Book Forum — Nayanika Mookherjee’s The Spectral Wound: Sexual Violence, Public Memories, and the Bangladesh War of 1971 by Todd Meyers
Andrew Brandel has organized an extraordinary and diverse set of commentaries on Nayanika Mookherjee’s The Spectral Wound: Sexual Violence, Public Memories, and the Bangladesh War of 1971 (Duke University Press, 2015). Each intervention is a path that moves outward from Mookherjee’s remarkable study, finding ways through the brambles of memory and history. We hope you enjoy. — Todd Meyers, Associate Editor
Communicating Violence: Reviewing The Spectral Wound
Jennifer L. Culbert
Johns Hopkins University
The Performance of Public Secrets in The Spectral Wound
Johns Hopkins University
Time of the Writing, the Hour of Reading
The Grains of Experience
Johns Hopkins University
For more, Nayanika Mookherjee recently talked with BBC Radio 4. The link can be found here.
Download the PDF of this book forum:
Special Issues! The Publics of Public Health in Africa | Anthropological Interrogations of Evidence-Based Global Health by Anna Zogas
I’d like to highlight a pair of Special Sections in the early 2017 issues of Critical Public Health. The first is “The Publics of Public Health in Africa,” guest edited by Ann H. Kelly, Hayley MacGregor, and Catherine M. Montgomery. The second is “Anthropological Interrogations of Evidence-Based Global Health,” guest edited by Elsa L. Fan and Elanah Uretsky. Here are the abstracts for the articles in both sections!
The Publics of Public Health in Africa
The publics of public health in Africa (open access)
Ann H. Kelly, Hayley MacGregor & Catherine M. Montgomery
Excerpt: How do we understand the public character of public health in contemporary Africa? What are the parameters of community engagement in health care delivery, medical research and disease control programmes? To what extent is public health in Africa a project led by African Governments? Through what political processes and deliberative practices can African publics influence the priorities of research in health sciences and interventions which aim in broad terms to improve the health of such publics? Drawing insight from empirical research conducted with African scientists, nurses, community members, clinical trialists and policy-makers, this special section examines the multiple ways in which the publiccomes into being around public health provisioning and investigation in sub-Saharan Africa, its role and political reach. Collectively, these papers show how contestation and negotiation around different ideas about who the public is and what being public means can lead to the emergence of conflicting understandings, with implications for who and what is seen to represent the public interest, and for the acceptance of research and other interventions.
Communitarian societies and public engagement in public health
Morenike Oluwatoyin Folayan & Bridget Haire
For effective public health interventions in communitarian societies, public engagement must reflect cultural values that focus on preserving collectives, rather than individuals. The case of the Ebola epidemic in West Africa is used to reflect on the drivers and consequences of failure to incorporate local knowledge, local leaders and local ethical values in the adaption of programmes from elsewhere.
Comparison of social resistance to Ebola response in Sierra Leone and Guinea suggests explanations lie in political configurations not culture (open access)
Annie Wilkinson & James Fairhead
Sierra Leone and Guinea share broadly similar cultural worlds, straddling the societies of the Upper Guinea Coast with Islamic West Africa. There was, however, a notable difference in their reactions to the Ebola epidemic. As the epidemic spread in Guinea, acts of violent or everyday resistance to outbreak control measures repeatedly followed, undermining public health attempts to contain the crisis. In Sierra Leone, defiant resistance was rarer. Instead of looking to ‘culture’ to explain patterns of social resistance (as was common in the media and in the discourse of responding public health authorities) a comparison between Sierra Leone and Guinea suggests that explanations lie in divergent political practice and lived experiences of the state. In particular the structures of state authority through which the national epidemic response were organised integrated very differently with trusted institutions in each country. Predicting and addressing social responses to epidemic control measures should assess such political-trust configurations when planning interventions.
Nurses’ perceptions of universal health coverage and its implications for the Kenyan health sector
Adam D. Koon, Lahra Smith, David Ndetei, Victoria Mutiso & Emily Mendenhall
Universal health coverage, comprehensive access to affordable and quality health services, is a key component of the newly adopted 2015 Sustainable Development Goals. Prior to the UN resolution, several countries began incorporating elements of universal health coverage into their domestic policy arenas. In 2013, the newly elected President of Kenya announced initiatives aimed at moving towards universal health coverage, which have proven to be controversial. Little is known about how frontline workers, increasingly politically active and responsible for executing these mandates, view these changes. To understand more about how actors make sense of universal health coverage policies, we conducted an interpretive policy analysis using well-established methods from critical policy studies. This study utilized in-depth semi-structured interviews from a cross section of 60 nurses in three health facilities (public and private) in Kenya. Nurses were found to be largely unfamiliar with universal health coverage and interpreted it in myriad ways. One policy in particular, free maternal health care, was interpreted positively in theory and negatively in practice. Nurses often relied on symbolic language to express powerlessness in the wake of significant health systems reform. Study participants linked many of these frustrations to disorganization in the health sector as well as the changing political landscape in Kenya. These interpretations provide insight into charged policy positions held by frontline workers that threaten to interrupt service delivery and undermine the movement towards universal health coverage in Kenya.
‘$100 Is Not Much To You’: Open Science and neglected accessibilities for scientific research in Africa
Louise Bezuidenhout, Ann H. Kelly, Sabina Leonelli & Brian Rappert
The Open Science (OS) movement promises nothing less than a revolution in the availability of scientific knowledge around the globe. By removing barriers to online data and encouraging publication in Open Access formats and Open Data archives, OS seeks to expand the role, reach and value of research. The promises of OS imply a set of expectations about what different publics hope to gain from research, how accountability and participation can be enhanced, and what makes science public in the first place. This paper presents empirical material from fieldwork undertaken in (bio)chemistry laboratories in Kenya and South Africa to examine the extent to which these ideals can be realized in a sub-Saharan context. To analyse the challenges African researchers face in making use of freely available data, we draw from Amartya Sen’s Capabilities Approach. His theorisations of ‘conversion factors’ helps to understand how seemingly minor economic and social contingencies can hamper the production and (re-)use of online data. In contrast to initiatives that seek to make more data available, we suggest the need to facilitate a more egalitarian engagement with online data resources.
From ‘trial community’ to ‘experimental publics’: how clinical research shapes public participation
Catherine M. Montgomery & Robert Pool
In relation to clinical trials, it is far more usual to speak of the community (singular, static) than of publics (multiple, emergent). Rarely defined, the community is commonly taken to be the existing people in a given area, which the trial will engage, mobilise or sensitise to facilitate successful recruitment and retention. Communities are assumed to pre-exist the research, to be timeless, and to be a whole (sometimes consisting of different parts, referred to as stakeholder groups). In this paper, we suggest a conceptual shift from ‘trial community’ to ‘experimental publics’. Using an empirical case study of an HIV prevention trial in Zambia, we draw out the following key points: firstly, publics do not pre-exist research activities but are enacted in concert with them. Secondly, publics are dynamic and transient. And thirdly, experimental publics are situated at the intersection of various forms of inclusion and exclusion, both locally and globally. Our findings emphasise the need to create long-term forms of participation in science, which transcend both the instrumental goals and the individual timelines of specific trials.
Anthropological Interrogations of Evidence-Based Global Health
In search of results: anthropological interrogations of evidence-based global health (open access)
Elsa L. Fan & Elanah Uretsky
Excerpt: This special section brings together a collection of papers that interrogate evidence itself as an object of inquiry and examines how different forms of evidence are produced, negotiated, and valued across a range of health contexts. In unpacking evidence and the practices implicated in its production, these papers explore the health interventions mobilized in global health from within the positivist methods that dominate its discourse, attending specifically to the blind spots that sometimes emerge from the limited purview of what is recognized as evidence. In particular, all the papers foreground the business rationalities, measurement technologies, funding structures, and regime of actors and agendas that distinguish global health from its predecessor international health (see Brown, Cueto, & Fee, 2006) and its counterpart public health, both of which are bound by national governance and financing. Our papers thus aim to unravel that ‘obscure object of global health’ (Fassin, 2012) that seems to be less about the spatial and geographic boundaries that determine health and more about the financial and political arrangements through which health practices (and inequalities) are configured. The primary concern is often who is setting the standards for measuring health and how these forms of knowledge circulate in ways that shape the health outcomes themselves.
Our papers aim to interrogate the processes that guide this new practice of global health, thus highlighting the ‘perceptual deficits’ (Biehl & Petryna, 2013, p. 5) of paradigms that tend to occlude the complexities and contradictions of health issues in favor of standardized models that seek proof in the language of metrics. Collectively, these papers suggest that a view beyond the evidence reveals programs that struggle to reach their intended beneficiaries and goals, despite the fact that they find ways to demonstrate success.
“Guilty until proven innocent”: the contested use of maternal mortality indicators in global health (open access)
Katerini T. Storeng & Dominique P. Béhague
The MMR – maternal mortality ratio – has risen from obscurity to become a major global health indicator, even appearing as an indicator of progress towards the global Sustainable Development Goals. This has happened despite intractable challenges relating to the measurement of maternal mortality. Even after three decades of measurement innovation, maternal mortality data are widely presumed to be of poor quality, or, as one leading measurement expert has put it, ‘guilty until proven innocent’. This paper explores how and why leading epidemiologists, demographers and statisticians have devoted the better part of the last three decades to producing ever more sophisticated and expensive surveys and mathematical models of globally comparable MMR estimates. The development of better metrics is publicly justified by the need to know which interventions save lives and at what cost. We show, however, that measurement experts’ work has also been driven by the need to secure political priority for safe motherhood and by donors’ need to justify and monitor the results of investment flows. We explore the many effects and consequences of this measurement work, including the eclipsing of attention to strengthening much-needed national health information systems. We analyse this measurement work in relation to broader political and economic changes affecting the global health field, not least the incursion of neoliberal, business-oriented donors such as the World Bank and the Bill and Melinda Gates Foundation whose institutional structures have introduced new forms of administrative oversight and accountability that depend on indicators.
This paper explores how an array of HIV epidemic responders became embroiled in producing quantitative evidence for HIV interventions in India. Based upon extensive ethnographic fieldwork in Karnataka State, I examine the life history of the Gates-funded AIDS initiative in India known as Avahan as a case study to consider the social and political implications of large-scale, standardizing knowledge regimes enacted in the era of global health. Specifically, I analyze a sample of the key material artifacts that are implicated in the production of standardized knowledge in an attempt to illuminate the workings of what I refer to as ‘evidentiary sovereignty’. I argue that documents, forms, and other paperwork used to generate evidence in global health interventions neither merely reflect expert knowledge nor convey information about scientific standards but, rather, are integral to the re-instantiation of sovereignty. The effects of evidentiary sovereignty not only narrow the aperture of global health interventions to overlook the on-the-ground realities that shape health problems, but they also transform the very ground upon which communities responding to HIV epidemics conceive of and enact politics. As highly HIV-affected communities struggle with the bureaucratic demands of intensive form-filling and query agreed upon standards and systems of classification, a form of politicization of knowledge unfurls that pertains to the documents themselves.
Accountability and transparency are considered best practices within development cooperation frameworks characteristic of global health practice today. In this article, I ask: How do accountability and transparency work, and for whom? I develop three main arguments. Drawing on Geissler’s concept ‘unknowing,’ I first demonstrate that global health actors are aware, yet strategically obscure, the instabilities and problematics of data and indicators in Tanzania. Second, I suggest that multiple and contradictory forms of accountability are pursued by global health actors, while this multiplicity is often unspoken in order to render accountability frameworks legitimate to sustain the existing development cooperation system. Third, I argue that foreign and Tanzanian actors within the health sector perpetuate accountability and development cooperation frameworks which are neither cooperative, nor accountable to citizens and purported beneficiaries of aid, because doing so allows actors to pursue interests often unrelated to formal policy goals.
Disease prevention and health care delivery, areas traditionally governed by the nation state and local communities, are increasingly being inhabited by ‘mobile sovereigns’ who carry a global currency of prevention strategies and treatments grounded in the universal standards of scientific evidence. Drawing on ethnographic evidence from research conducted on HIV in southwest China, this paper examines the impact of evidence-based science on the effectiveness of global health programming. It interrogates the intentions of global health partnerships and how the balance of power waged between those with money, science, and technical expertise, and those seeking assistance and resources, influences global health programming. Ultimately, the paper demonstrates the disconnect between the demand for a system of universal standards developed on the basis of scientific evidence and an appreciation for the local context, which shapes the way these standards should be modified for effective implementation of global health programs.
In this paper, I examine the use of performance-based financing to scale-up HIV testing in men who have sex with men, or MSM, by global health initiatives in China. This mechanism, which ties financing directly to the achievement of targets and indicators, assures that measurable results are produced from health interventions and accounts for financial spending. On the one hand, its adoption into HIV programming in China articulates with broader shifts in global health that place currency on particular forms of evidence. At the same time, performance-based financing reshapes how HIV interventions are carried out and what counts in these programmes. The suturing of financing to outputs directs what gets counted and how, and as a consequence leads to the production of measurable results as an end in and of themselves. Based on 22 months of ethnographic research carried out in China, I explore the effects of this mechanism and, in doing so, ask what gets left out in the pursuit of evidence. In particular, I demonstrate how the demand for outputs undermines HIV prevention in MSM, thus risking the very lives these interventions are intended to save.
Before I began graduate school, I worked in water-related public health, and have continued to follow the news around water. This month, some stories (mostly) about water.
Trump signed an order last week to “expedite” the construction of the Dakota Access Pipeline, which jeopardizes the water source for the Standing Rock Sioux Reservation, and for many others who drink water from the Missouri River. Opponents of the pipeline are not surprised, and are gearing up for a fight. Although most of Silicon Valley has come out against Trump (though perhaps in somewhat tepid terms), particularly in light of his recent executive order on immigration, Peter Thiel has been tapped to help Trump pick someone to lead the FDA, with the goal of decreasing its regulations around drug approval process. Vox goes into detail about why that’s a bad idea. (And, before we move away from the topic of Trump’s horrifying first week in office, if you haven’t read CultAnth’s interview with prof of anthropology and lawyer Darryl Li on the travel ban, I recommend it).
California has recently gotten some much-needed rain (and snow) this month. Researchers and farmers there are experimenting with methods, which include flooding fields during the winter, to use this rain to recharge the depleted groundwater aquifers. Also, check out this time lapse of the California drought from 2011-present. The storms also toppled an iconic, if controversial, “drive-through” Sequoia tree, one of the last still standing in a public park.
Meanwhile, the state of Tamil Nadu, in South India, is experiencing its worst monsoon in nearly 150 years, a crisis worsened by the demonetization on November 9 (in which the Rupees 500 and 1000 notes were declared invalid), resulting in the deaths of numerous farmers and recent agitations by farmer’s groups. The state government has recently declared the state officially “drought-hit,” seeking assistance from the central government and offering aid to farmers, and compensation to the families of farmers who have died or committed suicide. Also off the coast of Tamil Nadu, two ships collided, causing an oil spill which is now washing up on Chennai’s Marina Beach.
A project out of Melbourne’s Monash University recently received USD 27 million in funding for a controlled trial testing innovative water infrastructure delivery in urban slum areas in Indonesia and Fiji. And The Guardian has an article about the complications of providing water to thousands of elephants in Hwange National Park in Zimbabwe, which has been hit by a drought.
Lead levels in water tested in Flint, Michigan, have now fallen below federal limits; however, because lead-tainted pipes have yet to be replaced, it is still not safe for residents to drink. 1700 residents have filed suit against the US Environmental Protection Agency for more than USD 722 million for its failure to protect residents from the toxic water. And, here’s an interesting, longish article about the unelected emergency managers who were running Flint at the time of the crisis, and how they contributed to it: Flint, Michigan’s water crisis: what the national media got wrong.
The NY Times has a piece on private equity firms taking over the water management of American municipalities, questioning the fairness in residents seeing their water rates rise while equity firms make returns. And yet, as the article also points out, the US water infrastructure is woefully in need of updating (something Trump has said he’ll address). Updates and improvements to infrastructure, along with other expenditures are to lead to an average increase of a substantial $49 over the next five years in monthly water bills in American households, according to new research out of Michigan State.
For some completely banal news, Vox has a piece on why La Croix sparkling water has suddenly became so trendy, which was probably only interesting for me, as a Wisconsinite who remembers my brother in California calling to excitedly tell me his grocery store now stocks it.
Speaking of Wisconsin, A2 milk (an older, supposedly healthier strain of milk which falls somewhere between health trend and health fad) will soon be available in the US. It is popular in Australia, and interestingly ties into debates and protests in Tamil Nadu about the recent ban (and its subsequent overturning) of a bull-taming sport called jallikattu, and its impact on indigenous cattle breeds.
The Internet is Mostly Bots – The Atlantic
The Moon May Be Covered With Oxygen Beamed From Earth – The Atlantic
Welcome to a new year of Somatosphere’s In the Journals section! Here are some of the articles available in January 2017. Enjoy!
Chronic Subjunctivity, or, How Physicians Use Diabetes and Insomnia to Manage Futures in the United States
Matthew Wolf-Meyer & Celina Callahan-Kapoor
Prognostication has become central to medical practice, offering clinicians and patients views of particular futures enabled by biomedical expertise and technologies. Drawing on research on diabetes care and sleep medicine in the United States, in this article we suggest that subjectivity is increasingly modeled on medical understandings of chronic illness. These chronic conceptions of the self and society instill in individuals an anxiety about future health outcomes that, in turn, motivate practices oriented at self-care to avoid negative health outcomes and particular medical futures. At its most extreme, these anxieties of self-care trouble conceptions of self and social belonging, particularly in the future tense, leading patients and clinicians to consider intergenerational and public health based on the threats that individual patients pose for others.
Decoding the Type 2 Diabetes Epidemic in Rural India (open access)
Matthew Little, Sally Humphries, Kirit Patel & Cate Dewey
Type 2 diabetes mellitus is an escalating public health problem in India, associated with genetic susceptibility, dietary shift, and rapid lifestyle changes. Historically a disease of the urban elite, quantitative studies have recently confirmed rising prevalence rates among marginalized populations in rural India. To analyze the role of cultural and sociopolitical factors in diabetes onset and management, we employed in-depth interviews and focus groups within a rural community of Tamil Nadu. The objectives of the study were to understand sources and extent of health knowledge, diabetes explanatory models, and the impact of illness on individual, social, and familial roles. Several cultural, socioeconomic, and political factors appear to contribute to diabetes in rural regions of India, highlighting the need to address structural inequities and empower individuals to pursue health and well-being on their own terms.
