant step in a good direction. In the UK, medical historians have contributed some interesting papers to the History & Policy platform (try a search for ‘medicine’). And I love it when historians of science and medicine discuss often esoteric topics on BBC Radio 4’s In Our Time. But we also need the help of editors such as Richard Horton. How about a regular history of medicine column in the Lancet, which is intellectually engaged and does more than gratify the antiquarian curiosity of physicians? And Richard, I’d be more than happy to send you an up-to-date reading list.
Carsten Timmermann teaches history of science, technology and medicine at the University of Manchester. He enjoys persuading students in medicine, science and engineering that it’s important to engage critically with the past to understand the present and plan the future, and in the humanities and social sciences that science can be accessible and interesting. His most recent book is on the history of lung cancer.
July’s web roundup will focus on recent conversations around organ transfer and its public perception. Organ transfer, with its complex and oftentimes invisible circuits of body parts, donors, recipients, doctors, markets and the state, is particularly ripe for intervention by social scientists. Ethan Watters’ profile of anthropologist Nancy Scheper-Hughes at Pacific Standard says that her work on organ transfer was, “an opportunity to show how an anthropologist could have a meaningful, real-time, and forceful impact on an ongoing injustice.” In so doing, Scheper-Hughes breached longstanding and significant divides between the academy, the medical establishment and the public. In her worthy response to the profile, she defends this controversial move toward opening up her work for broader audiences by saying that anthropology’s “reticence toward actively engaged scholarship has sometimes turned anthropologists into bystanders when crimes against humanity are taking place.”
Another lens through which to view current conversations about organ transfer in public spaces is the discussion around 3D-printed body parts. Over at Wired, Katie Collins dwells on the significance of advances in “bioprinting” when it comes to organ transplant: new research out of the University of Sydney points toward 3D-printed “artificial vascular networks that mimic those found within the human body’s circulatory system, bringing hope that eventually physicians will be able to print fully working organs on-demand.” An optimistic overview of techniques used to create organs in labs at LiveScience says of 3D-printing, “where nature takes off, 3D printing could take over.” A quoted source promises “any organ of any shape,” opening up a myriad of medical possibilities. Finally, the Motherboard blog at Vice has a piece on 3D-printed “bioskin” being developed by the US Army. Where there is no doubt that some of the most cutting edge research and development is on bioprinting is coming from sources like DARPA, the article predicts that this miracle skin is nearly “battle ready.” These three posts, just a few in a handful that ran this month on similar topics, reveal that bioprinting human organs is being discussed in mainstream and public spaces as something of a magic bullet. Not only do promises of 3D-printed organs hint at solving organ shortages, but they also point to public expectations of medicine when it comes to aging and rehabilitation. Organ transfer, freed of its organic confines by the 3D printer, no longer exists only in the realm of illness; instead, it is transplanted to a future where the body is modular, not just healthy but improved.
An Excellus BlueCross BlueShield study reports that New York citizens trail the rest of the United States in registered organ donors, sparking posts on Gothamist and the New York Daily News. Perhaps more telling than the report itself was user response to the allegations, where comments reveal many popularly held ideas about and against organ transplant: “A lot of it is religious bullshit. “Oh my Zod! Someone who is not a true believer in my (Insert Name of Putative Divine Being Here) might get my organs!” (user Nos Feratu), “[I] don’t want my body parts in the black market. if anyone read up on this donor stuff, it’s very sketchy what they do do your body afterwards… ” (user Jay Le), and, strangely, “As an incentive, cops are less likely to summons you if you hand over a license and it has the organ donor endorsement on it” (user okh). Gothamist’s post, and many like-minded commenters, also echoed a discourse of laziness and selfishness around not wanting to donate. Non-donors were not only ignorant, but selfish in a way that aligns with the archetypal Seinfeld-ian New Yorker: rude, in a hurry and unlikely to pause for reflection or the benefit of others.
Mashable ran a peek inside the waiting list for organ donations, where the list is actually “separate databases divided by organ type.” In fact, the piece points to the impactful role of Big Data in contemporary organ donation, where lists are truly and complexly algorithmic and information-rich. A blog post at Advocate Health Care Health eNews mentions the useful role of Big Data in detecting and preventing organ rejection. Perhaps this is another extension of better living through Big Data, or an instance of the hot term”Big Data” being tacked on to large scale statistical analyses, but it is interesting nonetheless.
More Links of Interest:
“Wishful Thinking About Natural Gas” – Guernica
Juanne N. Clarke
This paper explores how advice to mothers about raising healthy children differs in two distinct disease regimes as portrayed in articles in the pre-eminent Canadian women’s magazine Chatelaine about 50 years apart, 1928–1944 and 1990–2012. The paper compares intensive mothering, medicalization and the perception of risk. It suggests that both intensive mothering and medicalization are continuous from time period to time period (although the content of both mothering and medicalization differ in the two periods). Medicalization focused on the physical well-being and emphasized the importance of the routinized behaviours designed for conformity in the early period. In the latter period, there is a greater focus on individuality of children and their emotional well-being. This is linked to the rise of the discourses of the psy professions. With respect to risk, however, the paper documents an important change in the expansion of the degree to which life is considered risky. The substantive, theoretical and practical consequences of the findings are discussed.
Vincent La Placa, Dominic McVey, Ewen MacGregor, Amy Smith and Malcolm Scott
This paper presents the results of the qualitative phase of Healthy Foundations, a study that groups people according to their motivations to live healthily or otherwise, their lifestyles, and the circumstances that affect this. These segments are ‘Health Conscious Realists’, ‘Balanced Compensators’, ‘Live for Todays’, ‘Unconfident Fatalists’ and ‘Hedonistic Immortals’. The aim was to explore people’s attitudes and motivations to live healthily or otherwise and the targeted healthcare interventions appropriate for each segment. The qualitative phase involved two strands: (i) focus groups and immersion in-depth interviews and (ii) video ethnographic ‘pen portraits’. It provides robust insight into the five segments’ motivations and behaviour and how these are constructed within and influenced by the wider environment. It also enabled the segments to give their views of and design appropriate interventions aligned to their individual requirements, lifestyles and structural environments. It demonstrates the usefulness of the qualitative approach to health segmentations and enhances the case for methodological pluralism, and a critical perspective, to enable development of health-related behaviour change interventions and policy more widely.
Rod Knight, Jean Shoveller, Devon Greyson, Thomas Kerr, Mark Gilbertand Kate Shannon
Recently, scholars have called for more robust population and public health ethical frameworks to inform how the health of populations and individuals ought to be improved through various approaches to HIV testing practices. Our objective is to examine the breadth, range and foci of a variety of ethical issues pertaining to HIV testing approaches within the peer-reviewed literature, and how these issues address population and/or individual interests. We identify potential tensions between individual and collective approaches as well as other concerns, including equity, justice and distribution of health and risk—hallmarks of the emergent field of population and public health ethics. Based on our review, we suggest that additional theoretical work and empirical research are required in order to inform more ethically robust debates related to population HIV testing practices. Specifically problematic were consequentialist arguments that deem testing approaches as either morally permissible or impermissible without sufficient robust empirical and/or theoretical underpinnings and about how a particular approach would unfold among individuals and populations. The current review underscores the need to continue to articulate an evidence- and theory-informed population and public health ethics pertaining to HIV testing.
Morten Hulvej Rod, Liselotte Ingholt, Betina Bang Sørensenand Tine Tjørnhøj-Thomsen
This paper suggests that public health intervention research would benefit from more thorough considerations of the social dynamics in which public health interventions are embedded. Rather than simply asking ‘What works?’, researchers should examine the social effectiveness of intervention programmes; i.e. (i) the creation of shared understandings among researchers and practitioners and (ii) the ways in which programmes reconfigure social relationships. Drawing on the theoretical work of philosopher Charles Taylor and sociologist Marcel Mauss, we suggest that the term ‘the spirit of the intervention’ may enable researchers to further articulate—and hence discuss—the source of an intervention’s social effectiveness. The empirical impetus of the paper lies in our experiences as an interdisciplinary team of researchers, trained in social science and public health and now working within intervention research. We describe our attempts at reconciling the methodological requirements of an effect evaluation, modelled on the randomised clinical trial, with a process of intervention development grounded in ethnographic methods. In particular, we discuss how we have grappled with the schism between fidelity and adaptation, which is a key methodological issue in intervention research. While public health intervention research tends to conceptualise programmes as fixed and bounded entities, we argue that ‘the spirit of the intervention’ offers a conceptual starting point for reflections on programmes as on-going social processes. In order to capture and explore this dimension of public health interventions, a great deal of potential lies in a further engagement between intervention research, ethnographic methods and social theory.
Sarah A. Lovell, Robin A. Kearnsand Russell Prince
Concern for the creep of surveillance and control into the everyday lives of citizens has revived contemporary debates over the politics of health promotion. We examined how political changes have impacted on the work of health promoters through qualitative research with individuals working in the health promotion sector. Interviews and focus groups were undertaken between January 2008 and March 2009. Caught in a neoliberally influenced drive to increase the efficiency of the health sector, health promotion in New Zealand has been subject to considerable changes in the funding and provision of services. Characterised by a growth in limited-term contracts with constrained budgets, health promoters have responded to fiscal limitations by pooling resources. We find that rather than being uncritical agents of the government’s health promotion agenda, health promoters often became advocates of the community’s agenda, occupying a ‘grey space’ where the demands of contracts create tension with their commitments to communities. Any portrayal of health promotion must acknowledge the contested nature of the spaces of governance health promoters occupy and resist reducing them to uncritical agents of the state.
Julia Brassolotto, Dennis Raphaeland Navindra Baldeo
To date, Ontario public health units (PHUs) have generally neglected the social determinants of health (SDH) concept in favor of risk aversion and behaviorally oriented health promotion approaches. Addressing SDH and responding to the presence of health inequities is required under the Ontario Public Health Standards and is a component of provincial public health documents and reports. Nevertheless, units vary in their understanding and application of the SDH concept in their activities. The authors conducted 18 interviews with Medical Officers of Health and lead staff persons from nine Ontario PHUs, in order to better understand how these differences in addressing the SDH among health units come about. The findings suggest that differences in practice largely result from epistemological variations: conceptions of the SDH; the perceived role of public health in addressing them; and understandings concerning the validity of differing forms of evidence and expected outcomes. Drawing from Bachelard’s concept of epistemological barriers and Raphael’s seven discourses on the SDH, we examine the ways in which the participating units discuss and apply the SDH concepts. We argue that a substantial barrier to further action on the SDH is the internalization of discourses and traditions that treat health as individualized and depoliticized.