In this article I demonstrate what can be learned from the indigenous healing knowledge and practices of traditional Sasak midwives on Lombok island in eastern Indonesia. I focus on the treatment of infertility, contrasting the differential experiences of Sasak women when they consult traditional midwives and biomedical doctors. Women’s and midwives’ perspectives provide critical insight into how cultural safety is both constituted and compromised in the context of reproductive health care. Core components of cultural safety embedded in the practices of traditional midwives include the treatment of women as embodied subjects rather than objectified bodies, and privileging physical contact as a healing modality. Cultural safety also encompasses respect for women’s privacy and bodily dignity, as well as two-way and narrative communication styles. Local understandings of cultural safety have great potential to improve the routine practices of doctors, particularly in relation to doctor–patient communication and protocols for conducting pelvic exams.
This article examines how two chemical substances are woven into the infrastructure of global health as well as into the social lives of health workers in urban Nicaragua. One chemical is temephos, an organophosphate used to control mosquitoes. The other is chlorine-based products, which are used to disinfect surfaces and water. While global health projects tend to treat these substances as stable objects, there are three ways in which they might be understood as leaky things, implicated in fluid social interactions. First, global health chemicals are tracked through rigid accounting, but because of numerical leakages, they become vehicles for fashioning new forms of concern. Second, chemicals leak structurally: They can be dissolved and reproduced at a molecular level, although that dissolution is never absolute, and that reproduction is not everywhere the same. Third, chemicals leak in a sensory fashion. Sensory interactions with chemicals produce an entanglement of knowledge about bodies and environments.
Discourses on the Toxic Effects of Internal Chemical Contamination in Catalonia, Spain
Cristina Larrea-Killinger, Araceli Muñoz, Jaume Mascaró, Eva Zafra & Miquel Porta
Human exposure to and contamination by environmental toxic compounds generates discourses and practices that merit greater attention. In this article, we assess internal chemical contamination and the risk of toxic effects as an experience related to the production of meaning in everyday life. Drawing on the analysis of semantic networks of narratives from semi-structured interviews conducted with 43 informants in Catalonia, Spain, we consider participants’ perceptions of the health risks of toxic compounds, including social discourses on exposure, toxicity, and internal chemical contamination, and on responsibilities, consequences, and proposed strategies for controlling toxic compounds. Informants’ narratives on the relationships between nature and nurture suggest that they no longer perceive rigid boundaries separating the human body from the external environment and its chemical pollutants.
Drawing from an ethnography of HIV care in Santa Cruz, Bolivia, in this article I explore how the social imaginary surrounding gender relations shapes men’s experiences of seeking care for and living with HIV. Popular understandings of gender relations, which draw heavily on the machismo concept, intersect with a global health master narrative that frames women as victims in the AIDS epidemic in a way that generates a strong sentiment of blaming machismo within local HIV/AIDS-related services. Statements such as, “it’s because of machismo” are used to explain away epidemiological trends. Participant observation in the context of HIV care, coupled with illness narrative interviews, illuminate how blaming machismo shapes men’s experiences of care and the ways that they feel excluded from various forms of support. Thus, the illness experiences of men with HIV problematize the machismo concept and how it is drawn upon in the context of care.
There is also a themed section of Medical Anthropology titled “Between Biopolitical Governance and Care: Rethinking Health, Self, and Social Welfare in East Asia.” See the abstracts here.
Negotiating and valuing spaces: The discourse of space and ‘home’ in care homes
Andrea Kenkmann, Fiona Poland, Diane Burns, Paula Hyde, Anne Killett
This paper examines how space in care homes is experienced and negotiated by people who live and work in them. The analysis of qualitative data of five in-depth case studies of care homes in England revealed three key ways in which space is negotiated: a) the way in which values affect interactions inside versus outside the care home environment, b) the negotiation of boundaries and domains within the homes, and c) the sense of being at ‘home’. The paper illuminates how the design of the buildings and organisational factors can reinforce or bridge dichotomies between inside and outside spaces. Residents’ abilities to re-negotiate boundaries, domains and communal spaces within homes are shown to be affected by organisational factors such as priorities of staff members. Despite ‘home’ being a common discourse, the spaces within care homes were often organised, ordered and experienced as two distinct, co-present worlds: the dwelling place of residents and the workplace of staff.
Managing mosquito spaces: Citizen self-governance of disease vectors in a desert landscape
Nicolena vonHedemann, Paul Robbins, Melinda K. Butterworth, Katheryn Landau, Cory W. Morin
Public health agencies’ strategies to control disease vectors have increasingly included “soft” mosquito management programs that depend on citizen education and changing homeowner behaviors. In an effort to understand public responses to such campaigns, this research assesses the case of Tucson, Arizona, where West Nile virus presents a serious health risk and where management efforts have focused on public responsibility for mosquito control. Using surveys, interviews, and focus groups, we conclude that citizens have internalized responsibilities for mosquito management but also expect public management of parks and waterways while tending to reject the state’s interference with privately owned parcels. Resident preferences for individualized mosquito management hinge on the belief that mosquito-borne diseases are not a large threat, a pervasive distrust of state management, and a fear of the assumed use of aerial pesticides by state managers. Opinions on who is responsible for mosquitoes hinge on both perceptions of mosquito ecology and territorial boundaries, with implications for future disease outbreaks.
The uses and implications of standards in general practice consultations (open access)
Maria Laura Lippert, Susanne Reventlow, Marius Brostrøm Kousgaard
Quality standards play an increasingly important role in primary care through their inscription in various technologies for improving professional practice. While ‘hard’ biomedical standards have been the most common and debated, current quality development initiatives increasingly seek to include standards for the ‘softer’ aspects of care. This article explores the consequences of both kinds of quality standards for chronic care consultations. The article presents findings from an explorative qualitative field study in Danish general practice where a standardized technology for quality development has been introduced. Data from semi-structured interviews and observations among 17 general practitioners were analysed using an iterative analytical approach, which served to identify important variations in the uses and impacts of the technology. The most pronounced impact of the technology was observed among general practitioners who strictly adhered to the procedural standards on the interactional aspects of care. Thus, when allowed to function as an overall frame for consultations, those standards supported adherence to general recommendations regarding which elements to be included in chronic disease consultations. However, at the same time, adherence to those standards was observed to narrow the focus of doctor–patient dialogues and to divert general practitioners’ attention from patients’ personal concerns. Similar consequences of quality standards have previously been framed as manifestations of an inherent conflict between principles of patient-centredness and formal biomedical quality standards. However, this study suggests that standards on the ‘softer’ aspects of care may just as well interfere with a clinical approach relying on situated and attentive interactions with patients.
Treating the binge or the (fat) body? Representations of fatness in a gold standard psychological treatment manual for binge eating disorder (open access)
Amy Brown-Bowers, Ashley Ward, Nicole Cormier
This article reports the results of a Foucauldian-informed discourse analysis exploring representations of fatness embedded within an empirically based psychological treatment manual for binge eating disorder, a condition characterized by overvaluation of weight and shape. Analyses indicate that the manual prioritizes weight loss with relatively less emphasis placed on treating the diagnostic symptoms and underlying mechanisms of binge eating disorder. We raise critical concerns about these observations and link our findings to mainstream psychology’s adoption of the medical framing of fatness as obesity within the “gold standard” approach to intervention. We recommend that psychology as a discipline abandons the weight loss imperative associated with binge eating disorder and fat bodies. We recommend that practitioners locate the problem of fat shame in society as opposed to the individual person’s body and provide individuals with tools to identify and resist fat stigma and oppression, rather than provide them with tools to reshape their bodies.
Understanding the health of lorry drivers in context: A critical discourse analysis (open access)
Nick Caddick, Veronica Varela-Mato, Myra A Nimmo, Stacey Clemes, Tom Yates, James A King
This article moves beyond previous attempts to understand health problems in the lives of professional lorry drivers by placing the study of drivers’ health in a wider social and cultural context. A combination of methods including focus groups, interviews and observations were used to collect data from a group of 24 lorry drivers working at a large transport company in the United Kingdom. Employing a critical discourse analysis, we identified the dominant discourses and subject positions shaping the formation of drivers’ health and lifestyle choices. This analysis was systematically combined with an exploration of the gendered ways in which an almost exclusively male workforce talked about health. Findings revealed that drivers were constituted within a neoliberal economic discourse, which is reflective of the broader social structure, and which partly restricted drivers’ opportunities for healthy living. Concurrently, drivers adopted the subject position of ‘average man’ as a way of defending their personal and masculine status in regards to health and to justify jettisoning approaches to healthy living that were deemed too extreme or irrational in the face of the constraints of their working lives. Suggestions for driver health promotion include refocusing on the social and cultural – rather than individual – underpinnings of driver health issues and a move away from moralistic approaches to health promotion.
Using liminality to understand mothers’ experiences of long-term breastfeeding: ‘Betwixt and between’, and ‘matter out of place’ (open access)
Sally Dowling, David Pontin
Breastmilk is widely considered as the optimum nutrition source for babies and an important factor in both improving public health and reducing health inequalities. Current international/national policy supports long-term breastfeeding. UK breastfeeding initiation rates are high but rapidly decline, and the numbers breastfeeding in the second year and beyond are unknown. This study used the concept of liminality to explore the experiences of a group of women breastfeeding long-term in the United Kingdom, building on Mahon-Daly and Andrews. Over 80 breastfeeding women were included within the study, which used micro-ethnographic methods (participant observation in breastfeeding support groups, face-to-face interviews and online asynchronous interviews via email). Findings about women’s experiences are congruent with the existing literature, although it is mostly dated and from outside the United Kingdom. Liminality was found to be useful in providing insight into women’s experiences of long-term breastfeeding in relation to both time and place. Understanding women’s experience of breastfeeding beyond current usual norms can be used to inform work with breastfeeding mothers and to encourage more women to breastfeed for longer.
What led health professionals to study and practise acupuncture in Spain? (open access)
Esther García-Escamilla, Beatriz Rodríguez-Martín Vicente Martínez-Vizcaíno
Acupuncture is the most widespread practice of Traditional Chinese Medicine in the Western world. This confers special relevance to the experiences and circumstances of life to explain the health-illness process. Recent research has reported an increasing interest of Western health professionals in its practice. The aim of this study was to map and understand the motivation of health professionals to study and practise acupuncture in Spain. A total of 27 in-depth interviews were conducted with Spanish health professionals trained in acupuncture. Participants were selected following a theoretical sampling. Grounded theory dimensional analysis guided this research in order to obtain a theoretical explanation of the motivations of health professionals to study and practise acupuncture. Their motivations were focused on six categories: humanisation of medicine, acquiring additional therapeutic resources, efficacy and far-reaching healing potential of acupuncture, attraction to acupuncture philosophy, external influences (other professionals and relevant sources of information) and work-related motivation. Our results show that health professionals were attracted to acupuncture because of the Traditional Chinese Medicine worldview (a philosophical approach) and therapeutic benefits of acupuncture (a practical approach). Acupuncture offers the possibility to improve the healthcare assistance by transcending the reification of human beings resulting from the pre-eminence of the biomedical paradigm and facilitating cooperation between disciplines. Participants consider acupuncture as a complete medicine, not merely as a technique, and highlight the importance of traditional Chinese concepts to practise it.
Evidence of the efficacy of HIV treatment as prevention (TasP) precipitated a highly optimistic global response and a radical redesign of HIV policy. Sociologists and others have framed TasP within promissory or enterprising discourses which require HIV prevention planners and people with HIV to engage in anticipatory assessments of risk and uncertainty. In 2013, I conducted focus groups with people with HIV in London, UK, to explore their understandings and anticipations of TasP. An environment of economic constraint obliged participants to triage clinical need and presentation, and they expressed scepticism about the sustainability of pharmaceutical investment in treatment innovation. These perceptions were informed by an embodied knowledge of HIV which implies a construction of health as a form of capital that is finite and must be conserved. This is contrasted with a biomedical construction of health as a form of capital that can be exponentially generated through investment. The imperative of conservation entailed by people with HIV’s anticipations contrasts with the speculative economy of biomedical production entailed in planners’ anticipations of TasP. Rather than researching ‘TasP acceptability’ and considering whether people with HIV’s behaviours constitute an obstacle to TasP’s effectiveness, we should recognise that people with HIV are already involved in shaping what TasP is, what it will be and ultimately how it ‘works’.
Young bisexual women’s perspectives on the relationship between bisexual stigma, mental health, and sexual health: a qualitative study
Corey E. Flanders, Cheryl Dobinson & Carmen Logie
Young bisexual women experience worse mental and sexual health outcomes in comparison to their heterosexual and lesbian peers. These disparities are associated with stigma and devaluation of bisexual identities. The current paper addresses a community-based focus group project in which participants discussed bisexual stigma in regard to bisexual erasure and other stereotypes. Specifically, participants detailed experiences of feeling pressured to provide evidence of their bisexual identity, modifying their relationship or sexual behavior to conform to these expectations, as well as feeling excluded from queer community. Further, participants discussed how these experiences were related to decreased mental and sexual health. Future research should further investigate the relationship between bisexual stigma, pressure to provide evidence of bisexual identity, and negative mental and sexual health outcomes.
Much research has documented disparities in access to and uses of health care services in the US. With the rise of genomic medicine and its use of complex technology, some scholars are concerned that such inequalities of health care will not only continue but also grow. Drawing on 27 semi-structured interviews with front-line genetic workers – master’s-level genetic counselors – this qualitative study explores the factors they view as contributing to variable uptake of genetic health services among US population groups. Patient-centered factors such as attitudes, norms, and education were perceived by some genetic counselors as explanations for disparities in uptake of genetic services. However, genetic counselors more frequently discussed structural and institutional factors (e.g. cost, insurance, type and location of hospital/clinic, and/or staffing issues) when accounting for different rates of usage of genetic services among populations. The prominence of structural impediments to access found in genetic counselors’ narratives about population differences in the uptake of genetic services suggests that genetic medicine could exacerbate rather than ameliorate health disparities in the US.
A Feminist Quality Appraisal Tool: exposing gender bias and gender inequities in health research
Tessa Morgan, Lisa Ann Williams & Merryn Gott
Quality appraisal tools used in systematic reviews to evaluate health literature do not adequately address issues related to gender. This oversight is significant because disparities between genders have been identified as a major health equity concern, and systematic reviews are regarded as a powerful means for informing policy that could redress gender inequities. In this paper, we present our Feminist Quality Appraisal Tool that offers researchers a template to undertake a comprehensive gendered analysis of studies they review. Informed by a feminist perspective, the tool addresses issues of power, gender and inequity, thereby giving researchers the means to interrogate the scientific rigour of systematic reviews that focus on gender. Specifically, our tool outlines ways gender can be critically examined in terms of study design, data collection, analysis, discussion and recommendations. We argue that this tool has the potential to improve the provision of public health by providing solid understandings and critical reflections on the reasons why women continue to face barriers in their access to optimal health care.
Reconciling community-based Indigenous research and academic practices: Knowing principles is not always enough
Melody E. Morton Ninomiya, Nathaniel J. Pollock
Historically, Indigenous health research in Canada has failed to engage Indigenous peoples and communities as primary stakeholders of research evidence. Increasingly, research ethics and methodologies are being positioned as tools for Indigenous self-determination. In response, mainstream institutions have developed new ethical principles for research involving Indigenous people. While these transformations are necessary steps towards re-orienting research practices, they are not prescriptive. In this paper, we make visible three dilemmas from a case study in which Indigenous health research frameworks provided limited guidance or were unclear about how to balance community priorities with Indigenous research principles. We also discuss the strategies used to resolve each of these dilemmas. We draw examples from a project that examined the lived experiences of children and youth living with FASD and their caregivers. This project was conducted in collaboration with Sheshatshiu Innu First Nation, an Indigenous community in Labrador, Canada. In doing so, we argue that knowing the key guiding principles in Indigenous health research is not always enough, and that the ‘real-world’ context of practices and relationships can lead to conflicts that are not easily resolved with adherence to these principles.
Two approaches, one problem: Cultural constructions of type II diabetes in an indigenous community in Yucatán, Mexico
Sarah M. Frank, T. Elizabeth Durden
The emerging epidemic of obesity and type II diabetes in Mexico has recently propelled the nation into the public health spotlight. In the state of Yucatán, the experience of diabetes is greatly impacted by two cultural constructions of disease. In this setting, elements of Yucatec Mayan health practices as well as the biomedical model affect the approach to type II diabetes. Both frameworks offer unique understandings of the etiology of diabetes and recommend different ways to manage the condition. Based on in-depth and semi-structured interviews with both community members and clinicians, the present study seeks to understand how diabetes is understood and treated in indigenous settings in rural Yucatán. We explore the context in which community members navigate between locally available healthcare options, choose one over the other, or incorporate strategies from both into their diabetes care regimens. The tension between indigenous community members and their biomedical healthcare providers, the changing food environment of this community, and the persistence of traditional gender constructions affect the management of type II diabetes and its associated symptoms.
Public health and public trust: Survey evidence from the Ebola Virus Disease epidemic in Liberia
Robert A. Blair, Benjamin S. Morse, Lily L. Tsai
Trust in government has long been viewed as an important determinant of citizens’ compliance with public health policies, especially in times of crisis. Yet evidence on this relationship remains scarce, particularly in the developing world. We use results from a representative survey conducted during the 2014–15 Ebola Virus Disease (EVD) epidemic in Monrovia, Liberia to assess the relationship between trust in government and compliance with EVD control interventions. We find that respondents who expressed low trust in government were much less likely to take precautions against EVD in their homes, or to abide by government-mandated social distancing mechanisms designed to contain the spread of the virus. They were also much less likely to support potentially contentious control policies, such as “safe burial” of EVD-infected bodies. Contrary to stereotypes, we find no evidence that respondents who distrusted government were any more or less likely to understand EVD’s symptoms and transmission pathways. While only correlational, these results suggest that respondents who refused to comply may have done so not because they failed to understand how EVD is transmitted, but rather because they did not trust the capacity or integrity of government institutions to recommend precautions and implement policies to slow EVD’s spread. We also find that respondents who experienced hardships during the epidemic expressed less trust in government than those who did not, suggesting the possibility of a vicious cycle between distrust, non-compliance, hardships and further distrust. Finally, we find that respondents who trusted international non-governmental organizations (INGOs) were no more or less likely to support or comply with EVD control policies, suggesting that while INGOs can contribute in indispensable ways to crisis response, they cannot substitute for government institutions in the eyes of citizens. We conclude by discussing the implications of our findings for future public health crises.
The distribution of work, knowledge, and responsibilities between doctors and nurses is a longstanding object of interest for medical sociologists. Whereas the strategies through which nurses and doctors construct their professional boundary have been thoroughly examined, little is known about why the regulation of the medical-nursing boundary varies across care settings. In the article, I argue that this gap in knowledge can be attributed to insufficient examination of the ‘negotiation context’, namely the features of the social and organisational environment that directly affect doctor-nurse boundary negotiations. Adopting a negotiated order perspective, and drawing data from a hospital ethnography, the article describes the different ways of constructing the medical-nursing boundary (separating, replacing, and intersecting) which were observed in three different care settings (a neurology ward, a neurosurgical ward, and an intensive care unit). Constant comparison of the observed interactional patterns led to the identification of three factors that significantly affected the construction of the medical-nursing boundary, specifically: patients’ state of awareness, the type of clinical approach adopted by nurses and doctors, and the level of acuity on the ward. The article advances our knowledge of the medical-nursing boundary by shedding light on its flexible and contextual nature and by adding further nuance to the boundary-blurring/boundary-reinforcing dichotomy. New features of the ‘negotiation context’ are identified that enable more convincing explanations of why the medical-nursing boundary varies across care settings. Finally, the study advances the negotiated order theory by offering a framework for considering the structural differences that shape local negotiations.
Gifts and influence: Conflict of interest policies and prescribing of psychotropic medications in the United States
Marissa King, Peter S. Bearman
The pharmaceutical industry spends roughly 15 billion dollars annually on detailing – providing gifts, information, samples, trips, honoraria and other inducements – to physicians in order to encourage them to prescribe their drugs. In response, several states in the United States adopted policies that restrict detailing. Some states banned gifts from pharmaceutical companies to doctors, other states simply required physicians to disclose the gifts they receive, while most states allowed unrestricted detailing. We exploit this geographic variation to examine the relationship between gift regulation and the diffusion of four newly marketed medications. Using a dataset that captures 189 million psychotropic prescriptions written between 2005 and 2009, we find that uptake of new costly medications was significantly lower in states with marketing regulation than in areas that allowed unrestricted pharmaceutical marketing. In states with gift bans, we observed reductions in market shares ranging from 39% to 83%. Policies banning or restricting gifts were associated with the largest reductions in uptake. Disclosure policies were associated with a significantly smaller reduction in prescribing than gift bans and gift restrictions. In states that ban gift-giving, peer influence substituted for pharmaceutical detailing when a relatively beneficial drug came to market and provided a less biased channel for physicians to learn about new medications. Our work suggests that policies banning or limiting gifts from pharmaceutical representatives to doctors are likely to be more effective than disclosure policies alone.
Cesarean section rates have risen dramatically in China within the past 25 years, particularly driven by non-medical factors and maternal requests. One major reason women request cesareans is the fear of labor pain, in a country where a minority of women are given any form of pain relief during labor. Drawing upon ethnographic fieldwork and in-depth interviews with 26 postpartum women and 8 providers at a Shanghai district hospital in June and July of 2015, this article elucidates how perceptions of labor pain and the environment of pain relief constructs the cesarean on maternal request. In particular, many women feared labor pain and, in a context without effective pharmacological pain relief or social support during labor, they came to view cesarean sections as a way to negotiate their labor pain. In some cases, women would request cesarean sections during labor as an expression of their pain and a call for a response to their suffering. However, physicians, under recent state policy, deny such requests, particularly as they do not view pain as a reasonable indication for a cesarean birth. This disconnect leads to a mismatch in goals for the experience of birth. To reduce unnecessary C-sections, policy makers should instead address the lack of pain relief during childbirth and develop other means of improving the childbirth experience that may relieve maternal anxiety, such as allowing family members to support the laboring woman and integrating a midwifery model for low-risk births within China’s maternal-services system.
People with dementia can live meaningful and engaged lives with the appropriate social and physical supports in place. There has been relatively little research, however, on the experiences and desires of people with dementia themselves as they negotiate informal and formal support in rural and small town settings. In this article, we draw on semi-structured interviews with 46 community-dwelling people with dementia and 43 partners in care in rural Ontario, Canada to examine how people with dementia relate to and within their communities as well as their perceptions of community support services. We identify the continued contributions of people with dementia to their own care and the care of others as well as common social, cultural, and organizational factors related to delayed service use and refusal to use particular services. We argue that care is “not there yet” for people in the earlier stages of dementia and that more attention needs to be paid to what people with dementia can offer their communities as well as the role of culture and gender in developing support. Our findings make an important contribution to understanding the experience of dementia in rural and small town Canada, which is relevant to rural healthcare and community support in other industrialized countries.
Family social capital and health – a systematic review and redirection (open access)
Elena Carrillo Alvarez, Ichiro Kawachi, Jordi Riera Romani
The level (or scale) at which social capital can be conceptualised and measured ranges potentially from the macro-level (regional or country level), to the meso-level (neighbourhoods, workplaces, schools), down to the individual level. However, one glaring gap in the conceptualisation of social capital within the empirical literature has been the level of the family. Our aim in this review is to examine the family as the ‘missing level’ in studies on social capital and health. To do so, we conducted a systematic review on the use and measurement of this notion in the health literature, with the final intention of articulating a direction for future research in the field. Our findings are consistent with the notion that family social capital is multidimensional and that its components have distinct effects on health outcomes. Further investigation is needed to understand the mechanisms through which family social capital is related to health, as well as determining the most valid ways to measure family social capital.
Among friends: a qualitative exploration of the role of peers in young people’s alcohol use using Bourdieu’s concepts of habitus, field and capital (open access)
Georgie J. MacArthur, Nina Jacob, Pandora Pound, Matthew Hickman, Rona Campbell
Drinking is viewed by young people as a predominantly social activity which provides an opportunity for entertainment and bonding with friends. Using Bourdieu’s concepts of habitus, field and capital, this article explores young people’s attitudes and beliefs around alcohol use, influences on behaviour, and the role of peers, with a view to informing the development of preventive interventions. Semi-structured interviews were conducted with 28 young people aged 18–20 in the south west of England. We describe how friends were integral in drinking experiences, and drinking with friends was equated with fun and enjoyment. In this way, the desire for social and symbolic capital appeared to be a key motivator for adolescent drinking. Critically, however, wider cultural norms played the predominant role in shaping behaviour, via the internalisation of widely accepted practice and the subsequent externalisation of norms through the habitus. Applying Bourdieu’s theory suggests that population-level interventions that regulate alcohol consumption, and thus disrupt the field, are likely to facilitate behaviour change among young people by driving a response in habitus.
Determinants of dietary compliance among Italian children: disentangling the effect of social origins using Bourdieu’s cultural capital theory (open access)
Filippo Oncini, Raffaele Guetto
Making use of Bourdieu’s threefold conceptualisation of cultural capital, this paper examines and disentangles the association between social origins and children’s food consumption. The aim of the work is twofold. Using data from the Multipurpose survey on daily life conducted by Istat (2009–2012), we first show that children’s compliance with dietary advice is indeed influenced by their social origins, but more so in terms of familial cultural resources than economic ones. All types of cultural capital enhance the quality of children’s nutrition. Second, we concentrate on the role of the school canteen as a child-centred investment strategy intended to reduce health inequalities by providing a wholesome lunch for all children. Although the school meal effectively improves the degree of dietary compliance, the results indicate that this public service is less often used by children from lower social origins. Moreover, we do not find any equalising effect of the school meal on the diets of disadvantaged children. These findings are discussed in light of future research on sociology of health stratification and health promotion programmes.
‘Good’ patient/‘bad’ patient: clinical learning and the entrenching of inequality (open access)
This article develops sociological understanding of the reproduction of inequality in medicine. The material is drawn from a longitudinal study of student experiences of clinical learning that entailed 72 qualitative in-depth interviews with 27 medical students from five medical schools in the USA. To highlight the subtle, yet powerful, ways in which inequality gets entrenched, this article analyses ideas of the ‘good’ and the ‘bad’ patient. Bad patients question not only biomedical knowledge but also medical students’ commitment to helping people. Good patients engage with medical students in a manner that upholds biomedical knowledge and enables students to assume the role of the healer and the expert. At the same time, good patients possess cultural skills that align with those of medical practitioners. This alignment is, furthermore, central to definitions of the good patient. Distinctions drawn between good and bad patients thus both embody as well as enforce social inequality. The subtle reproduction of inequality is, however, difficult to discern because judgements about patients entwine with emotion.
The changing body work of abortion: a qualitative study of the experiences of health professionals (open access)
Carrie Purcell, Sharon Cameron, Julia Lawton, Anna Glasier, Jeni Harden
‘Body work’ has emerged at the nexus of sociologies of work and bodies as a means of conceptualising work focusing on the bodies of others. This article utilises this analytical tool in the context of contemporary abortion work. Abortion provision in Britain has seen significant change in the last 25 years, paralleling developments in medical methods, and the option for women under nine weeks’ gestation to complete the abortion at home. These shifts raise questions around how abortion work is experienced by those who do it. We apply the conceptual lens of body work to data drawn from in-depth interviews with 37 health professionals involved in abortion provision, to draw out the character, constraints and challenges of contemporary abortion work. We explore three key themes: the instrumental role of emotional labour in facilitating body work; the temporality of abortion work; and bodily proximity, co-presence and changes in provision. By drawing on the conceptual frame of body work, we illuminate the dynamics of contemporary abortion work in Britain and, by introducing the idea of ‘body work-by-proxy’, highlight ways in which this context can be used to expand the conceptual boundaries of body work.
Disentangling patient and public involvement in healthcare decisions: why the difference matters (open access)
Mio Fredriksson, Jonathan Q. Tritter
Patient and public involvement has become an integral aspect of many developed health systems and is judged to be an essential driver for reform. However, little attention has been paid to the distinctions between patients and the public, and the views of patients are often seen to encompass those of the general public. Using an ideal-type approach, we analyse crucial distinctions between patient involvement and public involvement using examples from Sweden and England. We highlight that patients have sectional interests as health service users in contrast to citizens who engage as a public policy agent reflecting societal interests. Patients draw on experiential knowledge and focus on output legitimacy and performance accountability, aim at typical representativeness, and a direct responsiveness to individual needs and preferences. In contrast, the public contributes with collective perspectives generated from diversity, centres on input legitimacy achieved through statistical representativeness, democratic accountability and indirect responsiveness to general citizen preferences. Thus, using patients as proxies for the public fails to achieve intended goals and benefits of involvement. We conclude that understanding and measuring the impact of patient and public involvement can only develop with the application of a clearer comprehension of the differences.
From medicalisation to riskisation: governing early childhood development (open access)
This study investigates the transformation of the regime of governing child developmental conditions in Taiwan. With the shift from a medicalised regime of disabilities to a riskised regime of developmental delays, early childhood development has become the primary focus of governance. Drawing upon a multi-sited ethnography to follow the process by which the ideas and practices of early intervention are imported and adapted to local conditions, I elucidate how and why the new subject, that is, children with developmental risks and their families, emerged with the concomitant re-configuration of governance. By using three riskisation strategies, namely, the truth claim of prevalence rate of developmental delays, mass screening with standardised instruments, and identification of risky families, child development is problematised collectively and surveilled individually. Within this new regime, every young child is no longer considered either normal or disabled but is rather located within a developmental risk continuum and subject to relentless medical and social interventions. While ‘returning to normal’ becomes the predominant goal of early intervention for developmentally delayed children, disabilities are increasingly enacted negatively and considered embodying an undesirable state of being. These changing delimitations and subsequent interventions have profoundly reshaped our understanding of the child, normality and disability.
How differences matter: tracing diversity practices in obesity treatment and health promotion (open access)
Ulrike Felt, Kay Felder, Michael Penkler
Diversity has become a buzzword in medical care, denoting a re-evaluation of what it means to attend to differences among human bodies and lives. Questions about what types of differences matter and how they should be defined have become important normative and analytical challenges. Drawing on two case studies, we show how differences between patients and patient-collectives are not simply waiting to be recognised and addressed but also enacted within situated healthcare practices. Although concerns with diversity are present in both cases, they take different forms. In a Viennese health–promotion project for obese clients, care practices are both based on and reproduce large-scale categories that divide the population into distinct subgroups with specific needs. Conversely, in an outpatient clinic for bariatric surgery patients, a technical fix-oriented procedure leads to concerns over diversity becoming an add-on realised by tending to each patient’s idiosyncrasies and personal stories. By tracing the practices of diversity and the tensions they produce, we show how classifications and understandings of human difference are based on infrastructures that enable and constrain them. Furthermore, we discuss how they become consequential in healthcare, thereby indicating the importance of remaining reflexive about the political implications of diversity discourse and practice.
Stratified, precision or personalised medicine? Cancer services in the ‘real world’ of a London hospital (open access)
Sophie Day, R Charles Coombes, Louise McGrath-Lone, Claudia Schoenborn, Helen Ward
We conducted ethnographic research in collaboration with a large, research-intensive London breast cancer service in 2013–2014 so as to understand the practices and potential effects of stratified medicine. Stratified medicine is often seen as a synonym for both personalised and precision medicine but these three terms, we found, also related to distinct facets of treatment and care. Personalised medicine is the term adopted for the developing 2016 NHS England Strategy, in which breast cancer care is considered a prime example of improved biological precision and better patient outcomes. We asked how this biologically stratified medicine affected wider relations of care and treatment. We interviewed formally 33 patients and 23 of their carers, including healthcare workers; attended meetings associated with service improvements, medical decision-making, public engagement, and scientific developments as well as following patients through waiting rooms, clinical consultations and other settings. We found that the translation of new protocols based on biological research introduced further complications into an already-complex patient pathway. Combinations of new and historic forms of stratification had an impact on almost all patients, carers and staff, resulting in care that often felt less rather than more personal.
Danger, Crime and Rights: A Conversation between Michel Foucault and Jonathan Simon (open access)
Michel Foucault, Jonathan Simon, Stuart Elden
This article is a transcript of a conversation between Michel Foucault and Jonathan Simon in San Francisco in October 1983. It has never previously been published and is transcribed on the basis of a tape recording made at the time. Foucault and Simon begin with a discussion of Foucault’s 1977 lecture ‘About the Concept of the “Dangerous Individual” in 19th-Century Legal Psychiatry’, and move to a discussion of notions of danger, psychiatric expertise in the prosecution cases, crime, responsibility and rights in the US and French legal systems. The transcription is accompanied by a brief contextualizing introduction and a retrospective comment by Simon.
Biopolitics, Thanatopolitics and the Right to Life (open access)
Muhammad Ali Nasir
This article focuses on the interrelationship of law and life in human rights. It does this in order to theorize the normative status of contemporary biopower. To do this, the case law of Article 2 on the right to life of the European Convention on Human Rights is analysed. It argues that the juridical interpretation and application of the right to life produces a differentiated governmental management of life. It is established that: 1) Article 2 orients governmental techniques to lives in order to ensure that both deprivation and protection of lives is lawful; 2) A proper application of Article 2 grounds itself on a proper discrimination of lives which causes Article 2 to be applied universally but not uniformly to all juridical subjects; 3) The jurisprudence of Article 2 is theoretically appreciable only in a ‘politics of life’. Finally, the article ends with a plea to analyse other fundamental human rights in the context of ‘biopolitical governmentality’.
Social Justice has put together an open access collection of blogs-articles on the social justice impact of Trump, which includes a brief review of Trump’s health care agenda.
Trump’s Health Care Agenda (open access)
The nomination of Tom Price to be Secretary of Health and Human Services and of Seema Verma to run the Medicare and Medicaid programs ensures a major attack on health services for the people of the United States. On health care, there is agreement between the Steve Bannon/Tea Party faction of the Trump pre-administration and the Paul Ryan/traditional Republican faction: they both want to repeal the Affordable Care Act (ACA). This agreement will affect both the individual mandate and the Medicaid expansion portions of the ACA. On the other major healthcare issue, the future of Medicare, the Trump factions disagree. The Paul Ryan faction and Tom Price hope to convert Medicaid into a privatized voucher system, whereas Trump’s pre-election statements—supported by much of his base—suggest that Trump wants to leave Medicare alone. This review of Trump’s health care agenda looks at the ACA’s individual mandate, the ACA’s Medicaid expansion, and the future of Medicare.
Alice Street’s “Biomedicine in an Unstable Place: Infrastructure and Personhood in a Papua New Guinean Hospital” by Mackenzie Cramblit
Biomedicine in an Unstable Place: Infrastructure and Personhood in a Papua New Guinean Hospital
by Alice Street
Duke University Press, 2014, 204 pages
Social anthropologist Alice Street’s first book is an ambitious ethnography of personhood and recognition in Madang Hospital, an under-resourced provincial hospital in Papua New Guinea. The book shows how doctors, nurses, and patients endeavor to make themselves “visible” to others in order to initiate relations of care at multiple scales, while also emphasizing the uncertainties of diagnosis and treatment within an institution subject to perennial shortages of staff and supplies.
The book’s main section explores the treatment and experience of disease within the public ward of Madang Hospital. Street introduces the concept of “biomedical uncertainty” to describe how doctors must forego conclusive diagnosis and embrace a pragmatic approach to treating patients in an under-resourced setting. That this kitchen-sink method is the one best suited to the circumstances at Madang Hospital seems reasonable – after all, the doctors themselves say so. But Street’s optimistic claim that this “uncertainty…is another productive form that biomedical knowledge can take” and her apparent endorsement of what she terms “technologies of not knowing” feels out of step with the real ways doctors in this environment struggle to produce care amidst difficult constraints (111). What should be commended is the Madang doctors’ commitment to take action in spite of the prevailing biomedical uncertainty in their ward, not the uncertainty itself – the unenviable result of chronic resource shortages. It would seem essential to distinguish between this kind of uncertainty on the one hand and a positive strategy of diagnostic suppleness or nonclosure on the other. When, in other words, is biomedical uncertainty a stance that doctors actively choose, and when is it an unwelcome imposition?
The book is most compelling when it combines insights from the fields of New Melanesian Ethnography and medical anthropology to show how social inequalities present as differential possibilities of care within the hospital. The elusiveness of recovery in this space contributes to patients’ profound anxieties about being properly recognized and acted upon by other actors within and outside the hospital. In a Melanesian context, visibility prompts social action, and being properly “seen” by others is the basis of relational and physical wellbeing. Thus, patients at Madang Hospital are more concerned about making themselves the subjects of others’ care than they are about understanding the cause of their disease. Paradoxically, getting well in Madang Hospital presupposes the social viability it takes to make oneself appear as a person worth caring for. Street explains that patients attempt to “make themselves visible as socially viable and well persons” in order to initiate the relations of care (with doctors, nurses, and family members) through which they will actually be healed (118). Patients in the Madang public ward therefore suffer doubly: languishing in their beds due to inadequate attention and medical resources, while also blaming themselves for failing to appear deserving of care. If the doctors at Madang are often unsure how to diagnose patients because their symptoms are indeterminate, the patients actually appear to be doing much of this work themselves, though they often invoke so-called “cultural” explanations to rationalize their inability to get well rather than biomedical ones. It might have been interesting for Street to explore in greater depth how the burden of diagnosis in Madang Hospital is shared both between doctors and patients and across “cultural” and “biomedical” epistemologies.