Alex Broom, Carla Meurk, Jon Adams and David Sibbritt
Complementary and alternative medicine is increasingly popular in Australia and particularly among women. While existing research provides some understanding of women’s engagement with complementary and alternative medicine and biomedicine, there has been comparatively little examination of the day-to-day character of their experiences. In this study, we utilise solicited diaries with women aged 60–65 years drawn from the 1946–1951 cohort of the Australian Longitudinal Study on Women’s Health to capture the temporal dimension of their therapeutic engagement. Focusing on 30 active complementary and alternative medicine users, we explore women’s experiences of managing their health, illness and well-being over a 1-month period. The themes that emerge from their diaries illustrate the day-to-day enactment of lay expertise through informal knowledge networks, practices of self-trialling and experimentation and the moralities underpinning self-care. The diaries provide unprecedented temporal insight into the (often problematic) enactment of lay expertise at the nexus of complementary and alternative medicine and biomedicine. They also point to the value of longitudinal techniques of data collection for augmenting more traditional sociological ways of exploring therapeutic pluralism.
Katy Flynn, Anna Daiches, Zoey Malpus, Nizar Yonan and Melissa Sanchez
Exploring patients’ narratives can lead to new understandings about perceived illness states. Intensive Care Unit delirium is when people experience transitory hallucinations, delusions or paranoia in the Intensive Care Unit and little is known about how this experience affects individuals who have had a heart or lung transplant. A total of 11 participants were recruited from two heart and lung transplant services and were invited to tell their story of transplant and Intensive Care Unit delirium. A narrative analysis was conducted and the findings were presented as a shared story. This shared story begins with death becoming prominent before the transplant: ‘you live all the time with Mr Death on your shoulder’. Following the operation, death permeates all aspects of dream worlds, as dreams in intensive care ‘tunes into the subconscious of your fears’. The next part of the shared story offers hope of restitution; however, this does not last as reality creeps in: ‘I thought it was going to be like a miracle cure’. Finally, the restitution narrative is found to be insufficient and individuals differ in the extent to which they can achieve resolution. The societal discourse of a transplant being a ‘gift’, which gives life, leads to internalised responsibility for the ‘success’ or ‘failure’ of the transplant. Participants describe how their experiences impact their sense of self: ‘a post-transplant person’. The clinical implications of these findings are discussed.
Katy Flynn, Anna Daiches, Zoey Malpus, Nizar Yonan and Melissa Sanchez
Exploring patients’ narratives can lead to new understandings about perceived illness states. Intensive Care Unit delirium is when people experience transitory hallucinations, delusions or paranoia in the Intensive Care Unit and little is known about how this experience affects individuals who have had a heart or lung transplant. A total of 11 participants were recruited from two heart and lung transplant services and were invited to tell their story of transplant and Intensive Care Unit delirium. A narrative analysis was conducted and the findings were presented as a shared story. This shared story begins with death becoming prominent before the transplant: ‘you live all the time with Mr Death on your shoulder’. Following the operation, death permeates all aspects of dream worlds, as dreams in intensive care ‘tunes into the subconscious of your fears’. The next part of the shared story offers hope of restitution; however, this does not last as reality creeps in: ‘I thought it was going to be like a miracle cure’. Finally, the restitution narrative is found to be insufficient and individuals differ in the extent to which they can achieve resolution. The societal discourse of a transplant being a ‘gift’, which gives life, leads to internalised responsibility for the ‘success’ or ‘failure’ of the transplant. Participants describe how their experiences impact their sense of self: ‘a post-transplant person’. The clinical implications of these findings are discussed.
Katharina T Paul, Cees JJ Avezaat, Jan N Ijzermans, Roland D Friele and Roland A Bal
An increasing number of patients become eligible for organ transplants. In the Netherlands, at the level of policy discourse, growing waiting lists are often referred to as a persistent “shortage” of organs, producing a “public health crisis.” In this way, organ donation is presented as an ethical, social, and medical necessity. Likewise, policy discourse offers a range of seemingly unambiguous solutions: improving logistical infrastructure at the level of hospitals, developing organizational and legal protocols, as well as public information campaigns. Instead of taking these problem and solution definitions as given, we critically examine the relationship between policy discourse and clinical practice. Based on a historical review, first, we trace the key moments of transformation where organ donation became naturalized in Dutch policy discourse, particularly in its altruistic connotation. Second, based on in-depth interviews with medical professionals, we show how those involved in organ donation continue to struggle with the controversial nature of their clinical practice. More specifically, we highlight their use of different forms of knowledge that underlie clinicians’ “transition work”: from losing a patient to “gaining” a donor.
Julianna Challenor and Jay Watts
Our objective was to explore how prospective altruistic kidney donors construct their decision to donate. Using a qualitative design and biographical-narrative semi-structured interviews, we aimed to produce text for analysis on two levels: the social implications for subjectivity and practice and a tentative psychodynamic explanation of the participants’ psychological investment in the discourses they used. A total of six prospective altruistic kidney donors were interviewed. A psychosocial approach to the analysis was taken. In-depth discourse analysis integrated Foucauldian with psycho-discursive approaches and psychodynamic theory was applied to sections of text in which participants seemed to have particular emotional investment. Analysis generated three major discursive themes: other-oriented, rational and self-oriented discourses. The desire to donate was experienced as compelling by participants. Participants used discourses to position themselves as concerned with the needs of the recipient, to resist questioning and criticism, and to manage difficult feelings around mortality. Participants tended to reject personal motivations for altruistic donation, positioning relatives’ disapproval as selfish and illogical. These results suggest that the term ‘altruistic’ for living non-directed organ donation constrains available discourses, severely limiting what can be said, felt, thought and done by donors, clinicians and the public. A more useful approach would acknowledge potential psychological motives and gains for the donor.
Across the United Kingdom, large numbers of crisis resolution and home treatment services have been established with the aim of providing intensive, short-term care to people who would otherwise be admitted to mental health hospital. Despite their widespread appearance, little is known about how crisis resolution and home treatment services are organised or how crisis work is done. This article arises from a larger ethnographic study (in which 34 interviews were conducted with practitioners, managers and service users) designed to generate data in these and related areas. Underpinned by systems thinking and sociological theories of the division of labour, the article examines the workplace contributions of mental health professionals and support staff. In a fast-moving environment, the work which was done, how and by whom, reflected wider professional jurisdictions and a recognisable patterning by organisational forces. System characteristics including variable shift-by-shift team composition and requirements to undertake assessments of new referrals while simultaneously providing home treatment shaped the work of some, but not all, professionals. Implications of these findings for larger systems of work are considered.
This article argues in favor of a sociological perspective on health and illness, drawing on recognized positions from the philosophy of health and illness about how to demarcate disorder from non-disorder. The argument specifies that a normative context in which bodies or behaviors are disvalued is a necessary component for identifying what constitutes a disorder, as this normative context allows material differences to be understood as dysfunctional and pathological. Descriptions of material states in themselves are insufficient to distinguish what is legitimately a disorder; some evaluative stance toward those states is also required. This article applies the argument to disorders of inattention and hyperactivity, currently best known as Attention-Deficit Hyperactivity Disorder. These disorders have been controversial since their formalization in the 1970s, the same time that they began receiving sociological attention. Sociological analyses have consistently expressed ambivalence toward recognizing claims about the biological status of such disorders. This ambivalence has at times committed to a problematic relationship between sociological explanation and medical explanation, implicitly allocating sociological explanation to an auxiliary position. This article argues that this is not necessary, as sociological perspectives address disorders on a fundamental, rather than secondary, register. Disorders are only intelligible due to the normative and social context in which they are found, and so medical sociology can recognize the validity of biological claims about disorders, such as Attention-Deficit Hyperactivity Disorder, while still asserting the essential social nature of disorder.
Louise Chawla, Kelly Keena, Illène Pevec and Emily Stanley
This paper investigates how green schoolyards can reduce stress and promote protective factors for resilience in students. It documents student responses to green schoolyards in Maryland and Colorado in the United States under three conditions: young elementary school children׳s play in wooded areas during recess; older elementary school children׳s use of a naturalized habitat for science and writing lessons; and high school students׳ involvement in gardening. Drawing on ethnographic observations and interviews, it describes how the natural areas enabled students to escape stress, focus, build competence, and form supportive social groups. These findings have implications for theories of resilience and restoration and school interventions for stress management.
Alex McClimens, Nick Partridge and Ed Sexton
The use of city centre spaces by people with learning disability is not much debated in the literature. Here we include the thoughts and opinions of groups of people with learning disability as we undertook some guided walks through Sheffield city centre. We found that few of the participants had independent access to the city centre. Many cited concerns over personal safety and the most, on few occasions when they did visit, did so with family and/or paid staff for pre-planned purposes, usually linked to shopping. The need for appropriate support figured prominently. There is also a need to re-assess what we mean by social inclusion for this cohort.
William T. Story
This study examines the association between social capital and the utilization of antenatal care, professional delivery care, and childhood immunizations using a multilevel analytic sample of 10,739 women who recently gave birth and 7403 children between one and five years of age in 2293 communities and 22 state-groups from the 2005 India Human Development Survey. Exploratory factor analysis was used to create and validate six social capital measures that were used in multilevel logistic regression models to examine whether each form of social capital had an independent, contextual effect on health care use. Results revealed that social capital operated at the community level in association with all three care-seeking behaviors; however, the results differed based on the type of health care utilized. Specifically, components of social capital that led to heterogeneous bridging ties were positively associated with all three types of health care use, whereas components of social capital that led to strong bonding ties were negatively associated with the use of preventive care, but positively associated with professional delivery care.
Joanna Busza, Sibongile Mtetwa, Petronella Chirawu and Frances Cowan
Adolescence, migration and sex work are independent risk factors for HIV and other poor health outcomes. They are usually targeted separately with little consideration on how their intersection can enhance vulnerability. We interviewed ten women in Zimbabwe who experienced sex work and migration during adolescence, exploring implications for their health and for services to meet their needs. For most, mobility was routine throughout childhood due to family instability and political upheaval. The determinants of mobility, e.g. inability to pay school fees or desire for independence from difficult circumstances, also catalysed entry into sex work, which then led to further migration to maximise income. Respondents described their adolescence as a time of both vulnerability and opportunity, during which they developed survival skills. While these women did not fit neatly into separate risk profiles of “sex worker” “migrant” or “adolescent”, the overlap of these experiences shaped their health and access to services. To address the needs of marginalised populations we must understand the intersection of multiple risks, avoiding simplified assumptions about each category.
Jeannie L. Haggerty, Danièle Roberge, Jean-Frédéric Lévesque, Josée Gauthier and Christine Loignon
Comparing accessibility between urban and rural areas requires measurement instruments that are equally discriminating in each context. Through focus groups we explored and compared care-seeking trajectories to understand context-specific accessibility barriers and facilitators. Rural care-seekers rely more on telephone access and experience more organizational accommodation but have fewer care options. Urban care-seekers invoke the barrier of distance more frequently. Four consequences of accessibility problems emerged across settings which could be used for valid comparisons of access: having to restart the care-seeking process, abandoning it, using emergency services for primary care, and health deterioration due to delay.
Michael Brown and Larry Knopp
We apply and extend Philo’s (2000) arguments about Foucault’s Birth of the Clinic as an inspiration for health geography and the study of governance of gays. Philo identified three spaces through which he argued disease is framed: disease tabled, embodied, and institutionalized. These focus attention on the spatialities through which the medical gaze is power-laden. We adopt this framework empirically through an historical geography of an urban public health system engaged with sexually transmitted infections (STIs) in the “homosexual” population of Seattle, Washington in the 1970s. It reveals the interaction of homophobia, heteronormativity and resistances across places typically understudied in queer historical geography. Our findings also extend this framework, however, by revealing other spaces that were important in the urban politics of sexual health: the gay city, the gay doctor, and the gay community. We suggest, therefore, that these and other spaces may be helpful in other health geographies interested in the dynamics of sexuality, governmentality, and urban public health.
Paul Mkandawire, Jenna Dixon, Isaac Luginaah, Frederick Armah and Godwin Arku
In this article, we draw on critical approaches to risk to examine varied and interlaced perceptions of personal risk for HIV which young men in an area of traditionally low male circumcision have to Malawi government’s new policy of medical male circumcision for HIV prevention, locally known as mdulidwe. In this article, we draw on data from in-depth interviews (n = 29) and focus groups (n = 24) with young men aged 18–24 years undertaken in 2013 in an area with traditionally low rates of circumcision, Livingstonia in the northern region district of Malawi. Our findings show that the push for medical male circumcision in this region has given rise to a perception that the penile foreskin is an inborn anomaly that leads to excessive risk for HIV provoking anxiety, confusion, uncertainty, fatalistic views, and waning faith in national response to the epidemic. Our analysis of the data indicates that medical male circumcision has ushered in a layered and sometimes conflicting understanding of risk for HIV/AIDS where established ideas grounded in sexual propriety and risk-taking are being re-evaluated and reinterpreted within an emerging worldview coloured with sensibilities pertaining to notions of bodily normalcy. This indicates that the men in our study had a nuanced understanding of risk for HIV that incorporated notions of sexual risk-taking with corporeal impropriety, necessitating appropriate public risk communication about HIV/AIDS and policy responses for its prevention.
Tone Aasenand John-Arne Skolbekken
Risk communication is widely recognised as playing an important role in how individuals at risk of familial cancer understand and interpret their genetic status. To date, however, there has been little empirical investigation directed towards understanding how genetic counsellors themselves understand and actually deal with the challenges of communicating uncertainty of being identified with a gene fault in cancer genetic counselling sessions. In this article, we explore this relationship by using interpretative phenomenological analysis of semi-structured interviews with two genetic counsellors, prior to initial sessions with six patients in Norway, to examine whether the communication during consultations reflects what the genetic counsellors say they do. Analysis of the interviews demonstrates that the counsellors approach the patients’ experiences of their uncertain genetic status by drawing on past family history information and clinical experience as much as numerical risk information. Communicating the uncertainty in a manageable manner is described as a balancing act, involving being supportive while presenting realistic outcomes of the gene tests. Furthermore, our findings from the consultations show that although their clinical experience is emphasised, the counsellors do not explicitly invite patients to express how they themselves experience uncertainty in the context of their lives. While the counsellors provide the patients with balanced risk information, they do not explore how this uncertainty is experienced from the patient’s perspective. As such, our findings provide insight into an under-researched area within the field of genetic counselling.
This interview with James Ferguson traces his thinking from his groundbreaking The Antipolitics Machine to his newest work on neoliberalism. Ferguson explains how the process of development is above all about building justifications for why more money is needed to fund the next project, thus less about increasing state control or oversight over society than simply about creating more state. Conversely, rather than using the term “neoliberalism” as a political cudgel to condemn structural adjustment policies, Ferguson presses critics to linger over what is actually taking place under post-neoliberal forms of governance.
Laila Asmal, Sumaya Mall, Robin Emsley, Bonginkosi Chiliza and Leslie Swartz
Background: Family interventional programmes are effective adjuncts to pharmacotherapy in patients with schizophrenia. Modification in content of such programmes in response to local challenges is considered important, but has not been fully explored in Africa.
Aims: To assess the feasibility and acceptability of an interventional family study for people with schizophrenia and their families in a socially deprived urban community in South Africa and to explore the contextual factors that could influence implementation of the intervention.
Method: A psychiatric nurse facilitated semi-structured interviews with four multi-family groups, each comprising adult outpatients with schizophrenia and their caregivers. Six sessions were held per group. Thematic analysis was applied.
Results: Three themes emerged: stigma and abuse; substance abuse comorbidity and caregiver burden of multiple stressors. Many of these stressors relate to the challenges of an impoverished urban environment.
Conclusions: Multi-family groups with a psycho-educational and behaviour modification frame are acceptable. Negative symptoms are seen as protective in areas of community violence. Modification of traditional models of family therapy to include factors related to poverty, violence, caregiver burden, stigma and limited health care access should be considered in this setting.
Marit B Rise, Marit Solbjør and Aslak Steinsbekk
Background: Few studies have investigated user involvement initiatives in whole organizations. The aim was to explore the experiences of professionals and user representatives taking part in the implementation of a user involvement plan.
Materials: A qualitative study in a mental health hospital included interviews and observational data.
Discussion: Three different stories emerged. The first described the implementation as a success. The second described the implementation as a success, but after overcoming several obstacles. The third described that the development plan had limited impact.
Conclusions: Close attention should be made to decision-making and resource allocation when implementing user involvement.
On 1 September 1967, the Nobel Prize-winning civil rights leader Martin Luther King Jr. delivered a speech entitled ‘The role of the behavioral scientist in the civil rights movement’ to the American Psychological Association (APA, 1999; King, 1968). With eloquence and passion, Martin Luther King championed the civil rights struggle and spoke to the interests of his audience. He stressed how behavioural scientists could and should support the civil rights movement. King’s eloquent and passionate speech is still relevant today—explaining how psychologists and other mental health professionals could help address today’s pressing social issues.
T. M. Luhrmann, R. Padmavati, H. Tharoor and A. Osei
We still know little about whether and how the auditory hallucinations associated with serious psychotic disorder shift across cultural boundaries.
To compare auditory hallucinations across three different cultures, by means of an interview-based study.
An anthropologist and several psychiatrists interviewed participants from the USA, India and Ghana, each sample comprising 20 persons who heard voices and met the inclusion criteria of schizophrenia, about their experience of voices.
Participants in the USA were more likely to use diagnostic labels and to report violent commands than those in India and Ghana, who were more likely than the Americans to report rich relationships with their voices and less likely to describe the voices as the sign of a violated mind.
These observations suggest that the voice-hearing experiences of people with serious psychotic disorder are shaped by local culture. These differences may have clinical implications.
Potent antiretroviral drugs (ART) have changed the nature of AIDS, a once deadly disease, into a manageable illness and offer the promise of reducing the spread of HIV. But the pandemic continues to expand and cause significant morbidity and devastation to families and nations as ART cannot be distributed worldwide to all who need the drugs to treat their infections, prevent HIV transmission, or serve as prophylaxis. Furthermore, conventional behavioral prevention efforts based on theories that individuals can be taught to modify risky behaviors if they have the knowledge to do so have been ineffective. Noting behavioral strategies targeting individuals fail to address broader social and political structures that create environments vulnerable to HIV spread, social scientists and public health officials insist that HIV policies must be comprehensive and also target a variety of structures at the population and environmental level. Nineteenth-century public health programs that targeted environmental susceptibility are the historical analogues to today’s comprehensive biomedical and structural strategies to handle AIDS. Current AIDS policies underscore that those fighting HIV using scientific advances in virology and molecular biology cannot isolate HIV from its broader environment and social context any more than their nineteenth-century predecessors who were driven by the filth theory of disease.
Katherine A. Chavigny
Historians have recognized that men with drinking problems were not simply the passive subjects of medical reform and urban social control in Gilded Age and Progressive Era America but also actively shaped the partial medicalization of habitual drunkenness. The role played by evangelical religion in constituting their agency and in the historical process of medicalization has not been adequately explored, however. A post-Civil War evangelical reform culture supported institutions that treated inebriates along voluntary, religious lines and lionized former drunkards who publicly promoted a spiritual cure for habitual drunkenness. This article documents the historical development and characteristic practices of this reform culture, the voluntarist treatment institutions associated with it, and the hostile reaction that developed among medical reformers who sought to treat intemperance as a disease called inebriety. Those physicians’ attempts to promote therapeutic coercion for inebriates as medical orthodoxy and to deprive voluntarist institutions of public recognition failed, as did their efforts to characterize reformed drunkards who endorsed voluntary cures as suffering from delusions arising from their disease. Instead, evangelical traditions continued to empower reformed drunkards to publicize their own views on their malady which laid the groundwork for continued public interest in alcoholics’ personal narratives in the twentieth century. Meanwhile, institutions that accommodated inebriates’ voluntarist preferences proliferated after 1890, marginalizing the medical inebriety movement and its coercive therapeutics.
Jessica Slijkhuis and Harry Oosterhuis
This article explores the approach of dementia paralytica by psychiatrists in the Netherlands between 1870 and 1920 against the background of international developments. The psychiatric interpretation of this mental and neurological disorder varied depending on the institutional and social context in which it was examined, treated, and discussed by physicians. Psychiatric diagnoses and understandings of this disease had in part a social–cultural basis and can be best explained against the backdrop of the establishment of psychiatry as a medical specialty and the specific efforts of Dutch psychiatrists to expand their professional domain. After addressing dementia paralytica as a disease and why it drew so much attention in the late nineteenth and early twentieth century, this essay discusses how psychiatrists understood dementia paralytica in asylum practice in terms of diagnosis, care, and treatment. Next we consider their pathological–anatomical study of the physical causes of the disease and the public debate on its prevalence and causes.