The book’s final section further develops the theme of social recognition to show how institutional and collective entities – nurses’ unions, hospital administrators, clinicians, and researchers – engage strategies of visibility to attract the attention of other bodies and multiply the resources at their disposal. Street’s analysis of a partnership between Madang Hospital and an Australian research hospital shows how the production of reputable global health research depends on and reinforces an unequal geography of place. While Australian researchers need to use Madang Hospital to collect samples from the local population, they are not willing to use its unreliable lab facilities to analyze them. But instead of investing in the improvement of these facilities – one lasting way that local hospital staff and patients might benefit from international research agreements – the researchers elect to ship samples back to Australia for analysis. Local hospital staff grumble because they are not engaged meaningfully in the partnership, and the Australian team’s ceremonious gift of a single copy of a medical textbook feels tokenistic because it is incommensurate with the value generated by the research. These stories dramatize the inequalities that result when partnership is pursued without reciprocity. The question implicitly raised by these stories is a powerful one: What kind of exchange relationship is possible when one party is only a visitor within the transactional field?
Every anthropologist who has done fieldwork is familiar with the ethical concerns motivating this question, and Street is no exception. In the course of her research, she realizes that she has been drawn into the same world that she is studying, but that her powers have been inaccurately assessed. Patients believe she holds the key to unlocking white people’s medicine, evidently viewing her “as another ‘hospital technology’” they can leverage in the course of their treatment (32). Street (not a trained physician) notes with measured disappointment that she was unable to provide the care that patients sought from her, even if her attentiveness was soothing in other respects. But this problem of incommensurability, which is central not only to the modes of partnership and exchange that this book examines, but also to the enterprise of ethnography itself, deserves more expansive commentary from the author – indeed, from all of us. Is it enough for anthropologists to continually intone that “[g]ood description is not inert”? (33) Or do we also bear the responsibility of asking more precisely how the ethnographies we write participate in reality? I would suggest that our capacity to really see each other – that is, to attend to each other in real and lasting ways – depends on it.
Mackenzie Cramblit is a PhD Candidate at Duke University motivated by questions of intimacy, care and value in relation to rural places. She is interested in understanding what constitutes an “environment,” how environments are made livable, and how we become attached to each other in their midst. Her dissertation approaches these ideas through a study of a remote community and “wild” landscape on the West Coast of Scotland.
Special Issue! Between Biopolitical Governance and Care: Rethinking Health, Self, and Social Welfare in East Asia by Anna Zogas
The first issue of Medical Anthropology in 2017 is a special issue, “Between Biopolitical Governance and Care: Rethinking Health, Self, and Social Welfare in East Asia.” Enjoy!
Between Biopolitical Governance and Care: Rethinking Health, Selfhood, and Social Welfare in East Asia (open access)
Amy Borovoy & Li Zhang
(There is a video abstract, too.)
In East Asia, health has historically been entwined with notions of morality and broader social ideals. But can the state and other institutions legitimate their involvement in everyday life habits that contribute to poor health outcomes? For example, food consumption, smoking, or cancer—issues that can be conceived as a matter of
‘individual choice’ and personal responsibility. In this issue, we explore the fine lines between exercises of social power that are repressive and controlling, and those that are productive, caring, or supportive. We examine intersections of individual desires and self-work with statism and the public good—for instance, drug addiction care and the use of psychological counseling in China, understanding cancer and stress in South Korea, and the containment of harmful behavior in Japan.
In this article, I explore how and why psychological intervention, often in the name of guanai (care), has gradually become a critical tool of managing the population and governing society in postsocialist China. Psychological counselors and experts are becoming a new form of authority, an indispensable part of creating and managing knowable, stable, and governable subjects for the military, the police, schools, and enterprises. ‘Therapeutic governing’ refers to the adoption of the therapeutic ethos, techniques, and care to improve the management of the work force and to help individuals cope with life in a rapidly changing society. I examine what drives local authorities to pursue this change, and how therapeutic governing takes on a different character and significance given China’s unique path. I suggest that incorporating psychotherapeutic intervention into postsocialist governing can simultaneously produce disciplining and nurturing, repressive and unfettering effects in everyday life.
Cancer incidence has been rising in South Korea, coincident with industrialization and with increased longevity. This has opened the way to a presentation of cancer as a symptom of prosperity and social advancement. Cancer care for older South Koreans is marketed widely as a way of giving back to the older generation, and is often portrayed as an opportunity to mobilize technological achievement alongside family care work to honor aging parents. Because breast cancer tends to affect a younger cohort, however, breast cancer patients seek more specific explanations for their illness in order to prevent recurrence. Many breast cancer patients identify ‘stress’ as the cause of their cancer, reflecting endemic stress in the lives of ordinary South Korean women. While this implies a critique of society and, specifically, of gender constructs, the emphasis on interpersonal ‘stress’ situates cancer causality in family relationships rather than in social, political, or environmental contexts. Cancer management and stress explanations together mute inquiry into causality.
In this essay, I revisit the politics of social control in the context of contemporary public health discussions, touching on the management of obesity and chronic illness. Foucault’s cautionary observations regarding the infiltration of normative social values into the terrain of healing offer a productive framework for considering the politics of public health in the industrialized world. I explore Japan’s public health paradigm and its key features of bureaucratic reform and health interventions through screening, socialization, education, and aggressive lifestyle training, and I consider the close proximity between health and socio-cultural values in the management of chronic conditions in Japan.
Seen through the prism of public health, the cigarette industry is an apparatus of death. To those who run it, however, it is something more prosaic: a workplace comprised of people whose morale is to be shepherded. Provisioning employees of the cigarette industry with psychic scaffolding to carry out effective daily work is a prime purpose of the China Tobacco Museum. This multistoried exhibition space in Shanghai is a technology of self, offering a carefully curated history of cigarette production thematized around tropes such as employee exaltation. Designed to anchor and vitalize the ethical outlook of those working for the world’s most prolific cigarette conglomerate, the museum is a striking illustration that industrial strongholds of ‘slow violence’ produce their own forms of self-care.
In this article, I explore a Chinese residential therapeutic community I call Sunlight in order to understand its quotidian therapies, its fraught nature binding China’s past with its future, and the to care for the self under postsocialism. Reviewing Sunlight ethnographically allows for broader theoretical exploration into how China’s economic transition created tensions between capitalism, socialism, and communism; between individual and community, care and coercion, and discipline and freedom. Sunlight blended democratic, communal, and communist values that in several ways transition drug addicts into a market-socialist society. In focusing on the socialist transition to capitalism much work concentrates on the neoliberal transition as the only path out of communism rather than exploring its exceptions. In exploring China as an exception, I ask: What do the residents, peer-educators and administrators reveal in their stories and reactions to community-based therapeutics of care and what happens when their notions of care clash?
Technologies of the Self and Ethnographic Praxis
The authors contributing to this special issue draw on Foucault’s notion of technologies of the self: the means by which people operate on their own bodies and souls in pursuit of self-transformation, always according to particular regimes of value. Foucault’s notion remains attractive to anthropology: the technologies are ethnographically visible, and they illustrate how power affects the intimate realms of social life. The authors in this issue take up three problems: (1) the process by which people craft new subjectivities, (2) the genealogy of the new technologies of the self now circulating in East Asia, and (3) the forms of governance and political rationality that they justify. The articles as a whole testify to the fruitful encounter between ethnographic praxis and Foucault’s philosophical project. They also show how transnational movement and hybrid cultural forms inflect the strategies of governance associated with modern technologies of the self, especially those allied with biomedicine.
On 11th May 2016 the Students of Medical Anthropology (SoMA) at University of Edinburgh, the student group within Edinburgh’s Centre for Medical Anthropology (EdCMA) held their inaugural event, a symposium entitled ‘Who Cares?’
As early career scholars in medical anthropology working across a variety of health-related contexts, we (SoMA) realised that care as a theme was present in all our work. This prevalence pointed to the anthropological significance of the concept and spurred discussions about ‘how care is different’ within and across our fields. However, it also highlighted that the concept of ‘care’ seemed to lack clarity and definable parameters within larger anthropological discussions. These concerns inspired SoMA’s first student-led symposium. Reflecting on some ideas within the published debate on ‘Care in Practice,’ within this symposium, we similarly “…sought to ask a how-question: how is “care” being done? Which modes and modalities of “caring” may we trace in various practices? How can each of these, different as they are, shed light on and help to specify the others” (Mol 2010: 84). We sought to do this by focusing on fieldwork experiences and considering how people within our sites are using the term care, and importantly, how they are performing care and for which reasons.
But why should anthropologists care about care? What does the term offer? What do we really know about care and caregivers? In answer, these papers are presentations of our understandings of care within our fields and statements arguing for the importance of examining care. They also aimed to instigate collective discussion about care as a concept and its role within society to “shed light on and help to specify” its parameters. In our papers and in the discussions that followed, this symposium addressed the role of care in social relationships: how care shapes power and dependency; the extent and limits of care; the relationship between harm, violence, and care; and the question of care and morality.
With support and resources supplied by the EdCMA, the aim for this event was to build on the experiences of students of medical anthropology and to launch SoMA as a group, while creating a fruitful discussion on care among EdCMA colleagues and guests. The SoMA event organisers and speakers were: Bridget Bradley, Sandalia Genus, Lilian Kennedy and Hannah Lesshafft . A roundtable discussion with EdCMA members Alex Nading, Stefan Ecks, Lucy Lowe, Koreen Reece and Alice Street, and chaired by Hannah Lesshafft, explored the ways that care might be a useful theme in medical anthropology and beyond. What follows here are abridged versions of these original presentations, a discussion paper by Alice Street, and a summary of the conversations that stemmed from the roundtable.
Bridget Bradley and Lilian Kennedy
Co-organised by: Bridget Bradley, Sandalia Genus, Lilian Kennedy, Hannah Lesshafft and Alice Street
Who we are
Students of Medical Anthropology (SoMA) at Edinburgh’s Centre for Medical Anthropology (EdCMA)
As part of the Centre for Medical Anthropology at Edinburgh University, the research students of Medical Anthropology (SoMA) have established a group to organise student-led events and facilitate research collaboration. SoMA allows early-career scholars to develop their work in dialogue with fellow researchers in the growing field of medical anthropology.
Bridget Bradley is a third year PhD student of social anthropology at The University of Edinburgh. Her doctorate research focuses on the experiences of people living with body-focused repetitive behaviours (compulsive hair pulling and skin picking) in the United Kingdom and United States. Bridget is currently the student representative for SoMA, the Students of Medical Anthropology group associated with the Edinburgh Centre for Medical Anthropology (EdCMA).
Sandalia Genus is currently a PhD candidate in Social Anthropology at the University of Edinburgh. From 2012 to 2015 she conducted 17 months of fieldwork among the various stakeholders of malaria control and malaria vaccine development in Tanzania and Belgium. Her research examines the intersection of global health and international development, with a focus on medical research, medical technologies and global health interventions.
Lilian Kennedy is a social anthropologist PhD candidate at the University of Edinburgh. Her research investigates practices of care, kinship, memory, and subjectivity as they relate to dementia. Her research is based on fieldwork conducted in London, working with people with dementia and the family members who help care for them.
Hannah Lesshafft is a social anthropologist and medical doctor. Her PhD research on Candomblé healing practices is based on 12 months fieldwork in Northeast Brazil. She currently works as a research fellow and teaching fellow at the Edinburgh Medical School.
Alice Street is Senior Lecturer and Chancellors Fellow in the School of Social and Political Science at the University of Edinburgh. Her research focuses on the material politics of global health, with a focus on Papua New Guinea and South India. Her book, Biomedicine in an Unstable Place: Infrastructure and Personhood in a Papua New Guinean Hospital was published by Duke University Press in October, 2014.
MAYS/SoMA Collaborative Conference, 15 -16 June 2017: ‘Medical Anthropology Beyond Academic Borders’
Follow us – Twitter: @SoMA_EdCMA
Become a Member of EdCMA – Email: Ian.Harper@ed.ac.uk
Material as opposed to what? Three recent ethnographies of welfare, biological labor, and human dignity by Leo Coleman
Catherine Fennell. Last Project Standing: Civics and Sympathy in Post-Welfare Chicago. Minneapolis: University of Minnesota Press, 2015.
Kalinda Vora. Life Support: Biocapital and the New History of Outsourced Labor. Minneapolis: University of Minnesota Press, 2015.
Gaymon Bennett. Technicians of Human Dignity: Bodies, Souls, and the Making of Human Dignity. New York: Fordham University Press, 2016
A new materialist studying housing projects, a feminist-Marxist postcolonialist, and a Foucauldian bioethicist—what do they have in common? This sounds like the start of a very bad academic joke. But a great deal of cultural anthropological research has in fact been motivated and disciplined—made readable as part of a common project—over the past fifteen or twenty years by such oddly overlapping interests in materiality or materialisms of diverse stripes, on the one hand, and reasoning about biology and the biological constitution of the human, on the other. Drawing on usefully heterogeneous philosophical and social-scientific currents, the discipline has turned to examine the physical effectiveness of things, networks, or infrastructures in shaping populations, and the medical and technical regulation of the biological life of these populations. World-spanning (and world-making) institutions and infrastructures have been opened to ethnographic investigation under the rubrics of technopolitics and biopower. This was no mere scholarly “turn” but was impelled by real forces that included an intense medical and institutional recrafting of humanity itself as a global biological reality (Rees 2014), and the disparate impact of novel machines, techniques, and infrastructures that worked to disaggregate governance, individualize the political subject and materially support new authority for corporate and private actors (e.g., Dumit 2012; Sunder Rajan 2015). Meanwhile new claims on life itself, as the common substance of biological being, and demands for its biological protection or material support (in highly particular ways) emerged and were granted attention as ethnographic and ethical sites for challenging these besetting realities (Petryna 2002; Biehl 2006; von Schnitzler 2013).
The three recent books under review here each open different, perhaps radically so, perspectives on the contemporary anthropology of technopolitics and the political uses of biology, or “life and infrastructure” (to coin a phrase). At first glance these books might not seem comparable: Catherine Fennel’s Last Project Standing is a local ethnography of “post-welfare” politics and the (material) reform of public housing in Chicago; Kalinda Vora’s Life Support is a partly ethnographic, partly literary-critical study of outsourcing, transnational surrogacy, and “biological labor” in India; and Gaymon Bennett’s Technicians of Human Dignity is an examination of a high-level discursive politics of “intrinsic worth” since World War II, revisiting debates over human rights and human dignity at the founding of the UN, at the Second Vatican Council, and in George W. Bush’s President’s Council on Bioethics. Yet read together, they offer distinctive insights not only into their particular fields but also into anthropology’s engagement with contemporary political life in the broadest sense, pushing beyond the now-standard models (the Deleuzian materialist, the feminist-Marxist, the Foucauldian) for examining biopolitics and the material and technical infrastructures that regulate (and relegate) populations and their vitality. Together, these books show us how ethnographers can craft new perspectives on biopolitics and its material processes, by examining the reflective processes through which people understand themselves and others as persons, subjects enmeshed not only in material relations but in structured sets of moral ones, too.
Catherine Fennel’s book begins amidst a technopolitical moment of the sort with which we might now think ourselves very familiar: in the context of neoliberal welfare reform in Chicago, in the early and mid 2000s the city’s public housing administration was reorganized to accord with new logics of community empowerment and market-discipline (as well as newly limited budgets), and mass demolitions of older housing projects were begun. What replaced Chicago’s projects, piecemeal, were individualized subsidies for poor people to rent apartments on the private market (vouchers which had been around for a long time), and new developments of “mixed-income” housing designed to integrate (some) former public housing residents into renovated neighborhoods that would also attract middle-class homeowners and private developers. Both reforms had the explicit goal of fostering whole new patterns of civility and everyday sociality—if not through homeownership for the poor, then by mimicking the spatial patterns and enforcing the social routines and diurnal patterns of middle-class neighborhoods. For the “New Urbanist” planners and charitable foundations that advocated for housing reform, the architectural design of the old public projects and their physical decay and social problems were two sides of the same coin, and could only be countered by new forms of self-management and collective concern to be catalyzed by the very design of new public housing on the model of private homes, and by the management discipline imposed by privatized charity.
Fennel argues, by contrast to New Urbanism’s focus on material lay-outs, that the success of the new developments—and of any civic future of mutual care—also really depended on sympathetic relations and imaginations that would enabled mutual recognition and civic cooperation among a broader urban citizenry. On this account, while the old projects had in fact provided some basis for mutual concern and forms of sympathy—often through the physical experience of breakdowns and dilapidation—the very materiality and temporality of the housing reforms militated against the formation of such bonds of attachment and care, at least in ways that would have made the housing reforms a success on their own terms (whether or not they were ever intended to succeed is another question altogether). Fennell is careful to show that the kinds of sympathy and attachment formed by the old public housing projects were not simple responses to the physical environment, and therefore were not amenable to reform by demolition and renovation. Moreover, such “old” attachments remain active forces within the new housing, durable as habitus and expectation, and continue to be recalled and articulated by relocated public-housing tenants as they forge their own understandings of, and way of life within, the new developments.
These claims are not presented as straightforward contradictions to the notions of organization and formal order, and materiality, integral to the efforts at reform that she studies. Rather, Fennell pins her analysis to a “materialist concept of sympathy” (p. 12) that helps her track how common concerns are provoked by interactions with others, within different material contexts and amidst fluctuating flows of resources. She describes her work as an account of the “physics” of social provision, the ways in which persons and spaces, goods and money, and communities of neighbors and strangers are all mutually constitutive. Through the analysis that these concepts empower, Fennell shows that the success of the new projects depended upon sympathetic participation by and adoption of new forms of sociability among not only former residents of public housing but also other citizens of diverse classes and races. But this was a kind of material participation which became harder to secure in the aftermath of the 2008 housing market collapse, and which easily declined in one direction into defensive protection of property (new forms of property and market-value being the whole point of reforms), and in the other into an empty sentimentality as the last material reminders of public obligation were demolished.
In the last chapter of the book, Fennell takes up this problem of the varying material sources for and depth and durability of sympathetic attachments, to push the limits of her own sophisticated framing of her project as a materialist account. She turns her attention to plans for a national museum of public housing in Chicago (as yet unrealized), related to campaigns for the preservation of a 1930s public housing project named after the 19th century activist and reformer Jane Addams. It is a significant fact that the “last project standing” is in fact from the 1930s, an earlier moment of social welfare than that which, after civil rights, produced the mass housing of African Americans in urban projects. Places like the Jane Addams houses have a distinct history, as (temporary) pedagogical spaces for (white, ethnic) immigrants who would emerge to build industrial Chicago and settle its suburbs. The barely-preserved materiality of the Addams Houses thus offers a site of civic memory which is frankly exclusionary of the very denizens of public housing who actually need to be rehoused after reform and demolition. Fennell takes care to point out that the planned museum includes the history of black Chicago only as part of a generalized “cultural heritage” (p. 235), and that facts of structural exclusion from homeownership and racial discrimination were generally elided in this planned museum of a mostly demolished material project.