America’s most widely read nutritionist of the postwar decades, Adelle Davis, helped to shape Americans’ eating habits, their child-feeding practices, their views about the quality of their food supply, and their beliefs about the impact of nutrition on their emotional and physical health. This paper closely examines Davis’s writings and argues that even though she is often associated with countercultural food reformers like Alice Waters and Frances Moore Lappé, she had as much in common with the writings of interwar nutritionists and home economists. While she was alarmed about the impact of pesticides and food additives on the quality of the food supply, and concerned about the declining fertility of American soil, she commanded American women to feed their families better and promised that improved nutrition would produce stronger, healthier, more beautiful children who would ensure America’s future strength. She believed that nearly every health problem could be solved through nutrition, and urged her readers to manage their diets carefully and to take extensive supplementation to ensure optimum health. As such, she played an important role in creating the ideology of “nutritionism”—the idea that food should be valued more for its constituent parts than for its pleasures or cultural significance.
This article examines how the practices of the Fetal and Infant Mortality Review–Case Review Team (FIMR CRT) in “Florida City” constructs particular types of maternal and fetal subjects and how these narratives about fetal and infant death reflect particular discourses about “bad mothers” and “good babies.” I argue that the very methods of the Florida City FIMR committee structure the types of conversations and, in effect, judgments that can be made about women who experience a fetal or neonatal death. In addition, I examine how many of these ideas resonate with the discourses around fetal rights that pervade contemporary abortion politics in the United States.
Erica van der Sijpta
Pregnancy losses are ambiguous affairs in East Cameroon. Childbearing is not always people’s primary aim within their fragile sexual and marital relationships, and it is often unclear to outsiders whether a pregnancy interruption is intended or unintended. Drawing on 15 months of fieldwork, I explore the discursive strategies Gbigbil women deploy while navigating such ambiguities around interrupted pregnancies. Suffering is central to their defensive discourses. Depending on the stakes in their relationships, women foreground the notion of suffering either to portray themselves as moral and innocent—and maintain social status or raise support—or to allude to or acknowledge their intention to terminate a pregnancy. This dynamic deployment of a suffering discourse reveals the interconnections of unintended and intended pregnancy losses, and of suffering (associated especially with the former) and agency (often associated with the latter).
Infanticide is a widespread practice, yet few ethnographic and theoretical works examine this. Drawing on ethnographic research conducted in the Indian Himalayas, I argue that infanticide is a form of reproductive disruption that elicits both public moral judgments and private silences. In this Himalayan context, the stigmas of abortion and premarital sex prevent community acknowledgement of infanticide and baby abandonment. Unmarried women hide their pregnancies, deliver and abandon their babies, and later are rushed to the hospital with postdelivery complications. While biomedical doctors deal with the debris of infanticide (postpartum hemorrhage), there is no formal accounting of the practice. I argue that by regarding infanticide as a form of reproductive disruption, we can open up women’s narratives of pain and suffering that are silenced because of moral repugnance.
Tirtha B. Thapa
Among the Dalit community in Nepal, people consistently describe their diabetes in relation to stress caused by social inequality and social marginalization. Drawing on the illness narratives of 30 people from this community, I argue that through linking diabetes with stress as a result of caste-based discrimination, respondents use diabetes as an ‘idiom of distress.’ Respondents report that discrimination based on caste creates and aggravates their dire financial circumstances, resulting in the prolonged stress that causes and interacts with diabetes. Suffering with diabetes, and its ensuing financial struggles and accompanying stress, has for some led to suicidal thoughts and the preference of death to living with diabetes.
M. Saiful Islam
This article draws on ethnographic data from rural Bangladesh to examine how community members affected by arsenicosis understand, explain, and experience this deadly illness. Biomedically, arsenicosis has been described as a disease caused by drinking arsenic-contaminated water, and it is manifested through physiological complications such as symmetric hyperkeratosis of the palms and soles, cancer of the skin, kidney and lungs, and diseases of the blood vessels. This article goes beyond such biomedical discourse and illustrates how arsenicosis has been vernacularized as ghaa in practice. It focuses on lay world views, logic, local knowledge systems, and sociocultural factors that shape popular understandings of the disease. This article is thus a contribution to our understanding of how arsenicosis, apart from its biomedical and clinical manifestations, is understood and experienced by affected individuals living within the particular sociocultural and ecological constraints of rural Bangladesh.
History of Psychiatric Epidemiology — An International Journal of Epidemiology supplement by Aaron Seaman
The International Journal of Epidemiology just published a special supplement, edited by Anne Lovell and Ezra Susser and entitled “History of Psychiatric Epidemiology.” The supplement consists of an introduction by Lovell and Susser and five articles, the abstracts of which are below.
What might be a history of psychiatric epidemiology? Towards a social history and conceptual account
Anne M. Lovell and Ezra Susser
This supplement heralds the start of an interdisciplinary and international effort to trace the origins of psychiatric epidemiology. As a first step, these papers focus primarily on developments during the period 1945 to 1980, in the USA, UK and France, as well as internationally through the World Health Organization (WHO). A post-war modern epidemiology centred on risk factors emerged during this time.1 One exemplar of a ground-breaking study that advanced psychiatric epidemiology along similar lines is sociologist Lee N Robins’ 1960s investigation of the relationship between childhood behaviour problems and adult antisocial behaviour.2 The papers herein, however, show that despite such exemplars, these developments were uneven and highly contested within the distinctive sphere of psychiatric epidemiology. Often the debates brought to light are still relevant today, and some have implications beyond psychiatric epidemiology.
This paper focuses on the relatively late emergence of psychiatric epidemiology as an international discipline, through local-global exchanges during the first 15 years of the World Health Organization (WHO). Building an epidemiological canon within WHO’s Mental Health Programme faced numerous obstacles. First, an idealist notion of mental health inherent in WHO’s own definition of health contributed to tensions around the object of psychiatric epidemiology. Second, the transfer of methods from medical epidemiology to research on mental disorders required mobilizing conceptual justifications, including a ‘contagion argument’. Third, epidemiological research at WHO was stymied by other public health needs, resource scarcity and cultural barriers. This history partly recapitulates the development of psychiatric epidemiology in North America and Europe, but is also shaped by concerns in the developing world, translated through first-world ‘experts’. Resolving the tensions arising from these obstacles allowed WHO to establish its international schizophrenia research, which in turn provided proof of concept for psychiatric epidemiology in the place of scepticism within and without psychiatry.
This article takes up the history of North American psychiatric epidemiology with reference to production of knowledge concerning sociopathic or antisocial personality disorder and drug dependence, abuse, and/or addiction. These overlapping arenas provide a microcosm within which to explore the larger shift of postwar psychiatric epidemiology from community studies based on psychological scales to studies based on specific diagnostic criteria. This paper places the figure of sociologist Lee Nelken Robins within the context of the Department of Psychiatry in the School of Medicine at Washington University in St Louis, Missouri. The St Louis research group—to which Robins was both marginal and central—developed the basis for specific diagnostic criteria and was joined by Robert Spitzer, Jean Endicott and other architects of DSM-III in reorienting American psychiatry towards medical, biological and epidemiological models. Robins was a key linchpin working at the nexus of the psychiatric epidemiological and sociological drug addiction research networks. This article situates her work within the broader set of societal and governmental transformations leading to the technologically sophisticated turn in American psychiatric epidemiology and research on the aetiology of drug abuse and mental health and illness.
Social disorder and diagnostic order: the US Mental Hygiene Movement, the Midtown Manhattan study and the development of psychiatric epidemiology in the 20th century
Dana March and Gerald M. Oppenheimer
Recent scholarship regarding psychiatric epidemiology has focused on shifting notions of mental disorders. In psychiatric epidemiology in the last decades of the 20th century and the first decade of the 21st century, mental disorders have been perceived and treated largely as discrete categories denoting an individual’s mental functioning as either pathological or normal. In the USA, this grew partly out of evolving modern epidemiological work responding to the State’s commitment to measure the national social and economic burdens of psychiatric disorders and subsequently to determine the need for mental health services and to survey these needs over time. Notably absent in these decades have been environmentally oriented approaches to cultivating normal, healthy mental states, approaches initially present after World War II. We focus here on a set of community studies conducted in the 1950s, particularly the Midtown Manhattan study, which grew out of a holistic conception of mental health that depended on social context and had a strong historical affiliation with: the Mental Hygiene Movement and the philosophy of its founder, Adolf Meyer; the epidemiological formation of field studies and population surveys beginning early in the 20th century, often with a health policy agenda; the recognition of increasing chronic disease in the USA; and the radical change in orientation within psychiatry around World War II. We place the Midtown Manhattan study in historical context—a complex narrative of social institutions, professional formation and scientific norms in psychiatry and epidemiology, and social welfare theory that begins during the Progressive era (1890-1920) in the USA.
This article uses archival as well as published materials to trace the development of psychiatric epidemiology in France from 1945 to 1980. Although a research programme in this field was launched in the early 1960s at the National Institute of Medical Research (INH, later renamed INSERM), psychiatric epidemiology remained an embryonic field in France during the next two decades. French researchers in this field were hampered by limited resources, but their work was primarily characterized by a deep engagement with the epistemological challenges of psychiatric epidemiology. The history of French psychiatric epidemiology in the 1960s and 1970s can be seen as an attempt to create a specifically French way of doing psychiatric epidemiology research. In the first part of this article, the author relates this unique history to internal professional dynamics during the development of psychiatric research and, more broadly, to the biomedical institutional context in which epidemiological work was being done. The next part of this article examines the conditions under which the INH research team framed epidemiological research in psychiatry in the 1960s. The last part focuses on INH’s flagship psychiatric epidemiology programme, developed in cooperation with pioneers of French community psychiatry in Paris’s 13th arrondissement in the 1960s.