If earlier chapters of Fennell’s book examine truly material, even biological, experiences in public housing—risks to bodily health, dilapidation—that formed the biopolitical ground beneath the legal and political marginalization of black Chicagoans (and the basis for sympathetic attachments and mobilizations for reform), in the last chapter she examines how still-pressing material realities and sympathies now evanesce in a fog of sentiment, not least through museum-ification and social-science reconsiderations of the supposed problems and pathologies of public housing. Sympathy is no longer cultivated in shared experiences, or given purpose by the real stakes of living together in a city, but instead is provoked by imagistic reminders and decayed remainders of a misunderstood past. This leaves Fennell at best ambivalent about whether material sympathies can still forge more inclusive urban relations, and indicates some sort of lesson—not fully spelled out here—about the durability of race in America as the sharp edge where sympathetic relations, in their very materiality, are cut across by other powerful forces that hierarchically order both affective identifications with, and material investments in, black America.
I strongly recommend Fennell’s concluding discussions for close attention by any reader seeking to be better armed against the forced sentiment so often enjoined by talk of decay and decline in the post-industrial Midwest, and wishing to challenge the narrow social and racial limits set on notions of “rust belt” suffering and anomie. The “rust belt” includes inner cities and public housing, too! But on the evidence of her last chapter, even deeply material sympathies and common bonds forged in shared spaces may be fatally compromised by other processes of identification. To be sure, we are now in an political impasse of mutual non-recognition that has become deeper than she could have predicted: we are caught between moralized and racialized narratives of public squalor and urban danger, and rosy images of a past of industrial solidarity under the penumbra of corporate beneficence (the latter image untroubled by acknowledgement of either biopolitical exclusion or demands for inclusion). These political imaginations both stand in relation to material realities of decay and disinvestment, which could be made the starting point for sympathy and common concern. But racial antipathy and nativist longing for an imagined past maintain stern separations between past and present, and between public and post-industrial forms of ruin. What can connect them up again—to each other, and to contemporary conditions—may not be a materialist concept of sympathy itself, but rather an act of reflection that only truly comparative engagement can provide. Fortunately, Fennell’s ethnography provides an internal example of just such reflection, across the temporal lines and material differences that divide old projects from new houses.
Fennell acknowledges often that there is no one outcome of reforms for all the residents of public housing, except for their physical removal from the projects that had stood as both the symbol of state-supported welfare and the crucible of its successes and its supposed pathologies. But in some ways that act of removal and distancing is the most important thing she examines: physical dissociation and distanciation from old flows of sympathy and resources provide Fennell’s informants with their most pointed understandings of the new housing as well as their most telling insights into the old. They talk not only about what they have lost, but at the same time also reflect on the social life that fills—or fails to—the spaces they now occupy. Fennell’s great achievement rests on her ability to capture those critiques of the new housing not as a nostalgia for the old—that kind of thing is the preserve of the social scientists and the museum-advocates in her narrative—but rather as a negotiation of the difference between sympathetic attachments and abstract, sentimentalized obligations to anonymous others. This negotiation between past and future, and reconfiguration of sympathy that it entails, is what grants her ethnography its point. In some respects, since this is an ethnography of post-reform housing, it is an ethnography of what Sarah Franklin (2013) has called in a different context “the after.” For Franklin and, implicitly, for Fennell, coming ethnographically after some thing that is in the process of being figured as an event (after reform here, after IVF for Franklin) necessarily involves a reflective process of historical comparison and moral contrast, for the ethnographer and her informants alike. Such reflection, I would argue, is always culturally richer, and ethnographically more revealing, than an account of the material effects of a technique or the costs and benefits of a political reform alone.
A kind of physics of life that operates within and through material infrastructures, and a complex moral process of reflection and understanding, are both also integral to Kalinda Vora’s critical reading of outsourcing, transnational surrogacy, and affective labor in globalized India. “Strange affinities,” she writes, bind the work of conducting customer service or back-office IT work in India for American businesses and customers, to the biological labor of bearing babies there for foreigners and non-resident Indians to take “home” to the West (p. 19). In both cases, according to Vora, “vital energy” is depleted in one place to provide critical “life support” to plans and projects unspooling elsewhere. She examines one side of these unequal exchanges only, focusing on the training, self-fashioning, and physical labor of birth demanded of and borne by bodies in India. Still, the transmission of vital energy, its reciprocal accumulation and depletion in different locations, provides her key analytic metaphor (p. 13), and her use of literary fiction and sociological vignettes allows her to juxtapose images of high-flying corporate elites and everyday American (debt-fueled) consumption practices against the straitened lives and yet equally vast imaginative horizons of service workers in India.
Vora’s analysis in terms of “vital energy” is given particularly force because of her choice to set labor of a very literally embodied sort—the biological labor of pregnancy, “commissioned” by intending parents from far away and compensated by a flat fee—alongside capital flows that are easier to mistake as simply financial and immaterial. Her comparison returns us sharply to the biological substance or embodied materiality of all labor (she builds especially on A. Aneesh’s important account of “virtual migration” as a labor-regime). To have critical purchase, however, beyond the argument that Indians are unfairly paid less for comparable work than people elsewhere might be, the comparison needs to pushed further than Vora takes it, to highlight the moral work at stake here—the work of comparison and judgment—which generates values that legitimate and license transfers of energy. Such values are integral to the cultural production that matters to her, in that they give some people free rein to move and to act while binding others in place and being, and allow both (and others) to reflect on their stations in life. Fortunately, materials exist in Vora’s ethnographic chapter on a surrogacy clinic in Delhi, where Indian surrogates interact with both biotechnologies and “commissioning parents,” that capture just such acts of reflective and reflexive comparison.
Vora introduces us to the surrogates’ own moral aspirations and understandings of the transfer they are engaged in, and with this introduces a critical contrast that buttresses her critique of transnational biocapital as an unequal exchange of vital energy. The surrogates, mostly recruited from rural villages, are shown to hope for and even plan for long-lasting exchanges with their “commissioning parents” (as the clinic calls the other parties to this labor relation). They model their work of surrogacy and the relations they hope to sustain with the commissioning parents on patron-client relationships with which they are familiar from their own quotidian lives of labor and subordination (pp. 130, 139). Transactions of a durability and quality that would sustain any such (still exploitative) moral economy of long-term relations between parents and surrogates are of course barred in advance by the contracts the surrogates sign and by the organization of the industry in which they perform their biological labor. Moreover, it is only a grim reminder of the legitimation work of globalization that the clinic where Vora worked encouraged the “commissioning parents” to think of the money they paid to their surrogates as charitable donations providing salvation from poverty, and even talked of providing the surrogate mothers with training in managing this payment as a kind of capital extracted from a gift-exchange, rather than a wage (see Coutin, Maurer, and Yngvesson 2002). Vora’s important and surprising observation is that clientage and patronage are real moral possibilities for the surrogates, albeit in ways that are systematically obscured from the commissioning parents. When they imagine long-term relations of clientage, these women also make explicit something that is equally present in the rest of Vora’s material: a yearning for some relational return on the work which consumes vital energy. An ethical response to these yearnings for socially-thicker relations might involve explicitly cultivating patronage roles for commissioning parents, insofar as such roles would demand mutual engagement by both commissioning parents and surrogates with the fact of material differences between them. Patronage, on these terms, could be a distinct and novel site of moral work and even offer terms for the reconstruction of bioethics beyond the contractual and the transactional.
In this regard, one might also note that the work of the surrogates is not only embodied biological labor but is itself enabled by a technological ensemble that is itself the subject of, and in part constituted by, intense and highly professionalized moral debate. These technologies are not just material, reproductive ones: they are also moral technologies. The cultivation of novel relations, interests, and aspirations through their deployment is a part of their very technical efficacy, for those who use them and those who are used by them—even when the realization of those relations may be otherwise blocked or barred. Rather than just a materialist reading of how they transfer “vital energy,” then, such technologies may require a different kind of critique, one that puts the conditions they materially instaurate under the description of distinct and specific moral vocabularies. The point is general, and applies to the communications technologies of outsourcing as well as the reproductive technology of IVF, but it is perfectly exemplified by the way the moral imagination of the surrogates themselves, with their unsentimental understanding of patronage, allows us to consider moral possibilities that are opened by, but not reducible to, the configuration of the technology of IVF and its material and legal conditions.
Bennett’s book on dignity as way of figuring the human being, and its protection, since World War II, provides an extended study of just such a process of putting material and technical realities under a new description in order to create conditions for acting upon them. He examines processes of “articulating a logic of governance and care that could subsequently be turned into [the] infrastructures and practices” of humanitarian intervention and bioethical regulation (p. 8). Importantly, for him the “figuration” of human dignity in the course of defining distinct institutional and practical aims is what comes first, rather than a history of the concept or an account of its practical successes and failures. Thus, he examines throughout his book the “reflective practices undertaken by concerned actors to give articulation to what human dignity means, signifies, and requires” (p. 276).
Much of this is a story of micropolitical negotiations, and of cautious delimitations of legal and political authority. If dignity has won a central place in normative philosophy, Bennett shows just how far it remains from being the universal institutional principle that its advocates claim for it (and neither he nor I are entirely convinced by those claims). But that distance between the articulation of a norm, its immediate conditions, and its potential realization is in fact the point: as an “event in the history of truth and power” dignity is worth studying anthropologically not because it allows us to answer material questions of justice or inclusion, but precisely because it offers a moral principle, an object of ratiocination rather than rationalization, around which a surprising array of actors and actions have gathered, often in response to modernity’s most terrible extensions of power over life. As Bennett argues in conclusion, “if talk of human dignity is not identical to the real-world apparatuses that have developed in connection to that talk, one needs to take care not to disregard such talk as utopian” (p. 284).
In Bennett’s terms, the task is not to describe epochal shifts in the bases of truth or power in the modern West, or to identify the origins and trajectory of an “age” of dignity. Rather, Bennett shows us dignity as a concept in formation in response to perceived breakdowns in care for human beings and their life, in the wake of and in response to state violence, secularism, or biotechnologies. This focus on breakdown and remediation is what makes his book seem relevant to the vastly different projects and concerns of Fennell and Vora. In both of those works, too, a breakdown is at stake, a failure to sustain life materially—whether because of the neglect and decay of public housing, or because of global inequalities that justify lower compensation for equivalent labor to some kinds of workers—and ethnographer and subjects alike find themselves dealing with the consequences of what only belatedly and through reflection emerge as critical events with significant moral consequences.
All three of these writers seek to provide the basis for a critical reconstruction of values and mutual obligations in the present. Fennell and Vora turn explicitly to the recent materialisms of affect, infrastructure, and biological life to do so. This is very different from the analysis of reason that Bennett undertakes. The first two projects both build upon broad critical challenges to liberal fictions such as “equality” that have long been pursued by materialisms of various stripes. Both working in contexts that have already been overwritten by ideological (contractual or constitutional) claims of equality, their critical labor brings material structures of inequality into view. Bennett turns the lens around, to see how a liberal fiction of universal dignity retains its form as a “constitutional object” in very different projects of institutionalization. The questions that impose themselves in the context of this reading, however, are these: is Bennett only studying a binding abstraction, a discourse, a figuration (as he explicitly says he is); and does this necessarily conflict with a more “materialist” attention to how that discourse is assembled into a larger, more besetting reality, or with a subsequent account of the unanticipated possibilities of action and relation that the new material configuration allows?
Of course, these alternatives are already unduly polarized. But sometimes an overstated dualism is necessary to clarify the shape and limits of an overweening monism. While “materiality” is certainly one way of designating historical processes, and thinking about the forcefulness of bodies and physical energy within them, it is important to remember that as a critical term, a point of intervention which justifies a certain way of organizing data, it has more than one genealogy and meaning. Not so long ago, in a very different critical moment, materiality itself designated the starting point of an uncontrollable proliferation of meaning, while also being a way of shifting the ground under other critical accounts of fixity and certainty. The literary-critical practice of deconstruction once situated “the materiality of the letter” as a marker of the final impossibility of fixing sign to signified, of sense to substance; in this regard, Mark Greif (2015) has recently noted how important it is to recall that deconstruction was itself part of a long reaction against reparative attempts to secure some essence for “Man,” some kernel of life and reason that would not be corrigible under the impact of overawing technical and political forces. New materialisms gain many of their important insights from this lineage in which deconstruction stands at the branching point of, precisely, a newly materialist challenge to technical determination and fixity. They too use materiality to mark the starting point for a proliferation of possibility, and make—like the whole philosophical and political movement of which deconstruction was a part—a virtue of indeterminacy and anti-essentialism. In this earlier moment, however, Stanley Cavell asked his critical colleagues to reconsider this move of playing indeterminacy against determination. If indeterminacy promised to free readers from illusions of essential meaning and humanistic finality, Cavell noted, we might first wish to be sure that the politics of this promise were “based on a true knowledge of what our illusions are” (Cavell 1982: 178).
Our illusions today have little to do with the essential qualities of “Man” or even of some group of people—against which indeterminacy would be a useful weapon—and even less to do with formal promises of liberal equality, in which case another materialism would be just the critical tool we might need. What illusions we have, I would wager, have to do with the potential and power of life itself (or sympathy, or affect—whatever it is, it is bodily and non-intellectual) to transform given conditions. Such potentials are said to emerge from and repair the material fixity of besetting material institutions and infrastructures. But Fennell, Vora, and Bennett indicate, by contrast, that the really significant unknown, one ever-obscured by false confidence in our knowledge equipment, is about what differently located and constituted persons actually understand to be the substance of their happiness, and how they orient their action toward that goal within and through material and technical conditions (“the substance of their happiness,” remember, is what Malinowski said the true object of ethnography ought to be). The people at issue in any given ethnography these days might include theologians, or defenders of universal human rights, or subalterns in the contemporary empire of science and technology, or the subjects of neoliberal programs of control. But what remains important is that their self-understandings are responsive to existing moral accounts of the relations that are possible, desirable, and materially sustainable for the kind of person they happen to be in the world in which they live. This self-understanding is built up over time through negotiations with the material realities of life and the judgments and assessments of others, and the moral accounts on which such people draw are in turn always under revision, or subject or repudiation. But figures of justice, morality, and solidarity—which these ethnographies show us are indeed given point and purpose by material experiences and structures of exploitation—do not stand opposed to materiality, or as the exhausted alternative to potential, but rather are the very resources with which persons can arrive at some common understanding, and set to work anew on the material conditions they inevitably share.
Leo Coleman is Associate Professor of Anthropology at Hunter College, City University of New York. His book A Moral Technology: Electrification as Political Ritual in New Delhi is forthcoming from Cornell University Press. firstname.lastname@example.org
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Von Schnitzler, Antina. 2013. Traveling Technologies: Infrastructure, Ethical Regimes, and the Materiality of Politics in South Africa. Cultural Anthropology 28(4): 670-693.
Rees, Tobias. 2014. Humanity/Plan; or, On the “Stateless” Today (Also Being an Anthropology of Global Health). Cultural Anthropology 29(3): 457–478.
Shortly after the election, I taught “Notes on a Balinese Cockfight” to my Anthropological Theory class, as I always do, at that point in the semester. By then we had covered “old ideas” – anthropologists who saw societies as bodies that successfully regulated themselves into homeostasis, cultures as cauldrons that take all that is natural and transform it into all that is social. Then, in the timeline of the history of anthropological thought, we consider the idea of culture as a manuscript, a palimpsest of layered stories, endlessly rich in meaning – stories that work both like horcruxes, where the soul of the culture is encoded, and as mirrors, reflecting how life is lived back to the ones that live it.
“The Balinese Cockfight” is, as every anthropologist knows, a classic article written in 1972 by Clifford Geertz, who observed cockfighting during his fieldwork in Indonesia. The cockfights are illegal but widespread, with cocks – roosters – serving as proxies for powerful men and their status competition. Geertz wrote that “the cockfight is the story the Balinese tell themselves about themselves.” When I teach this article, I always start the class by saying out loud what I’ve learned students are wondering and giggling about – I tell them, “yes, the whole article is basically one protracted dirty joke. Yes, he writes about cocks exactly for the reason you think. He even notes that the wordplay where a cock is both a rooster and a penis exists in Balinese just as it does in English.”
Intellectuals have an interesting critical relationship with archetypes, especially when they appear as instances of synecdoche – they are such concentrated semiotic clusters that when they are intentionally deployed in fiction, we are taught to read them as allegory. When an archetype is virtually merged with that which it signifies, to the point of word slippage around a homonym, we have critical skills training to acknowledge that a point is being made, and symbolically exaggerated, for effect. I am afraid that critical perspective, where our eye is trained to see exaggeration for symbolic purpose, spills over into “reading” (the way Geertz, who thought of culture as a manuscript that had to be “read”) real culture, real life – when the cesspool from which the ugliest archetypal values arise is rendered legible and transparent, we don’t register that it’s not exaggerated representation for effect, that it’s not a literary device.
If the narrative of this election were written as a short story, with actual events and quotes worked into the plot, an English class somewhere would analyze it as a feminist commentary – where the sexism of mainstream society is made visible through ongoing instances of explicit phallocentrism. They would write five-paragraph essays and, as the three examples, required by the five-paragraph essay format, they would point to Trump bragging about the size of his penis, the accusation so many women, myself included, experienced that we were voting “with our vaginas,” and the fact that at the last, crucial moment before the election, it was Anthony Weiner’s, pardon my technical term, dick pics, that triggered Comey’s announcement about the re-opening of the investigation. The man could not have been more appropriately named if we were in a medieval morality play (and at times it felt like we were). They would write in the conclusion that through these explicit, and perhaps hyperbolic examples, the author aims to make visible the underlying sexism of our political discourse and praxis.
Except this is not a short story. This is not hyperbole. This is what actually happened in this election. Each of those three examples is real – it does not “stand” for anything, it *is* – we simply just experienced an election where the sexist and literally phallocentric subtext of American politics finally manifested as text, with Jungian synchronicity providing a man named Weiner as the proximate trigger for the final denouement of the character trashing of Hillary Clinton. The cocks are both symbolic and real. This election is the story America told itself about itself.
Ironically, given my application here, Geertz’s article has been critiqued, for example by William Roseberry in his article “Balinese Cockfights and the Seduction of Anthropology” for its interpretive neglect of the role of women in his story about the Balinese society. The women are there, in his footnotes (and in the traditional markets appended to the cockfights), but their omission itself is obfuscated, as Geertz’s famous generalization jumps scale to a universalizing scope. A story that the Balinese men tell themselves about themselves becomes the story of and by “the Balinese” in general. In our election, the woman made it into the competition ring, and yet the interpretive frameworks that I see circulating are already de-centering gender, instead centering the issue of the working class, represented in the media through figures located in domains that are usually gendered as “male” – automotive workers, coal miners. So, the election then becomes not just a story America told itself about itself – but also a story about how America tells itself stories about itself, which lenses it reaches for, which interpretive framework it relegates to the footnotes.
In another classic essay, “The Effectiveness of Symbols,” Claude Levi-Strauss explores the power resultant from the merging of a substance and a symbol. In ritualistic moments of such synthesis, magical power can be deployed. One could write a separate essay on Trump’s occult online supporters who believe that “meme magic” got him elected, or on Marina Abramovic’s “spirit cooking” art project that, due to the public’s inability to differentiate between literal vs. metaphorical framing, precipitated Pizzagate and a widespread belief that the DNC was involved in Satanic dinners, and that Hillary Clinton ran a child pornography ring, as hyperbolic apex moments of the symbolic wars that constituted this election. But it also behooves us to think about the consequences in the material reality of such alignment between substance and symbol, cock and cock, man and ideology, Trump and the patriarchy. The effectiveness of symbols is not only for the kind of shamanic healing Levi-Strauss describes – it is also for undoing the material infrastructure and fabric of reality, particularly its fraught and contested patches. Americans told this story to themselves about themselves – but suddenly it is no longer a story. On the second day of Congress reconvening, two weeks out from the inauguration, Republican lawmakers have already initiated a push to defund Planned Parenthood. Women’s body sovereignty is under increased threat in a number of states. State Department employees are fearful that they are being targeted for work on gender related staffing, programming, and funding. “Grab’em by the pussy” T-shirts are available from online retailers in a number of designs and colors. Just like in the Balinese cockfight, symbolic, or at least proxy fighting, has real-world consequences in terms of financial stakes and recognition of status. The election has illuminated our cultural pecking order. A man who admits to and brags about sexual assault is about to be inaugurated instead of a woman widely considered the most qualified presidential candidate in history. Now that the symbolic hierarchy has been re-affirmed in the arena, the material, legal, epistemological consequences follow, both as a massive attack on women’s rights, and the obscuring of gender as an analytical framework in explanatory discourses about an election characterized by misogyny more than anything else.
Geertz, Clifford. “Deep play: Notes on the Balinese cockfight.” Daedalus (1972): 1-37.
Lévi-Strauss, Claude. Structural anthropology. Vol. 1. Basic Books, 1963.
Roseberry, William. “Balinese cockfights and the seduction of anthropology.” Social Research (1982): 1013-1028.
Dr. Veronica Davidov is an Assistant Professor of Anthropology at Monmouth University. Her research focuses on human-nature relations, with a specific emphasis on how natural resources are constructed and contested. She has conducted fieldwork in Ecuador and Northern Russia. She co-edits the journal Laboratorium: Russian Review of Social Research, and co-directs the Ecology and Culture University Seminar at Columbia University.
Book Forum –– Nancy Rose Hunt’s A Nervous State: Violence, Remedies, and Reverie in Colonial Congo by Todd Meyers
When Nancy Rose Hunt suggests that her book “joins the ferment” of colonial aggressions and uncertainties “while taking up harm and pleasure in a shrunken colonial milieu and in postcolonial historiography too” (4), an uninitiated reader might mistake Hunt’s appraisal of her project as attempting the impossible labor of largeness of scope and precision of subject. After spending time with A Nervous State:Violence, Remedies, and Reverie in Colonial Congo (Duke University Press, 2016), it becomes obvious that Hunt’s words verge on understatement. A Nervous State weaves the medical and administrative anxieties of infertility through violences and joys of life (lives worn thin, lives rich and dense) through songs and words, as a pursuit of futures. Hunt’s archive is immense, and she places it on offer in writing both lyrical and complex. It’s no wonder that the book was awarded the 2016 Martin A. Klein Book Prize in African History from the American Historical Association. The commentaries that follow give diverse readings of Hunt’s remarkable book. We hope you enjoy.
Beyond Catastrophe: The Pasts and Futures of Kinship in Colonial Congo
Wayne State University
Tensions of Empire Redux?
Richard Keller and Emer Lucey
University of Wisconsin–Madison
Music and Infertility in the Nervous State
School of Oriental and African Studies
Enclaves and States in (Post)colonial Congo: Spatial Logics and Epidemiological Metaphors
Wits Institute for Social and Economic Research (WiSER)
Laboratoire d’Anthropologie Sociale, Collège de France
Nancy Rose Hunt
University of Florida
And so ends 2016 – a year many have regarded as pretty topsy-turvy and trying at times. The focus of this month’s web roundup relates to how we operate when faced with uncertainty. The last twelve months have certainly shed light on how it is within our nature to crave and create structure and meaning for ourselves, and what happens when we are confronted with disruptions to our sense of what is fact, what is a result of our own belief systems, and where the two intersect.
One fact that we can all agree on is that we now live in a time of unprecedented access to information, with seemingly limitless ways to find out what we want to hear, precisely when we want to hear it. This article addresses the question of why so many are afraid of so much, with the authors suggesting that fears themselves create a new risk for our health and well-being that need to be addressed. Perhaps when it comes to anxiety in relation to the unknown, it is sometimes better for us to be pessimistic from the start rather than suddenly thrown into the realm of uncertainty. The illusion of hope is more anxiety-inducing that the certainty of failure, and sometimes we are more adversely affected by not knowing if a result is going to be positive or negative than we are by expecting a negative result, as suggested here. Misperceiving certain risks may actually be more significant, and hazardous, than any one individual risk, however this is very much culturally based.
With risk comes uncertainty, something that can be seen in the proliferation of stories on the web related to how we arrive at our beliefs. In social psychology, there is the idea that the more uncertainty that exists in a person, the more a space is created for influence. There has been a lot of talk in the last few months about truth, fact, and the consequences of having so much information available to us. Psychological mechanisms such as confirmation bias, in which we seek to confirm or validate what we already know, are one reason the notion of “echo chambers” have taken hold in explaining the increasing polarization taking shape on a global scale. It is our own relationship to the unknown that steers how and what we choose to believe, something taken up in an interview with Jerome Ravetz, a “pioneer of post-normal science and a leading advocate of citizen science” discussing why it might be time to move beyond the doctrine of scientific certainty. The idea of democratizing science in an age of uncertainty positions specialized expert knowledge as not always being adequate to solve problems with multiple solutions. Whether it is lay knowledge, leaked documents, or other non-traditional sources of information, the extended peer community, or “citizen scientists” are crucial to emerging debates.
Addressing the question of scientific certainty and fact is no doubt central to the times we’re living in, and this growing wariness/skepticism around the idea of expert knowledge contributes to an unsettling sense of not knowing where to turn for the facts, and indeed what exactly constitutes a fact in the first place. This level of uncertainty fuels the spread of fake news (another talking point of 2016) as well as a lack of trust toward previously “established” sources of credible information (even scientific joke papers, once a lighthearted and funny addition to some peer reviewed journal publication years are now having a moment of reflection regarding how funny such pieces are in an age when just about anything can be adopted and perpetuated as factual ). The importance of lay knowledge in contributing to advances in, for example, service user led mental health movements has been a great boon to the decreasing stigma surrounding mental illness. But what about when competing, often contrary, lay knowledges drive the debates, as with climate change or links between vaccines and Autism. Our beliefs shape the core of our identity (one reason why its so hard to change someone else’s political beliefs, for example) leading any questioning to feel like a personal attack for many. This article in Nature profiles Hans Rosling in his quest to dispel outdated beliefs. He argues that experts can’t seek to solve major challenges if they are not operating on facts, however erasing long held beliefs and preconceived ideas is a challenge in and of itself. Facts, uncertainty, and belief are sure to be at the center of more and more discussion and debates in the social science in the years ahead, as social media becomes even more prevalent, and mechanisms for communication more sophisticated.
This post began with mention of the anxiety stemming from not knowing who or what to believe. Perhaps one small way to help alleviate this is in the form of a reminder of ways in which we are all connected. I didn’t want to end 2016 on a note of uncertainty, so I encourage you to have a look at this very cool website Radio Garden which allows you to listen to radio stations from even the most remote corners of the world.. Not directly related to anything else in this post, but perhaps a reminder of both the vastness and smallness of this world we share, and a reminder that amidst all of the uncertainty and questioning, we can still reflect on the beauty of human communication across borders.
Best wishes for a happy 2017.
Here is the second part of our article roundup for December (find the first set of articles here). Happy reading, and happy new year!
In 2004, the Italian Parliament passed a controversial law on medically assisted reproduction (Law 40/2004). The Law obliged clinicians to create a maximum of three embryos during one in vitro fertilization (IVF) cycle and transfer them simultaneously into the patient’s uterus. With this “three embryo” standard, the Parliament sought to secure the realization of rights of IVF embryos. Drawing on the concepts of boundary-work and bioconstitutionalism, this article explores the role that the constitutional obligations of the Italian State towards its citizens, including IVF embryos as its new “citizen subjects,” played in how it envisaged and demarcated the professional boundaries of medical expertise. It argues that the latter depended upon how it balanced its commitments to protect the rights of IVF embryos and those of adult citizens. As such, the demarcation of the jurisdictional boundaries of medical expertise, and the definition of constitutional rights, formed two sides of the same governing project.
In this paper, I argue that uncertainty and nonknowledge, and not just research results, can be important vehicles of translation through which genetic research participation comes to affect the lives of research participants. Based on interviews with participants in a genetic research project, I outline epistemic, emotional, relational and moral implications of research participation. Many of them resemble what the literature has described as the social implications of genetic counseling, but here they stem from interaction with knowledge-in-the-making or what I simply call nonknowledge. While policies aimed at stimulating translation from bench to bedside tend to build on the assumption that research only works when knowledge translates into technological ability and creates utility, I suggest acknowledging that research has implications long before any clinical applications are at hand. Research questions, and not just results, may serve as a generative form of knowledge that can travel as fast as any answer.
Voluntary DNA-based information exchange and contact services following donor conception: an analysis of service users’ needs
Marilyn Crawshaw, Lucy Frith, Olga van den Akker & Eric Blyth
Medical science has enabled the creation of families through the use of donor conception but some lifelong policy and practice implications are only recently being recognized. Research and practice have shown that donor conception can, for some, carry substantial long-term consequences. In this paper we present findings from a questionnaire-based study that sought to shed light on donor-conceived adults’ and gamete donors’ views on service and support needs when searching for genetic relatives with the aid of DNA testing. The findings demonstrate the complexity and sensitivity of providing services in this newly emerging area of need. Such provision requires collaboration between very different disciplines and agencies (scientific and psychosocial), introduces the potential for blurring of lines of accountability and responsibility, and highlights the challenges of identifying appropriate funding streams. In addition, the findings demonstrate the opportunities and limitations afforded by the use of DNA in identifying unknown genetic relatives.
This paper explores the promise of induced pluripotent stem cells as a model system for the study of neurodegenerative diseases of Alzheimer’s, Parkinson’s and other diseases of the aging brain. Research in these areas, as in neuroscience more broadly, has struggled with the imperfect mapping between human and animal brains. The paper argues that the contemporary promise of induced pluripotent stem cells for research is established through their potential to resolve problems of translation, bridging laboratory and clinical contexts by acting as a model of “real” patient bodies. However, the paper shows how this promise is contested and renewed through a rearticulation of the relationship between neurodegeneration, aging and the qualities of “young” and “aged” bodies. This not only results in the introduction of new qualities and attributes to the model system, but also a re-imagining of how aging features within both late and early-onset neurological diseases.
Social media as a space for support: Young adults’ perspectives on producing and consuming user-generated content about diabetes and mental health (open access)
Gillian Fergie, Kate Hunt, Shona Hilton
Social media offer opportunities to both produce and consume content related to health experiences. However, people’s social media practices are likely to be influenced by a range of individual, social and environmental factors. The aim of this qualitative study was to explore how engagement with user-generated content can support people with long-term health conditions, and what limits users’ adoption of these technologies in the everyday experience of their health condition. Forty semi-structured interviews were conducted with young adults, aged between 18 and 30 years, with experience of diabetes or a common mental health disorder (CMHD). We found that the online activities of these young adults were diverse; they ranged from regular production and consumption (‘prosumption’) of health-related user-generated content to no engagement with such content. Our analysis suggested three main types of users: ‘prosumers’; ‘tacit consumers’ and ‘non-engagers’. A key determinant of participants’ engagement with resources related to diabetes and CMHDs in the online environment was their offline experiences of support. Barriers to young adults’ participation in online interaction, and sharing of content related to their health experiences, included concerns about compromising their presentation of identity and adherence to conventions about what content is most appropriate for specific social media spaces. Based on our analysis, we suggest that social media do not provide an unproblematic environment for engagement with health content and the generation of supportive networks. Rather, producing and consuming user-generated content is an activity embedded within individuals’ specific health experiences and is impacted by offline contexts, as well as their daily engagement with, and expectations, of different social media platforms.
Social networks, social participation, and health among youth living in extreme poverty in rural Malawi
Amelia Rock, Clare Barrington, Sara Abdoulayib, Maxton Tsoka, Peter Mvula, Sudhanshu Handa
Extensive research documents that social network characteristics affect health, but knowledge of peer networks of youth in Malawi and sub-Saharan Africa is limited. We examine the networks and social participation of youth living in extreme poverty in rural Malawi, using in-depth interviews with 32 youth and caregivers. We describe youth’s peer networks and assess how gender and the context of extreme poverty influence their networks and participation, and how their networks influence health. In-school youth had larger, more interactive, and more supportive networks than out-of-school youth, and girls described less social participation and more isolation than boys. Youth exchanged social support and influence within their networks that helped cope with poverty-induced stress and sadness, and encouraged protective sexual health practices. However, poverty hampered their involvement in school, religious schools, and community organizations, directly by denying them required material means, and indirectly by reducing time and emotional resources and creating shame and stigma. Poverty alleviation policy holds promise for improving youth’s social wellbeing and mental and physical health by increasing their opportunities to form networks, receive social support, and experience positive influence.
The Quality and Outcomes Framework: Body commodification in UK general practice
Armando H. Norman, Andrew J. Russell, Claudia Merli
The UK’s Quality and Outcomes Framework (QOF) is the largest pay-for-performance scheme in the world. This ethnographic study explored how QOF’s monetary logic influences the approach to healthcare in UK general practice. From August 2013 to April 2014, we researched two UK general practice surgeries and one general practice training programme. These environments provided the opportunity for studying various spaces such as QOF meetings, consultation rooms, QOF recoding sessions, and the collection of computer-screen images depicting how patients’ biomarkers are evaluated and costed through software systems. QOF as a biomedical technology has led to the commodification of patients and their bodies. This complex phenomenon breaks down into three main themes: commodification of patients, QOF as currency, and valuing commodities. Despite the ostensible aim of QOF being to improve healthcare in general practice, it is accompanied by a body commodification process. The interface between patients and care providers has been commodified, with QOF’s pricing mechanism and fragmentation of care provision performing an important role in animating the UK economy.
Everyday tactics in local moral worlds: E-cigarette practices in a working-class area of the UK (open access)
Research into e-cigarette use has largely focused on their health effects and efficacy for smoking cessation, with little attention given to their potential effect on health inequalities. Drawing on three years of ethnographic research between 2012 and 2015, I investigate the emerging e-cigarette practices of adult smokers and quitters in a working-class area of the UK. I first use de Certeau’s notion of ‘tactics’ to describe the informal economy of local e-cigarette use. Low-priced products were purchased through personal networks and informal sources for financial reasons, but also as a solution to the moral problems of addiction and expenditure on the self, particularly for older smokers. E-cigarette practices were produced in local moral worlds where smoking and cessation had a complex status mediated through norms of age and gender. For younger men, smoking cessation conflicted with an ethic of working-class hedonism but e-cigarette use allowed cessation to be incorporated into male sociality. Continued addiction had moral implications which older men addressed by constructing e-cigarette use as functional rather than pleasurable, drawing on a narrative of family responsibility. The low priority which older women with a relational sense of identity gave to their own health led to a lower tolerance for e-cigarette unreliability. I draw on Kleinman’s local moral worlds to make sense of these findings, arguing that smoking cessation can be a risk to moral identity in violating local norms of age and gender performance. I conclude that e-cigarettes did have some potential to overcome normative barriers to smoking cessation and therefore to reduce health inequalities, at least in relation to male smoking. Further research which attends to local meanings of cessation in relation to age and gender will establish whether e-cigarettes have similar potential elsewhere.
Realities of environmental toxicity and their ramifications for community engagement
Justin T. Clapp, Jody A. Roberts, Britt Dahlberg, Lee Sullivan Berry, Lisa M. Jacobs, Edward A. Emmett, Frances K. Barg
Research on community responses to environmental toxicity has richly described the struggles of citizens to identify unrecognized toxins, collect their own environmental health facts, and use them to lobby authorities for recognition and remediation. Much of this literature is based on an empiricist premise: it is concerned with exploring differences in how laypeople and experts perceive what is presumed to be a singular toxic reality that preexists these varying perspectives. Here, we seek to reexamine this topic by shifting the focus from facts to facticity—that is, by exploring the many types of knowledge that communities develop about toxicity and how these knowledges articulate with the ideas of scientific and governmental authorities about what kinds of information are valid bases for policymaking. In making this shift, we are influenced by work in semiotic anthropology and science and technology studies (STS), which emphasizes that lived experience generates distinct realities rather than different perceptions of the same underlying state. Using this framework, we present an analysis of oral history interviews conducted in 2013–14 in the small American town of Ambler, Pennsylvania. Part of Ambler’s legacy as a nineteenth- and twentieth-century center of asbestos manufacture is that it is home to two massive asbestos-containing waste sites, one of which was being remediated by the Environmental Protection Agency (EPA) at the time of this study. Our interviews demonstrate that even asbestos, a toxin with a well-established public narrative, is a fundamentally different object for different members of the Ambler community. For many of these individuals, the epistemology and practices of the EPA are incongruent with or tangential to their toxicity-related experiences and their consequent concerns for the future. As such, our findings suggest caution in framing the community engagement efforts of environmental health agencies primarily as facilitations of citizen science; this approach does not acknowledge the multiplicity of toxic realities.