Psychiatric epidemiology, or the story of a divided discipline
This article traces the historical decisions, concepts and key professional collaborations that laid the foundations for the formation of American psychiatric epidemiology during the 20th century, up to the discipline’s institutional consolidation, circa 1980, when the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) was published. Thomas Kuhn’s ‘disciplinary matrix’ is mobilized as a framework that allows the institutional and intellectual construction of a discipline to be analysed as separate but intertwined components, without assuming that the two evolve in tandem. The identification of the strengths as well as the frailties and internal divisions of the discipline as it developed reveals a paradoxical situation: a time lag between psychiatric epidemiology’s institutionalization and public recognition, on the one hand; and the weak coherence of its intellectual components, on the other hand. We briefly trace the origins of split among the discipline’s aetiological models of mental disorders and suggest that the lack of coherence among them has prevented psychiatric epidemiology from achieving the status of a normal scientific discipline, in the Kuhnian sense. Without a more explicit attention to the intellectual rationale of the discipline, psychiatric epidemiology will continue to maintain a strong institutional dimension and weak intellectual matrix.
[Chagas disease in Argentina. Scientific research, social problems and health policies]
Universidad Nacional de Quilmes, Argentina. 2010. 360 pages.
“Mal de Chagas” is a disease that affects 2.5 million people in Argentina and 8 million in Latin America. Caused by the parasite Trypanosoma cruzi, it generates heart, digestive and/or nervous system problems that may lead to death. The main vector of contagion is an insect (in Argentina, called “vinchuca”, in Brazil, “barbeiro”), which nests in the walls and roofs of dilapidated huts. Chagas disease is effectively a disease of poverty, as its transmission is associated with deficient housing, insufficient material conditions and sanitation facilities, malnutrition, and lack of access to sanitary information.
Chagas is considered a “neglected disease”. This is due to: the lack of overt symptoms; the lack of information about the disease; the resignation concerning its existence and effects among populations where the disease is endemic; the tendency of infected people to hide their diseased status to avoid job discrimination; and lack of interest of private laboratories to develop new treatments due to the low purchasing power of the sick. Despite this relative neglect, research on Chagas in Argentina goes back to the early twentieth century and in the last thirty years the disease has received increasing attention from researchers in biomedical circles. These researchers have increased awareness of the disease in prestigious Argentinian academic circles. This has led to new research opportunities facilitated by the academic researchers’ working conditions, funding, research expertise, and international connections. Simultaneously, research agendas on Chagas have been displaced, from drug and vaccines development to basic research, with the discursive use of the first to assert the legitimacy of Chagas as an object of scientific research within the latter.
At a conceptual level we might ask: how was a set of scattered phenomena transformed into a scientific object – an ontological, observable and manipulable entity? At a socio-political level we might ask: how does the disease become ‘real’ as a social problem? What place does it take in the country’s political agenda and in the science and technology (S&T) policy agenda?
In his book, Juan Pablo Zabala studies the dynamics of inextricably intertwined social and conceptual worlds, examining how they define and redefine the landscape in which heterogeneous elements interact: research, physicians, scientists, research centers, state agencies, international networks, and policy makers. He shows how the trajectory of attention to Chagas disease was strongly shaped by factors including: the political and institutional agendas of the actors who promoted its construction as an “issue”; the scientific disciplines considered the main knowledge producers at different points in time (and intervention strategies with which they were associated); the broader political circumstances at the level of the state (government changes, coups d’états and political persecution); and international networks and research funding.
Chagas disease in Argentina provides a historical and sociological account in which three main levels of analysis are interwoven. These include analyses of:
(a) The formation of an epistemic object and the production of scientific knowledge: How were the object and research problems constructed?;
(b) The relationship between scientific knowledge and the development of public health interventions: How – and by whom – were the social and health problems constructed? What solutions were developed in response to the different understandings of the problems? How did the results of scientific research shape the intervention strategies on society?;
(c) How interactions between actors, groups and institutions led to the acceptance and stabilization of certain representations over others as well as the allocation of resources to certain forms of intervention rather than others.
Through his focus on this particular case and the interweaving of these three levels of analysis – with attention to historical particularities – Zabala calls for reflection on the social utility of science and the orientation of S&T policies in developing countries.
The book is structured chronologically. Within the socio-conceptual trajectory, we first encounter a period of the construction and definition of the disease in which the main actors were a small group of scientists, with training in protozoology and tropical medicine, interested in identifying the links between the pathogenic agent and a set of clinical symptoms. In a second phase, during the 1920s and under the microbiology paradigm, the characterization of the disease became stabilized by the representation of its acute stage. The eye inflammation associated with this acute stage of infection, a clinical sign that could be identified by non-specialists as easily as by specialists, allowed for a widespread redefinition of the disease and facilitated its recognition by the country’s medical community and secured its place in the public health agenda.
Between 1940 and 1960 Chagas became recognized as an important sanitary and social problem. This reconceptualization involved a new set of actors, sanitary physicians and policy makers, leading to another new conception of the disease, specifically as the cause of a chronic heart condition of great epidemic proportions – rural at first and urban thereafter, due to internal migrations. New public health interventions and practices were introduced, focusing on epidemiological diagnosis, measurement, and prophylaxis.
Finally, beginning in the 1970s, in a fourth stage, intervention policies were stabilized and the disease was taken up by new actors: biomedical researchers from the fields of biochemistry, immunology and molecular biology. At first, research was oriented toward the development of therapeutics and vaccines. However, with increasing academic interest in and incentives for basic research on molecular explanations of the disease (namely, funding availability, insertion within international research networks, possibilities for academic career promotion), the objective of developing therapeutics and vaccines was displaced. Concurrently, in the late 1970s, the importance of the disease within national health policies declined and state agencies that were devoted to their implementation entered into a process of institutional weakening.
As Shapin and Schaffer (1985) argue, “solutions to the problem of knowledge are embedded within practical solutions to the problem of social order, and that different practical solutions to the problem of social order encapsulate contrasting practical solutions to the problem of knowledge”. On this level of analysis, Zabala traces the process of co-construction of knowledge about social and health problems (i.e. different ways of constructing the problem and object of research) and solutions for these problems (i.e. diverse intervention practices). In this sense, while different ways of framing knowledge prefigured diverse solutions in the form of health policy measures, the political stances that prevailed at each historical period tended, in turn, to promote certain knowledge production practices that fostered those measures. The measures, at the same time, stabilized the political positions of the different stances over time, both at the level of national politics and within expert communities.
The author frames his research within a tradition of sociology and history of science and technology, returning in his analysis to heuristic tools from both the constructivist and the neo-institutional approaches to the sociology of science. From a constructivist perspective, Zabala delineates a journey through the meanings that different social groups attributed to Chagas disease as a conceptual and social problem and the interventions that were accordingly carried out. The analysis recounts the negotiation of meanings between actors in the construction of Chagas as a morbid entity, as an object for public health and a research object, and the respective ways of representing the disease: its symptoms, diagnosis, the actors that were involved, privileged spaces for knowledge production and ways of considering and intervening on the infected population.
Using a neo-institutional matrix, the book examines how disciplinary frameworks shaped knowledge production (enabling some research paths while constraining others) and the different “scientific subcultures” that predominated across the different historical periods: parasitology, microbiology, entomology, immunology, biochemistry, molecular biology. Analyzing disciplinary framings of the disease along with the institutional conditions under which scientific activities took place (i.e. research practices, ways of posing questions, institutional constraints and incentives, international networks involved, possibilities for participating in policy decision making), permits Zabala to identify how the relations between knowledge production and social-sanitary interventions were shaped.
From the resulting conceptual framework, Zabala – through a thorough historical account – captures the complexity of Chagas disease’s “biography” as an “epistemic thing” (Rheinberger, 1997), as a social problem and as an object of intervention.
But what lessons can be learned from the case of Chagas? From a policy perspective, who is included and who is excluded via diagnostic practices, agenda setting, policy design and implementation? Whose views are taken into account? How are S&T and health policy agendas interwoven? And how does this research encourage us to reflect on national scientific and technological policies in Latin American countries? Along the journey delineated by Zabala, three elements remain stable: the consideration of the disease as a “social problem” at the policy level, the participation of scientists in the definition of these processes, and endemic poverty of people infected by the parasite. Regarding this last point, while a multitude of heterogeneous actors have been involved in ascribing meaning to the disease and shaping its representations, one group has been conspicuously absent: the sick.
Strikingly, the population affected by Chagas disease has not been engaged directly in the struggle against the disease; their needs have always been represented by other, more powerful, actors (Kreimer and Zabala, 2006). This leads us to pose the challenging question: how can Chagasic patients become activists for promoting R&D and policy interventions? While there are many diseases for which patient activism and expertise has played a significant role (AIDS is a prime example, Epstein, 1995), in the case of Chagas disease, conditions of structural poverty, lack of access to information, and general neglect has prevented “chagasics” from becoming acknowledged actors within discourses about the disease. Their empowerment as a group, and the possibility of their inclusion into the Chagas debate, is thus a structural challenge: it needs to go far beyond aiming at a specific solution to a specific problem, but instead to seek a systemic socially inclusive process.
Chagas disease in Argentina also allows us to critically analyze the reasons why finding solutions for neglected diseases – Chagas is a paradigmatic case – have not yet become scientific and technological priorities even within countries where these diseases are prevalent and where there are sufficient R&D capacities to take up the challenge. In addition, the book raises questions about the kind of R&D solutions that are sought (and funded): do national and international funding agencies promote and pursue basic or applied research? In case of the latter, do they look for new high-tech diagnostic kits (for a disease that already has a diagnostic gold standard) or do they fund R&D for prevention and treatment? Are the R&D solutions that are sought articulated with the actual needs of the health system?
Lastly, the book identifies a dilemma that is integral to research strategies and norms of academic evaluation: if career promotion and funding assignment is related to publishing in international high impact journals (most of which focus on basic science), what are the possibilities for developing R&D institutional agendas oriented towards solving local social problems? And what are the possibilities for engaging in research that may be less fruitful in terms of publication but may result in interesting technological developments for addressing social needs?
Zabala’s Chagas disease in Argentina presents an interesting study of a disease that is emblematic to Latin America and a fruitful analysis of the socio-conceptual trajectory of a research object which is perpetual being reconstructed. The analysis presented in the book is not only relevant to rethinking other neglected diseases prevalent in the region (tuberculosis, dengue, leishmaniasis), but also, and in a broader sense, to promoting wider research-based discussion – and stakeholder engagement – on how S&T policies are oriented (or not) towards addressing local problems and needs.
Gabriela Bortz is a Researcher at the Institute for Science and Technology Studies, Universidad Nacional de Quilmes and a PhD Fellow at the National Science and Technology Research Council (CONICET). Her research focuses on the analysis of public policies, knowledge production and innovation in biotechnology and how they are enrolled to solve social and environmental problems in Argentina, as part of the research program “Technology for Social Inclusion – Public Policies in Science, Technology and Inclusive Development”. Gabriela is also founder and editor of Eä Journal, open access peer reviewed journal in social and humanistic studies of Health, Science & Technology. Contact: firstname.lastname@example.org, email@example.com
The “Foreign Correspondents” series features reviews of books published in languages other than English. It is edited by Stephanie Lloyd (Laval University). If you would like to suggest a non-English language book for review or if you are interested in reviewing for “Foreign Correspondents,” please contact Stephanie directly at firstname.lastname@example.org.
Epstein, S. (1995) The Construction of Lay Expertise: AIDS Activism and the Forging of Credibility in the Reform of Clinical Trials. Science, Technology, & Human Values, Vol. 20 (4), Special Issue: Constructivist Perspectives on Medical Work: Medical Practices and Science and Technology Studies, 408-437.
Kreimer, P. and Zabala, J. P. (2006). ¿Qué conocimiento y para quién? Problemas sociales, producción y uso social de conocimientos científicos sobre la enfermedad de Chagas en Argentina, Revista Redes, 23, 49-77.
Rheinberger, H-J. (1997). Toward a History of Epistemic Things: Synthesizing Proteins in a Test Tube. Stanford, California: Stanford University Press.
Shapin, S. and Schaffer. S. (1985). Leviathan and the Air-Pump: Hobbes, Boyle, and the Experimental Life. Princeton: Princeton University Press.
Zabala, J. P. (2010). La enfermedad de Chagas en Argentina. Investigación científica, problemas sociales y políticas sanitarias, Bernal, Universidad Nacional de Quilmes.
“Globalizing schizophrenia and other severe mental disorders” – a 3-yr doctoral fellowship at CERMES3/EHESS (Paris) by Anne Lovell
CERMES3 announces a three-year doctoral fellowship (2014-2017) on “Globalizing schizophrenia and other severe mental disorders” financed through the European Research Council project GLOBHEALTH, “From international to global: Knowledge and diseases and the post-war government of health”. The PhD will be defended at the EHESS – Paris.
This doctoral research should centre on a critical history of the development of international research on schizophrenia and other severe mental disorders and the central role of WHO, including but not limited to the 25-year WHO international research programme on schizophrenia. It may address the scientific findings and controversies; the relationship of this research to international public health, epidemiology, psychiatry and oth- er branches of medicine; the changing nature of expertise. The project may also focus on more recent history of the incorporation of schizophrenia into global health through new alliances (e.g. NGOs, universities, phar- maceutical markets), metrics (e.g. Global Burden of Disease), and movements for health and human rights. The nature of the project may be historical, anthropological or sociological. However, it should focus on local- global exchanges, particularly in outside Europe and North America. The doctoral project falls into the do- main, “Placing mental health on the world health agenda: the globalization of a refractory problem”, one of four to be examined by the ERC programme GLOBHEALTH.
The PhD project will be located at CERMES3, Villejuif/Paris, but will involve on-site research in Geneva (WHO) and possibly sites in Africa or Asia. Supervision will be offered by Jean-Paul Gaudillière (historian) and Anne M. Lovell (medical anthropologist).
Applicants should hold a Masters’ Degree in anthropology or history, but other disciplines will be considered. Some background or interest in mental health, psychiatry, pharmaceuticals or public health is an asset. Good oral, reading and writing skills in English are required; some knowledge of French is preferable.
Applicants should include the following in their application:
- contact details, including phone number
- CV (degrees, educational/training experiences, work history, skills, honours/awards, publications)
- transcripts from university diplomas
- letter of motivation
- draft project of 5 to 10 pages. Include: subject, materials, methods, field-site, intended outcomes, dissemination and a 3-year timeline for the project.
- Sample of writing that applicant deems relevant to the project.
- Names and contact details of two references
Information on CERMES3 is available through http://www.cermes3.fr.
Description of the ERC Project is accessible through http://globhealth.vjf.cnrs.fr
The complete applications to be sent to email@example.com and firstname.lastname@example.org
Please indicate “Globalizing Schizophrenia – GLOBHEALTH” in the subject line.
The NEW deadline for applications is September 15, 2014.
The selection will completed at the end September 2014 and the successful candidate is expected to start employment by the end of October 2014.
Call for papers – Psychopathological fringes: Historical and social science perspectives on category work in psychiatry by Nicolas Henckes
Venue: Berlin, Institute for the History of Medicine, Dahlem
Organization: Nicolas Henckes, Volker Hess, Emmanuel Delille, Marie Reinholdt, Stefan Reinsch, Lara Rzesnitzek,
Over the last few years, the revision process of both the DSM and the Chapter V on mental disorders of the ICD has stimulated within psychiatry a series of attempts at challenging established diagnostic categories. These challenges reflect both dissatisfaction with categories as they are defined in existing diagnostic classifications, and a will to adjust them to the demands of clinical and research activities. They are expressed in ways that sometimes strongly resembles the discourse of critical social science. For instance, the conveners of the conference “Deconstructing psychosis” – organized by the American Psychiatric Association along with the WHO and the US National Institutes of Health in 2005 – developed a stringent critique of the proliferation of diagnostic categories in the field of psychosis: “Although these categories are meant to refer to broadly defined psychopathological syndromes rather than biologically defined diseases that exist in nature, inevitably they undergo a process of reification and come to be perceived by many as natural disease entities, the diagnosis of which has absolute meaning in terms of causes, treatment, and outcome as well as required sampling frame for scientific research.”
Controversies over diagnostic categorization in fact have a long history in psychiatry. Rejection of diagnosis has long been prominent among certain segments of psychiatry, from Adolf Meyer’s synthesis in interwar US psychiatry through parts of phenomenological psychiatry in Germany to antipsychiatry and Lacanian psychoanalysis in 1970s France. However, the deconstruction of diagnosis has also been a core feature of what might be termed category work in psychiatry, at least since the fall of the unitary psychosis concept in the last quarter of the 19th century. By the notion of category work we understand the multifaceted practices developed by clinicians, epidemiologists, biologists, administrators and patients to negotiate and objectify the boundaries of diagnostic categories. While such practices have mostly been devoted to securing the internal coherence of major categories, the requirements of both research and clinical work have prompted the development of liminal categories meant to target conditions situated between illness and health, or between broader established diagnostic classes. Examples of such categories include prodromal schizophrenia, latent depression as well as “borderline” disorder and a range of personality disorders. Closely related to these constructs are notions of comorbidity and dimensional concepts of diagnostic spectra or continua. In many of these cases, the challenge for psychiatrists has been to devise entities that include in their very definition the possibility of their transitory status. These diagnostic constructs thus convey a paradox: while they question categorical thinking, they are usually framed within the language of categories.
The aim of this workshop is to offer a historical and social science perspective on the history and current status of category work at the fringes of psychopathology. Unlike constructionist perspectives on psychiatric diagnosis that have aimed to demonstrate the less than solid nature of core categories such as depression, schizophrenia and neurosis, we are interested in the already internally contested and marginal categories devised to target conditions situated at the borders of psychopathology. Thus, rather than elaborating on the longstanding debates between “lumpers” and “splitters”, we would like to examine the ways in which psychiatry has developed knowledge and practices to target these conditions.
This workshop has its origins in the German-French research program “Psychiatric Fringes. A historical and sociological investigation of early psychosis in post-war French and German societies” funded by the ANR and the DFG for the period 2012-2014, and it will be an opportunity to discuss results from this research project. We welcome papers on other aspects of the history, the sociology and the anthropology of psychiatry at the fringes of psychopathology that complement our research and might lead to a wider understanding of this work. Papers may explore for instance one or more of the following issues:
- The construction of knowledge at the fringes of psychopathology. What knowledge practices have been involved in the creation of categories targeting liminal conditions? What have been the respective roles of epidemiology, biological science, brain imaging, biometrics, and the clinic in the development and objectification of these categories? What have been the practical and ethical implications of such work?
- Diagnostic practices. Liminal categories have been developed to address specific clinical uncertainties, but they also have raised new ones. What are these, and how are they practically managed by clinicians and patients? What are the specific diagnostic instruments developed by clinicians, and how are these used? What has been the role of psychopathological scales, psychological tests or biological treatments in diagnostic processes?
- The specific role of patients´ experience in category work. To what extent have patients, as individuals or as organized groups, contributed to shaping categories at the borders of psychopathology?
- The trajectories of categories. Like the psychiatrists quoted above, we might be tempted to think that categories always end up in some ways reified. Is this always the case? What has been the use of liminal categories in different historical and social contexts? What has been the influence of these contexts on the very definition of such categories?
Interested prospective participants should send a title and a 350-word paper description to Ms. Stefanie Voth: email@example.com by September 15th. Travel expenses and accommodation in Berlin will be covered by the conference organizers.
 van Os, J. and C. Tamminga (2007). “Deconstructing psychosis.” Schizophrenia Bulletin 33(4) p. 861
University of Chicago Press, 2013, 344 pages
by Stefan Sperling
Sperling’s Reasons of Conscience is an ethnographic study of two German Bioethics commissions – the Enquete Kommission and the Nationaler Ethikrat. His particular focus is on the way that the national, political and cultural context influences the democratic and bureaucratic processes involved in the production of bioethical regulations. These influences can be summarized in terms of the Kantian moral character of German culture, the structural and procedural transparency of German politics, and the enduring legacy of the Holocaust in the ethico-political imaginary of the German nation-state. This latter influence can be contrasted with the distinct absence of influence that, Sperling suggests, can be accorded to the former GDR (East German) in the political life of a post-reunification Germany. Whilst this absence of influence is interesting, the very fact it is an absence makes this section of the book its least relevant part. Consequentially my review focuses on the importance Sperling accords to transparency, Kant, and the Holocaust in the bioethical discourses of the German nation-state.
In his pretext Sperling discusses various aspects of German cultural life that can be read as supporting his main thesis: that the principle of transparency that informs German political life produces a concomitant responsibility on the part of citizens–they must be politically literate. This means that, in the context of specific debates or policy-making processes, citizens must be given the opportunity to acquire the relevant literacies. As with the 19 Articles of Basic Law, etched into glass plates and on public display near the Reichstag in Berlin, transparency is not aperspectival. Political transparency does not result in the practices of government being comprehensible from anywhere and everywhere, it does not result from the simple removal of opacity or obstacles to our vision, rather it requires the observer to look from a particular vantage point and to engage actively in the task of perception. Thus, Sperling argues that public meetings – or ‘citizen conferences’ – are not simply occasions at which the ethics commissions could present their work nor are they fora for collecting the views of ‘the public.’ Rather they are occasions for the performance of democracy and the creation of citizens. In order that the public might fully appreciate and understand the issues at hand they needed to be educated, something that is achieved by exposure to experts in a democratic context, at least in part.