Suffering and medicalization at the end of life: The case of physician-assisted dying (open access)
Hadi Karsoho, Jennifer R. Fishman, David Kenneth Wright, Mary Ellen Macdonald
‘Suffering’ is a central discursive trope for the right-to-die movement. In this article, we ask how proponents of physician-assisted dying (PAD) articulate suffering with the role of medicine at the end of life within the context of a decriminalization and legalization debate. We draw upon empirical data from our study of Carter v. Canada, the landmark court case that decriminalized PAD in Canada in 2015. We conducted in-depth interviews with 42 key participants of the case and collected over 4000 pages of legal documents generated by the case. In our analysis of the data, we show the different ways proponents construct relationships between suffering, mainstream curative medicine, palliative care, and assisted dying. Proponents see curative medicine as complicit in the production of suffering at the end of life; they lament a cultural context wherein life-prolongation is the moral imperative of physicians who are paternalistic and death-denying. Proponents further limit palliative care’s ability to alleviate suffering at the end of life and even go so far as to claim that in some instances, palliative care produces suffering. Proponents’ articulation of suffering with both mainstream medicine and palliative care might suggest an outright rejection of a place for medicine at the end of life. We further find, however, that proponents insist on the involvement of physicians in assisted dying. Proponents emphasize how a request for PAD can set in motion an interactive therapeutic process that alleviates suffering at the end of life. We argue that the proponents’ articulation of suffering with the role of medicine at the end of life should be understood as a discourse through which one configuration of end-of-life care comes to be accepted and another rejected, a discourse that ultimately does not challenge, but makes productive use of the larger framework of the medicalization of dying.
How food insecurity contributes to poor HIV health outcomes: Qualitative evidence from the San Francisco Bay Area
Henry J. Whittle, Kartika Palar, Hilary K. Seligman, Tessa Napoles, Edward A. Frongillo, Sheri D. Weiser
Rationale: Food-insecure people living with HIV/AIDS (PLHIV) consistently exhibit worse clinical outcomes than their food-secure counterparts. This relationship is mediated in part through non-adherence to antiretroviral therapy (ART), sub-optimal engagement in HIV care, and poor mental health. An in-depth understanding of how these pathways operate in resource-rich settings, however, remains elusive.
Objective: We aimed to understand the relationship between food insecurity and HIV health among low-income individuals in the San Francisco Bay Area using qualitative methods.
Methods: Semi-structured in-depth interviews were conducted with 34 low-income PLHIV receiving food assistance from a non-profit organization. Interviews explored experiences with food insecurity and its perceived effects on HIV-related health, mental health, and health behaviors including taking ART and attending clinics. Thematic content analysis of transcripts followed an integrative inductive-deductive approach.
Results: Food insecurity was reported to contribute to poor ART adherence and missing scheduled clinic visits through various mechanisms, including exacerbated ART side effects in the absence of food, physical feelings of hunger and fatigue, and HIV stigma at public free-meal sites. Food insecurity led to depressive symptoms among participants by producing physical feelings of hunger, aggravating pre-existing struggles with depression, and nurturing a chronic self-perception of social failure. Participants further explained how food insecurity, depression, and ART non-adherence could reinforce each other in complex interactions.
Conclusion: Our study demonstrates how food insecurity detrimentally shapes HIV health behavior and outcomes through complex and interacting mechanisms, acting via multiple socio-ecological levels of influence in this setting. The findings emphasize the need for broad, multisectoral approaches to tackling food insecurity among urban poor PLHIV in the United States.
Culture: The missing link in health research
M. Kagawa Singer, W. Dressler, S. George, The NIH Expert Panel
Culture is essential for humans to exist. Yet surprisingly little attention has been paid to identifying how culture works or developing standards to guide the application of this concept in health research. This paper describes a multidisciplinary effort to find consensus on essential elements of a definition of culture to guide researchers in studying how cultural processes influence health and health behaviors. We first highlight the lack of progress made in the health sciences to explain differences between population groups, and then identify 10 key barriers in research impeding progress in more effectively and rapidly realizing equity in health outcomes. Second, we highlight the primarily mono-cultural lens through which health behavior is currently conceptualized, third, we present a consensus definition of culture as an integrating framework, and last, we provide guidelines to more effectively operationalize the concept of culture for health research. We hope this effort will be useful to researchers, reviewers, and funders alike.
First depressed, then discriminated against?
Stijn Baert, Sarah De Visschere, Koen Schoors, Désirée Vandenberghe, Eddy Omey
Each year a substantial share of the European population suffers from major depression. This mental illness may affect individuals’ later life outcomes indirectly by the stigma it inflicts. The present study assesses hiring discrimination based on disclosed depression. To this end, between May 2015 and July 2015, we sent out 288 trios of job applications from fictitious candidates to real vacancies in Belgium. Within each trio, one candidate claimed to have become unemployed only recently, whereas the other two candidates revealed former depression or no reason at all for their unemployment during a full year. Disclosing a year of inactivity due to former depression decreases the probability of getting a job interview invitation by about 34% when compared with candidates who just became unemployed, but the stigma effect of a year of depression is not significantly higher than the stigma effect of a year of unexplained unemployment. In addition, we found that these stigmas of depression and unemployment were driven by our male trios of fictitious candidates. As a consequence, our results are in favour of further research on gender heterogeneity in the stigma of depression and other health impairments.
After 9/11/2001 the United States launched a global War on Terror. As part of this War, terrorism suspects were detained by the U.S. military and by the C.I.A. It is now widely recognized that the United States tortured a number of these detainees in the context of its ‘enhanced interrogation’ programme. This article examines how and why U.S. organizations developed standards that allowed healthcare professionals to become involved in torture; why the standards developed by U.S. security institutions failed to control the actions of enhanced interrogation personnel on the ground; and what the role of standards were in stopping the enhanced interrogation initiative. The article concludes by discussing the general lessons that the enhanced interrogation programme has for social science research on standards, namely that individuals can experience ambivalence when caught between competing organizational and professional standards and that it might be inherently difficult to successfully enact certain protocols when these relate to deviant or destructive acts.
Increased drug use and the timing of social assistance receipt among people who use illicit drugs
Emanuel Krebs, Linwei Wang, Michelle Olding, Kora DeBeck, Kanna Hayashi, M.-J. Milloy, Evan Wood, Bohdan Nosyk, Lindsey Richardson
Background: The monthly disbursement of social assistance (SA) payments to people who use illicit drugs (PWUD) has been temporally associated with increases in drug-related harm. Yet, whether SA receipt changes drug use intensity compared to levels of use at other times in the month has not been established. We therefore examined this relationship among PWUD in Vancouver, Canada (2005–2013).
Methods: Data were derived from prospective cohorts of HIV-positive and HIV-negative PWUD. Every six months, participants were asked about their illicit drug use during the last 180 days and the past week. We determined whether SA receipt occurred within the assessment’s one-week recall period. We employed generalized estimating equations controlling for confounders to examine the relationship between SA receipt and the change in drug use intensity, defined as a 100% increase in the average times per day a given drug was used in the last week compared to the previous 6 months. We tested the robustness of this relationship by stratifying analyses by whether individuals primarily used stimulants, illicit opioids or engaged in polydrug use and examining the timing of SA receipt relative to date of assessment.
Results: Our study included 2661 individuals (median age 36, 32% female) with 1415 (53.2%) reporting SA receipt occurring within the one-week recall period of the assessment at least once. SA receipt was independently associated with intensified drug use (Adjusted Odds Ratio [AOR]: 1.79; 95% Confidence Interval [CI]: 1.53, 2.09), and remained significant when stratified by primary use of stimulants (AOR: 1.87; 95% CI: 1.54, 2.26), opioids (AOR: 1.96; 95% CI: 1.23, 3.13) and polydrug use (AOR: 1.53; 95% CI: 1.11, 2.10).
Conclusion: We found a temporal association between SA receipt and drug use intensification. While the health and social benefits of SA are significant, these findings suggest that alternative disbursement strategies, such as staggered or smaller and more frequent SA payments may be able to mitigate drug-related harm. Alternatives should be tested rigorously.
A home for science: The life and times of Tropical and Polar field stations (open access)
P Wenzel Geissler, Ann H Kelly
A ‘halfway house’ between the generic, purified space of the laboratory and the varied and particular spaces of the field, the field station is a controlled yet uncontained setting from which nature can be accessed and anchored. As living quarters for visiting scientists, field stations are also enmeshed in the routine and rhythms of everyday domestic life, and in longer cycles of habitation, wear, and repair. This introduction considers the empirical and conceptual significance of Polar and Tropical field stations as homes for scientific work and scientific lives. The field station’s extra-territorial yet intimate character affects the credibility and circulation of knowledge along science’s frontiers. The challenge of making a home in the (non-temperate) field and the mundane experiences of expatriation and appropriation establish particular political dynamics of knowledge-making in these locations. They bring into focus the imaginaries of nature and science that drive transnational research and put into relief the aesthetic and affective dimensions of work and life in these distant homes for science. All these themes are pursued and amplified in a different medium by the artists who contributed to our research and are also featured in this special issue.
Habituating field scientists (open access)
This article explores the sensory dimensions of scientific field research in the only region in the world where free-ranging bonobos (Pan paniscus) can be studied in their natural environment; the equatorial rainforest of the Democratic Republic of Congo. If, as sensory anthropologists have argued, the senses are developed, grown and honed in a given cultural and environmental milieu, how is it that field scientists come to dwell among familiarity in a world which is, at first, unfamiliar? This article builds upon previous anthropological and philosophical engagements with habituation that have critically examined primatologists’ attempts to become ‘neutral objects in the environment’ in order to habituate wild apes to their presence. It does so by tracing the somatic modes of attention developed by European and North American researchers as they follow bonobos in these forests. The argument is that as environments, beings and their elements become familiar, they do not become ‘neutral’, but rather, suffused with meaning.
Field station as stage: Re-enacting scientific work and life in Amani, Tanzania (open access)
P Wenzel Geissler, Ann H Kelly
Located high in Tanzania’s Usambara Mountains, Amani Hill Station has been a site of progressive scientific endeavours for over a century, pushing the boundaries of botanical, zoological and medical knowledge, and providing expertise for imperial expansion, colonial welfare, national progress and international development efforts. The station’s heyday was from the 1950s to the 1970s, a period of global disease eradication campaigns and the ‘Africanization’ of science. Today, Amani lies in a state of suspended motion. Officially part of a national network of medical research stations, its buildings and vegetation are only minimally maintained, and although some staff report for duty, scientific work has ceased. Neither ruin nor time capsule, Amani has become a quiet site of remains and material traces. This article examines the methodological potentials of re-enactment – on-site performances of past research practices – to engage ethnographically with the distinct temporalities and affective registers of life at the station. The heuristic power of re-enactment resides in its anachronicity, the tensions it introduces between immediacy and theatricality, authenticity and artifice, fidelity and futility. We suggest that re-enacting early post-colonial science as events unfolding in the present disrupts straightforward narratives about the promises and shortfalls of scientific progress, raising provocative questions about the sentiments and stakes of research in ‘the tropics’.
How does science make a home for itself in a public hospital? This article explores how scientists working in ‘resource poor’ contexts of global health negotiate relationships with their hosts, in this case the doctors, nurses and patients who already inhabit a provincial-level hospital. Taking its lead from recent works on science, ethics and development, this article seeks to ‘provincialize the laboratory’ by focussing on the scientific tropics as a space of productive encounter and engagement. A view from the hospital reveals the tenuous process of ‘setting up’ a place for science, in a world that does not immediately recognize its value. The article examines the material exchanges of infrastructure, bodily tissues and labour that enable one young scientist to establish a scientific life for himself. The success of those transactions, it argues, ultimately derives from their objectification of scientific vulnerability and their enactment of relationships of mutual recognition. As opposed to asking how scientific knowledge is produced in the tropics, the view from the hospital challenges us to focus on the establishment of relationships between scientists and their hosts as a productive endeavour in its own right.
Science, ethnography, art (open access)
Excerpt from the introduction by P Wenzel Geissler and Ann H Kelly: The conference ‘A Home for Science’ from which this special issue originated, and the larger project of which the conference was part, sought to combine anthropological and historical studies of science, and contemporary artists’ engagements with scientific practice, to jointly interrogate scientific work in marginal places (Geissler et al., 2016). Collaborations between ethnography and conceptual art have evolved in recent decades, drawing on older convergences between anthropology and art practice (Gell, 1998). Conceptual artists entered into broadly ethnographic terrains and found inspiration in ethnographic methods, while social and cultural anthropologists and archaeologists pursued experimental methods beyond social scientific realism, gesturing towards or learning from conceptual art – variously contriving social situations and observing their unfolding, studying the social by way of material objects and forms, or emphasizing performative and playful dimensions of fieldwork, seeking poesis and surprise rather than ‘data’ (Marcus, 2010; Pearson, 2004; Schneider and Wright, 2013; Ssorin-Chaikov, 2013) … What follows are samples of the art presented at the ‘A Home for Science’ conference, along with excerpts from the statements that artists made about their work.
Here is the first part of our December article roundup. Three journals have special issues this month (abstracts in the post below):
- Body and Society: The New Biologies: Epigenetics, the Microbiome and Immunities
- Ethos: Anthropology and Psychoanalysis
- Medical Anthropology Quarterly: Special Focus Section on Comorbidity
Enjoy reading (and what’s left of the holidays)!
Betsey Behr Brada
One consequence of the recent expansion of anthropological interest in humanitarianism is the seeming obviousness and conceptual stability of “humanitarianism” itself. In this article, I argue that, rather than being a stable concept and easily recognizable phenomenon, humanitarianism only becomes apparent in relation to other categories. In short, humanitarianism is contingent: it depends on circumstance and varies from one context to another. Furthermore, its perceptibility rests on individuals’ capacity to mobilize categorical similarities and distinctions. One cannot call a thing or person “humanitarian” without denying the humanitarian character of someone or something else. Drawing on research conducted in clinical spaces where Botswana’s national HIV treatment program and private US institutions overlapped, I examine the processes by which individuals claimed people, spaces, and practices as humanitarian, the contrasts they drew to make these claims, and the moral positions they attempted to occupy in the process. More than questions of mere terminology, these processes of categorization and contradistinction serve as crucibles for the larger struggles over sovereignty, inequality, and the legacies of colonialism that haunt US-driven global health interventions.
Abortion laws offer a point of entry for “the state” to intervene in intimate clinical matters. In this article, I explore the various uses of scripts and scripting in state-mandated abortion counseling following the implementation of North Carolina’s (2011) Woman’s “Right to Know” Act. The law mandates that women receive counseling with specific, state-prescribed information at least 24 hours prior to an abortion. Drawing on interviews with abortion providers in North Carolina, I analyze how the meaning of scripting shifts across different clinical and bureaucratic contexts and show that abortion providers perceived themselves to be scripted by “the state” even though their words were not explicitly chosen by lawmakers. Thus, rather than viewing the law merely as a product of North Carolina legislative activity, I argue that abortion providers also help to create the law, and its social and moral power, by interpreting and enacting it. However, abortion providers also revealed creative strategies for “scripting dissent” from the law—that is, rejecting, challenging, or otherwise subverting the state’s ideological message. This demonstrates that the linguistic force of the script stretches beyond its textual meaning to encompass the way it is performed within a particular context and how it is sometimes used for unexpected ends.
In contemporary England, amateur paranormal investigators actively seek empirical evidence of the paranormal. These investigators are self-fashioned experts who aim to balance scientific and spiritual perspectives in hopes of researching the existence of ghosts from an objective perspective. Despite actively seeking out ghosts and amassing firsthand paranormal experiences, investigators remain deeply doubtful about the nature of their evidence and the existence of the paranormal. Here, I explore the production and experience of doubt by examining paranormal investigators’ struggles to define and quantify the paranormal. Competing ideas about the substance or nature of ghosts lie at the heart of this struggle. Paranormal investigators agree that collecting and analyzing electromagnetic energy offers the most promising pathway for establishing empirical evidence of the paranormal. However, there is analytic uncertainty regarding the meaning of electromagnetic energy: it might indicate a spiritual or natural presence. Here, I argue that these two competing frames of interpretation engender and sustain states of doubt among investigators; however, paradoxically, these very states of doubt allow them to maintain and sustain embodied encounters with the very paranormal forces they doubt.
Christine Hauskeller and Lorenzo Beltrame
Umbilical cord blood (UCB) is an important source for stem cells used in clinical treatments. For this purpose, UCB has to be collected at birth and stored in biobanks. The discourse about UCB biobanking practices commonly holds that it occurs in two opposite economies, the public sector and a competing private one. They correspond with moral economies of gift-giving in a redistributive economy versus private ownership of cord blood in a market economy. Our analysis of UCB banking in Europe shows that this opposition narrative is both empirically and analytically unsatisfactory. Using the analytic concepts of entanglement (Callon) and biomedical platforms (Keating and Cambrosio), we demonstrate how the network of actors, objects, interests and practices in biobanking creates different kinds of value and shared issues across public and private services. Our case study illustrates how the interrelation between technical, ethical, economic and logistical considerations plays out and generates a field of practices where redistributive and market economies coexist, are co-dependent and hybridize each other. The narrative of opposition therefore can inform STS studies regarding the normative values written into the public facing side of biobanking, but bioeconomic analyses benefit from building on concepts that enable the examination of the complex interrelations between the wider network of heterogeneous elements on which UCB banking relies.
Annette Leibing, Virginie Tournay, Rachel Aisengart Menezes, and Rafaela Zorzanelli
This article focuses on Canadian stem cell researchers working on therapeutic applications of autologous stem cells for heart disease. Building on the concept of ‘multiverse’ – coined by William James and then further developed by Ernst Bloch – we are interested in the simultaneity of the certain and uncertain, sometimes contradictory arguments articulated by these scientists. In the first part of the article we illustrate some of the factors that provide certainty for researchers and clinicians. The second part analyzes the ways in which uncertain elements become integrated into a discourse of certainty. What we would like to show, using the concept of multiverse, is that a relatively new bio-technology such as stem cell treatments generally relies on both certain and uncertain reasoning. However, uncertainty has to give way to a platform of partial certainty, if crucial action is to be taken on issues as diverse as treatments and grant applications. The principle mechanisms we found that can make this kind of transformation possible target future developments (what we call ‘if only arguments’), including past encouraging results in need of further research.
Thinking with the vital materiality of placentas as it is evinced in a placental stem cell research lab in Korea, this article explores the relations and practices of care that are essential to the circulation of biological matters as infrastructure of tissue economies. I attend to the flows of care that sustain tissue economies with the notion of ‘placental economies’. Shifting attention from donor subjects and tissue objects to practices and relations of care as an infrastructure for the circulation of tissues, I explore how the vitality of biological matters is an achievement made and sustained through the relations and practices of care that animate the placenta in different forms. On the basis of an ethnographic fieldwork conducted in Korea, this article focuses on two different forms of care (lab workers’ care of cells, and pregnant women’s care of fetuses) that enable the (re)production and circulation of placenta-derived stem cells possible. I argue that the flows of tissues and vitality are indeed the flows of care, as an anticipatory as well as responsive practices, without which the vitality cannot exist in its current form. Furthermore, I suggest that relations and practices of care are a kind of infrastructure of promissory biotechnological enterprises.