In this way the issues addressed, and the development of the commissions’ views, are rendered transparent through their engagement with a process of public reasoning. The idea and ideal of ‘public reason’ is a vital, and Kantian, part of German culture and politics. However, it is important to note what is meant by its counterpart: ‘private reason.’ This is not to be understood as the reason one uses in one’s private or ‘non-public’ life, but is the reasoning one uses when ‘under orders’ or when one is in some way carrying out a mandated action or activity (p.157). Private reason is what is used when one acts or is commissioned to act on behalf of a collective, particularly the state but also other organizations whose perspective, framework or world-view is accepted and adopted by its delegates, those who join and work for such organizations. The primary example of this are the Beamte, German civil servants who, on condition of giving up some of their liberties and constitutional rights, including the right to engage actively in political organizations (p.162), collectively embody the state and its infrastructure. In aligning themselves with the private reason of the state there is a sense in which the Beamte are required to set their own moral conscience to one side in favor of acting in accordance with the bureaucratic and procedural dictates of the collective hierarchy. This same requirement is placed on those who worked for the commissions. Their personal views were to be considered subordinate to the task delegated to them and the processes through which they were to carry it out. Thus Kantian ideals result in a compartmentalisation and division of labor where the private reasons of the state and its organs structure the way it makes use of public reason and, therefore, the kind of public reasoning it is capable of recognizing.
Depending on one’s perspective such arguments – that the politics of transparency engenders a particular co-constitution of citizen and democracy and the private reason of the state limits the recognition it can offer to the public reason of the polity – can lead one to despair or to rejoice. If one has faith in democratic proceduralism and the arrangements that have been made for it, then one will be confident in the ability of bioethics commissions to not only get to the heart of the matters they address but to resolve them in a laudable manner. If one is more sceptical about the Kantian moral project, and Habermas’ ethico-political reconstruction, then concerns will remain. Given that most do not hold one or the other of these positions but, instead, accord the state both confidence and concern, then we might take the Holocaust as representative of the ambivalence we, and not just Germany, have in regards the role of procedure in the political philosophy of modernity. On the one hand we are enjoined not to forget, to never again let such a thing happen and to see the products of procedure – such as the conclusions of the ethics commissions studied by Sperling and, one might add, the moral notion and legal actuality of universal human rights – as ensuring it never can. However, pace Bauman’s (1989) analysis, we cannot but acknowledge that it was this same proceduralism, and the associated division of labor embedded in the distinction between public/ private reason, that not only set the conditions for the Holocaust but, ultimately, facilitated its conduct. Thus when Sperling suggest that remembering the Holocaust, and a desire to ‘learn its lessons,’ plays a significant role in Germany’s bioethical debates, it cannot be because such a thing could never again happen. It must be because it very well could. Modernity does not merely have ends, it has an end. It is a project to be completed or perfected and, as such, it is imbued with an idea of finality. Just as in Kant we have the Kingdom of Ends so in Nazi Germany we had the Final Solution. And were the ends of The Enlightenment to be achieved we would find ourselves at the end of history. Whilst were are attracted to such utopias because we consider them morally superior to contemporary society it is not clear that there is a path we can take to reach such places, or that any such path could be ethically traversed. Thus we must remain ambivalent about what the politics of transparency has to offer. Sperling’s ethnographic experience and analysis leads him to conclude that:
“The State displays itself with the goal of making its transparent workings open to critique, but with the purpose that citizens understand, and adopt its governing logic. … The transparency of government acts to shut down alternative readings.” (p.280)
Whilst transparency is designed to make critique possible, the structural arrangements it requires means that perspectives that do not adopt the governing logic are delegitimized. An unavoidable consequence of bureaucracy, a form of government named for a piece of office furniture (Kafka 2012:77), is a dehumanising rationalisation of life and experience. The realities and practices of government are not neutral with respect to the governed, citizens are not born, but made, and Sperling’s analysis of bioethical regulation in the making offers a compelling illumination of the democratic process.
Nathan Emmerich is Visiting Research Fellow, School of Politics, International Studies and Philosophy, Queen’s University Belfast.
Bauman, Z. 1989. Modernity and the Holocaust. Cambridge, UK. Polity.
Kafka, B. 2012. The Demon of Writing: Powers and Failures of Papwerwork. Zone Books.
Questions of health, medicine and science have long animated sub-disciplinary attentions in the social sciences and humanities. Recently, however, research around these topics has taken a marked collaborative turn. If topics in the medical and health sciences were once straightforward objects of study for anthropological, sociological or philosophical analysis, increasingly, to work ‘on’ such topics often means also to work both ‘with’ and ‘through’ them. While this collaborative turn has been enacted in distinct ways, shaped by national and regional institutional structures and epistemic communities, for many in medical anthropology, the sociology of health and illness, the medical humanities, and science and technology studies, ‘science’ and ‘medicine’ are not simple disciplinary specialities. Instead, they are desired collaborators, allies, and co-producers, for an interdisciplinary research complex that is less invested in institutional or philosophical dividing-lines between the ‘biological,’ ‘social’ and ‘human,’ and much more committed to exploring the ways in which social life, conceptual labour, and biological existence run through one another.
This development has many antecedents. They include the emergence, in recent decades, of a bioscience-based research-complex (for example in epigenetics, in social and developmental neuroscience, in global health and infectious disease research) that has deepened our understanding of the co-constitution of the social and the biological in many areas of health and disease. Equally significant is the ongoing development of an international funding infrastructure that favours large-scale, interdisciplinary approaches to ‘big questions’, and research (from whatever discipline) that has a direct impact on health outcomes. Simultaneous with these developments, the epistemological politics around issues such as climate change, global health, and other pressing concerns, have shifted the stakes of critiquing certain forms of expert knowledge – a development that marks (but does not exhaust) a broader wearing-out, in social and cultural theory, of suspicions around the biology and materiality of the body, the relationship between inheritance and cultural and social life, the place of scientific expertise, and so on.
“The collaborative turn” – which will appear as a series of essays on Somatosphere – seeks to open up a critical dialogue on collaboration and interdisciplinarity across medical anthropology, medical sociology, and the medical humanities. It also addresses the emergence of similar issues in allied health sciences – not least in epidemiology, demography, and the other population sciences – where on-going re-alignments of ‘health’ and ‘the social’ also generate complex (and not always comfortable) spaces of collaboration and hybridity. Finally, we include recent efforts to engage patient and provider publics (and counter-publics), including ‘participatory’ interdisciplinary initiatives framed in terms of co-production, ‘involvement’ and/or ‘emancipation.’ If interdisciplinary collaboration around medical and scientific topics is often taken as a good in itself, questions remain about the bases on which, and purposes for which, collaborations are established. There is much to be optimistic about in collaborative endeavours. But the epistemological, ontological, and institutional complex that has come to organise and propel this future (or futures) has been the object of surprisingly little scholarly attention from medical anthropology and sociology, or from the medical humanities – even as it has come to reshape the fields in which those disciplines operate. Indeed, it is not always clear in whose name the promissory future of interdisciplinary collaboration is promoted (both inside and outside the academy), with what desired benefits, with what goals, and with what broader-scale effects. Nor is there always clarity about conditions under which the question of collaboration and interdisciplinarity emerge; especially across different national and disciplinary contexts, there is little attention to the terms under which different epistemological perspectives are drawn together. The series thus asks: what is fundamentally at stake in collaboration around topics in health, medicine and science? What does it mean for scholars in the social sciences in the humanities (and sometimes users and practitioners) to learn to live in such collaborative terrain? And how can such questions open up analysis of a broader collaborative turn, of the ways in which unruly questions in health, medicine and science are understood today, and of how the social sciences and humanities are coming to be entangled in this understanding?
We invite submissions for this series from scholars working in the social sciences and humanities of medicine, health and science as well as from researchers and practitioners in the biosciences and medicine. Please contact us with a short (250-500 word) proposal at firstname.lastname@example.org. There is no strict deadline and submissions will be considered as they are received, although we hope for posts in the series to begin appearing in the Fall of 2014.
“The collaborative turn” is collaboratively edited by Des Fitzgerald, Nev Jones, Suparna Choudhury, Michele Friedner, Nadine Levin, Stephanie Lloyd, Todd Meyers, Neely Myers, and Eugene Raikhel.
Paper Knowledge: Toward a Media History of Documents
Duke University Press, 2012, 224 pages
The Demon of Writing: Powers and Failures of Paperwork
Zone Books, 2012, 208 pages
by Ben Kafka
Ben Kafka and Lisa Gitelman, colleagues at New York University, have both written books about the intricate nature of paper as a medium. While Kafka delves into the nature of paper as enabling agent of bureaucracy – i.e. paperwork – Gitelman’s focus is on “documents” and how they were shaped by print and are now transformed by the digital.
Given the digitization of all things social and the recent debate about issues for democracy through digital surveillance (Wikileaks, Edward Snowden), books about specific media and their implications for governance such as Kafka’s and Gitelman’s are tapping into current issues.
The Demon of Writing
The Demon of Writing by Ben Kafka focuses on the meaning of a particular medium (here: paper) for governance – specifically: bureaucracy. His narrative revolves around “paperwork”, which he defines “to mean all those documents produced in response to a demand – real or imagined – by the state” (p. 10). In what is probably one of the most entertaining scholarly books ever written, Kafka uses the period of the French Revolution to detail the travails of individuals exposed to the madness of bureaucracy. The largest part of his treatise (three chapters) narrates the stories of people caught up in this treadmill of paperwork. The first chapter, for example, focuses on Edme-Etienne Morizot in (pre-)revolutionary France, whose fate offers obvious parallels to the great novel The Trial by Ben Kafka’s famous namesake, Franz Kafka. Fired from his job in the Ministry of Finance in 1788, Morizot has to endure similar struggles, being sent from one committee to the next in the hope of finding an open ear; that is, of receiving the pension that was promised him.
While taking the reader on a roller-coaster ride of individuals struggling with the system, Kafka cleverly interweaves these accounts with some more general remarks about the history and nature of bureaucracy. For example, he shows that it was the Constituent Assembly and not Napoleon that invented administrative organization (p. 103); and that “modern political thought was both founded and confounded by encounters with paperwork” (p. 10); Kafka also points out that paperwork was a precursor to, if not the first step of, industrialization (p. 12). Quills and ink were not very efficient; bureaucracy resulted from a need for a division of labor, as societies became larger and more complex (p. 35). In connection with cheaper means of producing paper and the notion (advanced by the French Revolution) that public servants had to be accountable (now that they properly represented the people; p. 43), bureaucracy began to enjoy an unbridled existence.
Kafka does not equate paperwork with bureaucracy per se. He points out, for instance, that the Roman Empire, while bureaucratic, used far less paperwork (p. 54). “Modern” bureaucracy is therefore a markedly different form of governance than feudal bureaucracy, characterized by the availability of paper and the “paperwork” that ensues.
One could argue that Kafka’s book is – in terms of topic and scholarly insight – not very different from the path-breaking work on bureaucracy by Max Weber (to whom Kafka refers briefly on three occasions). Indeed, much of the narrative echoes Weber’s points, albeit in a much richer and more entertaining style. Both the promises and perils of bureaucracy are clearly outlined by Weber. The hope for accountability of public servants and a hope for a “simple and coordinated state” (p. 34), as well as the danger of the same public servants becoming so entangled in paperwork that they cease to serve the public and become automatons following an administrative script were all dealt with by Weber, in what he famously termed the “iron cage of rationalization”. Given the nature of Kafka’s narrative about individuals harassed and restrained by modern administration, one would also expect a stronger reference to the work of Michel Foucault, for example, in the discussion of “dissemination of power by paperwork” (p. 82) (Jon Agar’s Government Machine, 2003, also comes to mind).
Rather, Kafka – unpersuaded by Bruno Latour’s media ethnography – wants to focus on “unconscious processes” (p. 14). His stated methodology of choice is psychoanalysis, in an attempt at “renewing and reinvigorating psychohistory” (p. 16). His use of psychoanalysis aims to stress “paperwork’s symbolic function – its function of telling us about the world and what to do or what not to do to it” (p. 108). Psychohistory is a rather controversial concept among most historians and rarely seen these days. Oddly enough, this is also the case in Kafka’s book. Very rarely does the book make explicit use of psychohistory, an absence which adds to its high level of readability, one might add.
My main criticism of Kafka’s book is therefore not its shortcomings in terms of methodology, but his negligence of the digital. Given the prominence of e-governance and the “paperless office” in today’s political discourse, one wonders why Kafka doesn’t juxtapose the historic cases of bureaucracy running haywire with current debates. His conclusive chapter is indeed rather short (six pages), and he dismisses both e-governance and the paperless office as “wandering myths” (p. 149). While he makes a valid point about the versatility and durability of paper – a circumstance that will in fact guarantee its survival in administration for the time being – many of the issues he discusses demand attention to digital media. After all, Kafka delivers the perfect sound bites for a debate of recent events. His central argument – that without paper, there wouldn’t be any paperwork – is the perfect opener to a discussion about e-governance, that is, paperwork without paper. Even more so is his remark that the committee (in the case of Morizot in chapter one) is a new kind of villain which requires a new kind of hero to defy it (p. 70). While the revelations by Edward Snowden about the NSA spying on people had not yet been made when Kafka’s book was published (2012), the debate about Wikileaks was certainly ongoing. In the eyes of many, Julian Assange and Edward Snowden are exactly that kind of new hero defying the new villain: IT and the novel forms of surveillance and governance it enables.
In summary, Kafka’s book, while extremely well written and a delight to read, leaves one wanting more. His topic – paperwork and its perils – begs for a discussion of the nature and meaning of media and their implications for governance on a broader level.
Lisa Gitelman provides much needed attention to digital media in her book, Paper Knowledge. As a matter of fact, her main topic is the idea of the “document” and its transformation from print to digital. Gitelman follows this transformation from nineteenth century blank form printing, to the appearance of photocopiers in the 1960s, to the emergence, in the 1990s, of digital documents such as Adobe’s Portable Document Format (PDF).
In addition to “document,” the second pillar of Gitelman’s argument is the concept of “genre”, which she uses to uncouple the debate from the ambiguities of the term “media”. The concept of “medium”, widely discussed since Marshall McLuhan’s famous treatise Understanding Media (1964), remains fuzzy and hard to pinpoint. “Better, indeed”, as Gitelman points out, “to admit that no medium has a single, particular logic, while every genre does and is” (p. 9). “Genre”, in her words, thus “is a mode of recognition instantiated in discourse” (p. 2).
Gitelman’s argument circles around these two terms: “document” and “genre”. Documents, according to her definition, are not only imbued with “the social order that they inhabit” and “integral to the ways people think” (p. 5); documents are objects “framed as or entered into evidence” (p. 3). Documents are thus not simply meaningless objects, but are a “genre”, both a “pattern of expression” and “familiar material objects” (p. 3). This holds true for electronic publishing as well.
Like Kafka, Gitelman dismisses the paperless office as myth on several occasions, giving some very good examples to back up her claim. A good deal of her discussion of the photocopier revolves around the fact that people used them to copy computer manuals, such as the early UNIX manuals, leaving photocopies and digital documents deeply intertwined (pp. 98, 110). One wonders, however, whether this simply marks a transition period in which digital devices convenient enough to replace printed books had not yet entered the market. Especially in the field of computer manuals, many of them are happily used in digital formats nowadays.
Her own journey into C19 printing is a prime example of this intertwined space. Gitelman starts with the observation that “the term ‘print’ was always in flux, referring to changing technologies and practices” (p. 7). Where “printer” once referred to a trade, it now refers to a device sitting by the edge of your desk. The same is true for “computer”, obviously: once describing a person doing computations with pencil and paper (and maybe an abacus or mechanical calculator), for three generations or so now it is solely known as a digital, programmable machine. One wonders if the same fate is in store for the document as well; maybe one day “document” will be entirely associated with digital media, just as the word “file” already is largely a synonym for “digital file”. Gitelman makes that point early in her book when she outlines the immediacy of the concept of “document” and its instance as paper for the designers of digital media (p. 4). Gitelman delivers more examples of this by describing, among other things, the transformation of print in the nineteenth century. She does this by showing the role blank forms started to play in public administration; a form of governance only enabled by the ability to print forms in large quantities at a low price, made possible by big steps in printing technology in the 1800s. Blank forms became so ubiquitous – and here Gitelman’s book interfaces nicely with Kafka’s – that it pushed paperwork to new levels. (Indeed Gitleman refers to Kafka’s book on three occasions.) “Blank forms work on their face to rationalize work, but they are also one small part of the way that bureaucracy assumes an objective character” (p. 31). Referring to Max Weber’s point about the perfection of bureaucracy through dehumanization, Gitelman describes the ambition of bureaucracy to rid itself from all emotions and subjective judgements, an ambition epitomized by blank forms.
Again, one wonders why the seminal work of Foucault finds little to no mention in this discussion. Gitelman’s assertion that “the people who designed and deployed them [blank forms] were thinking ahead to their filling in” (p. 24) is exactly the kind of discursive framework that Foucault spoke of as advanced organizer.
Despite not drawing explicitly on Foucault or other philosophers, Gitelman provides further examples of the notion of how technology transformed our handling of resources. She eloquently outlines the challenges of photocopiers to copyright, for example. Copyright was contested in the nineteenth century already by cheap, pirated reprints of popular novels and cartoons. These, however, could be stamped out by the police relatively easy, given the size and cost of printing presses. Photocopiers, on the other hand, through their low price, speed and ubiquity would break down that barrier (p. 108). Here, too, we detect a parallel to current debates about copyright infringements and digital media. Not only has the industry tried to steer legislation to maintain its market share, but the advent of new media/technology has challenged and ultimately transformed our understanding of copyright, and thus its very nature.
Gitelman’s account of the rise of the UNIX operating systems, which was characterized by its nature of copying and annotation (p. 98—99) – both the code and manual – provides obvious similarities to today’s social media and Alvin Toffler’s term of “prosumer”, i.e. the blurring of distinctions between “producer” and “consumer” (p. 150). She gives several examples of this notion, including that of “amateurdom” as a means of overcoming monopolized cultural debates. Where previously discourse was controlled by magazine editors with the “Letters to the Editor” used as a fig-leaf (pp. 78,145), social media now allows everyone to utter their thoughts to the world, for better or worse. Filing – once the primary privilege of bureaucracies (p. 32) – was brought to individuals first by photocopiers and then by computers: “Filing, like reading, has become a means of self-possession” (p. 93).
Paper Knowledge is thus a well-rounded exploration of publishing technology and how it transforms every aspect of our lives, from the way we are governed to the way we read books and news.
Both books are relevant contributions to the debate about the transformation of governance through new media. Both show us the effect that the ubiquity of certain media – paper, print and digital publishing – has on administrative practices. Kafka and Gitelman’s books are thus important both for academic discourse in media studies, as well as for public debates about current challenges in governance. While Kafka’s focus is more on historic cases of bureaucracy gone wild, Gitelman’s approach is somewhat broader. Her favoring of categories like “genre” and “document” over the rather fuzzy “media” is a promising angle which hopefully will inspire future studies in this field.
While both books have their methodological weaknesses, they are also both eloquent, informative and great food for thought. This concerns Kafka’s book to a greater extent. While extremely well written, it leaves much to be desired methodologically. His negligence of e-governance is also a shortcoming, stoked by his tying of modern bureaucracy to the medium of paper.
Comparing the two books is therefore somewhat difficult. In a way, they complement, rather than contrast with, one another. Gitelman picks up the story where Kafka leaves off. Kafka deals with the age of the French Revolution, i.e. the late eighteenth century, while Gitelman starts her treatise in the nineteenth century. Kafka elaborates individual fates entrapped in bureaucracy – the micro level, while Gitelman looks at general issues – the macro level. Readers interested in either level of inquiry might therefore consider both books, or pick the one closest to their own scope of interest to begin.
Alexander von Lünen holds a degree in computer science and a PhD in history (of science and technology), both from the Technical University Darmstadt, Germany. For the last seven years he has been working in Digital Humanities. He is currently a Research Associate at the Centre for Information Management at Loughborough University, UK.
Image credit: “boat” (2012) by zhu jinshi, xuan paper, bamboo and cotton thread, 590 x 137 x 165 in. (1500 x 350 x 420 cm)
image courtesy of the rubell family collection, miami