State regulation of oocyte donation in the context of human embryonic stem cell (hESC) research has increased since California’s landmark passage of Proposition 71 and the establishment of the first state-funded stem cell agency, the California Institute for Regenerative Medicine (CIRM). Scholarship has largely focused on California’s regulation of stem cell research as a patchwork of private sector and state regulations, reflecting major debates about the social contract for science. Given California’s political exceptionalism, how does examining alternative state histories, political structures, and institutions at the state level illuminate the ways that bio-innovation is being regulated in a federal regulatory vacuum? Examining state management of oocyte donation in the context of hESC research, this article considers New York and California as comparative sites of stem cell science regulation, which enriches our understanding of how regulation of stem cell science arises out of an engagement with representative politics and the private sector in the United States. Employing a process tracing of policy development in New York and California, this article highlights alternative democratic pathways to the management of oocyte donation in research contexts: given differences in direct democratic action, legislative representation, executive leadership, and publicly funded state stem cell research institutions, distinct regulatory outcomes occur with important bioethical implications for publics and participants in stem cell science at the state level.
Alison Kraft and Beatrix P. Rubin
This paper analyses the changing conceptualisation of cellular differentiation during the twentieth century. This involved a move away from a view of this process as irreversible to an understanding of it as contingent. We examine the import of this shift for the transformation of stem cell biology, including the therapeutic promise attributed to this field, and how it came to challenge historical conceptions of both the cell and stem cell. We take as our starting point the 2012 Nobel Prize for Physiology and Medicine awarded jointly to John Gurdon and Shinya Yamanaka. In the view of the Nobel Committee, their work delineates a paradigm shift in the understanding of cellular differentiation, one that incorporates the concept of ‘plasticity’. We explore the emergence, uses and meanings of this concept within this specific biological context, examining and emphasising its role as an epistemological tool. In this setting, ‘plasticity’ was introduced by cell biologist Helen Blau in the course of research undertaken in the 1980s into the genetics of cell differentiation. We argue that Blau’s experimental and theoretical contributions were seminal to a reconceptualisation of this process and provide a crucial link between the work of Gurdon and Yamanaka. Overall, the paper highlights the contested process of conceptual change within the biomedical sciences. It also draws attention to the dynamic and reciprocal relationship between conceptual and technical change, exemplified here in the changing conceptions of cell differentiation following from the analysis of gene expression using new cell fusion and cloning techniques. More broadly, the paper also affords a window onto the shifting priorities, goals and values within late twentieth-century biomedical research.
Special Issue: The New Biologies: Epigenetics, the Microbiome and Immunities
Beginning in the 1940s, mass production of antibiotics involved the industrial-scale growth of microorganisms to harvest their metabolic products. Unfortunately, the use of antibiotics selects for resistance at answering scale. The turn to the study of antibiotic resistance in microbiology and medicine is examined, focusing on the realization that individual therapies targeted at single pathogens in individual bodies are environmental events affecting bacterial evolution far beyond bodies. In turning to biological manifestations of antibiotic use, sciences fathom material outcomes of their own previous concepts. Archival work with stored soil and clinical samples produces a record described here as ‘the biology of history’: the physical registration of human history in bacterial life. This account thus foregrounds the importance of understanding both the materiality of history and the historicity of matter in theories and concepts of life today.
Megan Warin, Vivienne Moore, Michael Davies, and Stanley Ulijaszek
Bourdieu suggested that the habitus contains the ‘genetic information’ which both allows and disposes successive generations to reproduce the world they inherit from their parents’ generation. While his writings on habitus are concerned with embodied dispositions, biological processes are not a feature of the practical reason of habitus. Recent critiques of the separate worlds of biology and culture, and the rise in epigenetics, provide new opportunities for expanding theoretical concepts like habitus. Using obesity science as a case study we attempt to conceptualise the enfolding of biological and social processes (via a Deleuzian metaphor) to develop a concept of biohabitus – reconfiguring how social and biological environments interact across the life course, and may be transmitted and transformed intergenerationally. In conclusion we suggest that the enfolding and reproduction of social life that Bourdieu articulated as habitus is a useful theoretical frame that can be enhanced to critically develop epigenetic understandings of obesity, and vice versa.
Rebecca Scott Yoshizawa
Extensively employed in reproductive science, the term fetal–maternal interface describes how maternal and fetal tissues interact in the womb to produce the transient placenta, purporting a theory of pregnancy where ‘mother’, ‘fetus’, and ‘placenta’ are already-separate entities. However, considerable scientific evidence supports a different theory, which is also elaborated in feminist and new materialist literatures. Informed by interviews with placenta scientists as well as secondary sources on placental immunology and the developmental origins of health and disease, I explore evidence not of interfacing during pregnancy, but of intra-action, or the mutual emergence of entities in simultaneous practices of differentiation and connection. I argue that attending to evidence that can be figured as intra-action enables us to recognize, account for, and attend to diffuse responsibilities for fetal–maternal outcomes that extend beyond mothers to the biosocial milieus of pregnancy. In reimaging the intra-action of placentas, a new understanding of what constitutes a ‘healthy pregnancy’ becomes possible.
The issue of what is proper to nature, or life itself, is central to critical accounts of biomedicine and its complex interrelations with social, political and economic forces. These engagements, namely biopolitical accounts of medical practices and ethical-political critiques of biomedical discourse, grapple with the indistinction between the political and biological that biomedicine enacts. Making a significant contribution to both literatures, Ed Cohen’s A Body Worth Defending argues that the emergence of the concept of biological immunity signals the entry of politics into life itself and, as such, constitutes a concrete example of biopolitics. This article examines Cohen’s account of how the political becomes biological, and the view of life it assumes. Seeking to open up the question of biology, it draws on the work of Georges Canguilhem, and New Materialist accounts of matter–meaning entanglement, to offer a reading of knowledge and life, or politics and biology, as ontologically entangled.
Mark Davis, Paul Flowers, Davina Lohm, Emily Waller, and Niamh Stephenson
This article examines discourse on immunity in general public engagements with pandemic influenza in light of critical theory on immuno-politics and bodily integrity. Interview and focus group discussions on influenza with members of the general public reveal that, despite endorsement of government advice on how to avoid infection, influenza is seen as, ultimately, unavoidable. In place of prevention, members of the general public speak of immunity as the means of coping with influenza infection. Such talk on corporeal life under microbial threat is informed by self/not-self, network and ‘choice’ immunity, and therefore makes considerable allowance for cosmopolitan traffic with others, microbes, ‘dirt’ and immune-boosting consumer products. The immuno-political orientation of members of the general public, therefore, appears to trend towards a productive cosmopolitanism that contrasts with more orthodox bioscientific and governmental approaches to pandemic influenza. We reflect on the implications of the immuno-cosmopolitanism of everyday life for the advent of global public health emergency and for biopolitical rule in general.
Joshua I Newman, Rachel Shields, and Christopher M McLeod
This article offers a series of critical theorizations on the biopolitical dimensions of methicillin-resistant Staphylococcus aureus (MRSA), with specific attention to what has recently been referred to in the United States as the ‘MRSA Epidemic’. In particular, we reflect on the proliferation of biomedical discourses around the ‘spread’, and the pathogenic potentialities, of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). We turn to the work of Roberto Esposito and Jean-Luc Nancy to better make sense of how, during this immunological crisis, the individualized fleshy and fluid body is articulated to dimensions of community and corporeal proximity; the body is thus conceived in popular biopolitical framings as a site of transmission, inoculation, and isolation – as a living ecological and pathological vessel. We give emphasis to the spatial relations of flesh, namely in how biomedical ‘experts’ have sought to (bio-)technologize spaces of heightened communal bodily contact (such as playgrounds or gymnasia).
Devon E. Hinton, David H. Barlow, Ria Reis, and Joop de Jong
We present a general model of why “thinking a lot” is a key presentation of distress in many cultures and examine how “thinking a lot” plays out in the Cambodian cultural context. We argue that the complaint of “thinking a lot” indicates the presence of a certain causal network of psychopathology that is found across cultures, but that this causal network is localized in profound ways. We show, using a Cambodian example, that examining “thinking a lot” in a cultural context is a key way of investigating the local bio-cultural ontology of psychopathology. Among Cambodian refugees, a typical episode of “thinking a lot” begins with ruminative-type negative cognitions, in particular worry and depressive thoughts. Next these negative cognitions may induce mental symptoms (e.g., poor concentration, forgetfulness, and “zoning out”) and somatic symptoms (e.g., migraine headache, migraine-like blurry vision such as scintillating scotomas, dizziness, palpitations). Subsequently the very fact of “thinking a lot” and the induced symptoms may give rise to multiple catastrophic cognitions. Soon, as distress escalates, in a kind of looping, other negative cognitions such as trauma memories may be triggered. All these processes are highly shaped by the Cambodian socio-cultural context. The article shows that Cambodian trauma survivors have a locally specific illness reality that centers on dynamic episodes of “thinking a lot,” or on what might be called the “thinking a lot” causal network.
Descriptions of patient mistreatment fill ethnographic accounts of healthcare in resource-poor settings. Often, anthropologists point to structural factors and the ways that the global political economy produces substandard care. This approach makes it difficult to hold parties accountable when there is blatant disregard for human life on the part of individuals providing care. In this article, I draw on the illness narrative of Magaly Chacón, the first HIV positive individual in Bolivia to file charges of medical negligence after failing to receive care to prevent mother-to-child transmission. Magaly’s narrative demonstrates how structural conditions are often used to explain away poor patient outcomes, shifting attention away from and normalizing the symbolic violence that also perpetuates substandard care of marginalized patients. I use Magaly’s accusations to interrogate how defining acts of mistreatment as medical negligence can be a productive exercise, even when it is difficult to disentangle structural constraints from blatant acts of negligence. Defining who is negligent in resource-poor settings is not easy, as Magaly’s case demonstrates. However, Magaly’s case also demonstrates that accusations of negligence themselves can demand accountability and force changes within the local structures that contribute to the systematic mistreatment of marginalized patients.
Emily Mendenhall, Kristin Yarris, and Brandon A. Kohrt
In the past decade anthropologists working the boundary of culture, medicine, and psychiatry have drawn from ethnographic and epidemiological methods to interdigitate data and provide more depth in understanding critical health problems. But rarely do these studies incorporate psychiatric inventories with ethnographic analysis. This article shows how triangulation of research methods strengthens scholars’ ability (1) to draw conclusions from smaller data sets and facilitate comparisons of what suffering means across contexts; (2) to unpack the complexities of ethnographic and narrative data by way of interdigitating narratives with standardized evaluations of psychological distress; and (3) to enhance the translatability of narrative data to interventionists and to make anthropological research more accessible to policymakers. The crux of this argument is based on two discrete case studies, one community sample of Nicaraguan grandmothers in urban Nicaragua, and another clinic-based study of Mexican immigrant women in urban United States, which represent different populations, methodologies, and instruments. Yet, both authors critically examine narrative data and then use the Center for Epidemiologic Studies Depression Scale to further unpack meaning of psychological suffering by analyzing symptomatology. Such integrative methodologies illustrate how incorporating results from standardized mental health assessments can corroborate meaning-making in anthropology while advancing anthropological contributions to mental health treatment and policy.
“Air (aire, also aigre) in the body” is a frequent explanation of illness according to the traditional medical beliefs in Mexico. Anthropologists have generally scrutinized aire in the context of other common folk illnesses treated by traditional healers (curanderas). However, drawing on my research in the communities of Northern Oaxaca I suggest that aire occupies a more distinct position in the folk medical cosmology than it has usually been credited with. This distinction rests on the notion’s exceptional ambivalence and openness to multiple interpretations. “Air” is recurred to as the cause of illness mainly in situations where every other explanation, either “traditional” or “biomedical,” seems to be inadequate. The physical properties of air—its transparency, invisibility, apparent immateriality, near omnipresence, and virtual “nothingness”—render it a suitable explanation of the last resort. Local understandings of what aire “is” are often vague and elusive, and in many respects the term functions in folk medical discourse as an “empty signifier.”
Hikikomori, often glossed as “social withdrawal,” emerged as a sociomedical condition among Japanese youth at the end of the twentieth century, and it continues to fascinate and concern the public. Explanatory frameworks for hikikomori abound, with different stakeholders attributing it to individual psychopathology, poor parenting, and/or a lack of social support structures. This article takes an interpretive approach to hikikomori by exploring parents’ narrative constructions of hikikomori children in support group meetings and in-depth interviews. I argue that some parents were able to find hope in hikikomori by ‘emplotting’ their children’s experiences into a larger narrative about onset, withdrawal, and recovery, which helped them remain invested in the present by maintaining a sense of possibility about the future. Contrary to literature that examines hikikomori as an epidemic of isolated individuals, I demonstrate how parents play a key role in hikikomori through meaning-making activities that have the potential to shape their children’s experiences of withdrawal.
Julie Netherland and Helena B. Hansen
The past decade in the U.S. has been marked by a media fascination with the white prescription opioid cum heroin user. In this paper, we contrast media coverage of white non-medical opioid users with that of black and brown heroin users to show how divergent representations lead to different public and policy responses. A content analysis of 100 popular press articles from 2001 and 2011 in which half describe heroin users and half describe prescription opioid users revealed a consistent contrast between criminalized urban black and Latino heroin injectors with sympathetic portrayals of suburban white prescription opioid users. Media coverage of the suburban and rural opioid “epidemic” of the 2000s helped draw a symbolic, and then legal, distinction between (urban) heroin addiction and (suburban and rural) prescription opioid addiction that is reminiscent of the legal distinction between crack cocaine and powder cocaine of the 1980s and 1990s. This distinction reinforces the racialized deployment of the War on Drugs and is sustained by the lack of explicit discussion of race in the service of “color blind ideology.” We suggest potential correctives to these racially divergent patterns, in the form of socially responsible media practices and of clinical engagement with public policy.
Ruth Kevers, Peter Rober, Ilse Derluyn and Lucia De Haene
In the aftermath of war and armed conflict, individuals and communities face the challenge of dealing with recollections of violence and atrocity. This article aims to contribute to a better understanding of processes of remembering and forgetting histories of violence in post-conflict communities and to reflect on related implications for trauma rehabilitation in post-conflict settings. Starting from the observation that memory operates at the core of PTSD symptomatology, we more closely explore how this notion of traumatic memory is conceptualized within PTSD-centered research and interventions. Subsequently, we aim to broaden this understanding of traumatic memory and post-trauma care by connecting to findings from social memory studies and transcultural trauma research. Drawing on an analysis of scholarly literature, this analysis develops into a perspective on memory that moves beyond a symptomatic framing toward an understanding of memory that emphasizes its relational, political, moral, and cultural nature. Post-conflict memory is presented as inextricably embedded in communal relations, involving ongoing trade-offs between individual and collective responses to trauma and a complex negotiation of speech and silence. In a concluding discussion, we develop implications of this broadened understanding for post-conflict trauma-focused rehabilitation.
Population Control and Reproductive Politics in Cold War Asia
Like many developing countries in the 1950s and 1960s, Taiwan experienced a social process of constructing and controlling population that relied on demography and fertility studies as essential governing tools. This article investigates population politics and biopolitical knowledge production in postwar Taiwan through synthesizing three bodies of literature that have just begun to comment on one another: histories of postwar population control, analyses of the technoscientific turn in Cold War history, and forensics into the production of social-scientific knowledge via science-study approaches. Along with the complexities of Asian biopolitics, three main social elements affecting the production of biopolitical knowledge at the time are discussed: (a) the historical backstage on which the Cold War and the civil war met, (b) the acting group of Taiwanese and US agencies and individuals who took part in the process, and (c) the three types of fertility studies and the data from them that ultimately expanded the focus of the process of population control from the population in general to the reproductive behavior of women. The complexities of Asia biopolitics are also discussed.
This article studies the formation of Japanese ventures in family planning deployed in various villages in Asia from the 1960s onward in the name of development aid. By critically examining how Asia became the priority area for Japan’s international cooperation in family planning and by analyzing how the adjective humanistic was used to underscore the originality of Japan’s family planning program overseas, the article shows that visions of Japanese actors were directly informed by Japan’s delicate position in Cold War geopolitics, between the imagined West represented by the United States and “underdeveloped” Asia, at a time when Japan was striving to (re)establish its position in world politics and economics. Additionally, by highlighting subjectivities and intra-Asian networks centered on Japanese actors, the article also aims to destabilize the current historiography on population control, which has hitherto focused either on Western actors in the transnational population control movement or on non-Western “acceptors” subjected to the population control programs.
Special Issue: Anthropology and Psychoanalysis
This article is based on fieldwork in a Chinese Protestant house-church in Beijing—more specifically, it focuses on a form of group therapy, which took place in the vicinity of the church. It combines two phenomena usually studied separately, namely the popularity of Chinese underground churches and China’s so-called “psycho-boom.” Drawing on attachment theory, I focus on the psychic conflicts that draw certain people, in this case a young woman, Lin, to this kind of therapeutic/ritual context. Filial piety, the moral value that children should respect and honor their parents, who have sacrificed so much for them, remains a strong social norm in Chinese society. I argue that forbidden feelings such as anger directed at parents found expression in this Chinese house-church. The ritual and therapeutic context can be understood as a cultural defense mechanism, which celebrates an inversion of dominant societal norms.
Tine M. Gammeltoft
Across the world, existing research indicates that many women respond with silence to marital abuse. This article offers an ethnographic investigation of the social and psychic forces behind Vietnamese women’s silencing of violence and a theoretical exploration of how the psychoanalytic concept of fantasy—understood as unconscious or subconscious mental processes—may contribute to the analysis of everyday violence and psychic distress. Distinguishing between what I term deliberate and subconscious silence, I explore the role that fantasy plays when Vietnamese women silently endure intimate partner violence. Closer ethnographic attention to the fantasy-constructions that sustain day-to-day lives can, I argue, strengthen the capacity of anthropology to comprehend how systems of everyday violence are upheld and rendered socially invisible.
Henrik Hvenegaard Mikkelsen
As states across the world develop strategies for administering their aging populations, different assumptions and anxieties regarding the condition of old age and how they haunt people are disclosed, across national-cultural settings. Within recent years, loneliness has been identified as one of the key threats to the well-being of the elderly in the Danish welfare society, and the tendency to view solitary seniors in terms of “loneliness” and “social isolation”—along with the attempts to reintegrate these solitary seniors into society—reveals how solitude is being tied to detrimental states of existence. Based on an ethnographic fieldwork among healthcare workers and solitary elderly men in the rural area of southern Sealand, Denmark, this article lays out the Danish configuration of what has been called the paradigm of “successful aging.” However, not only is the attention to loneliness among Danish eldercare professionals a sign of an inherent fear; at the same time, I will argue, it reveals an inherent inability to conceptualize “solitude” as other than “loneliness.” By employing the concept of the Real—the enigmatic realm within Lacanian psychoanalysis that represents the limit of language—the aim of this article is to uncover how the current discourse on successful aging renders solitude “unthinkable.”
Lotte Buch Segal
This article argues that over the course of the past three decades a mood change has occurred in terms of how Palestinians relate to the ideal of an independent Palestinian state. During the first Intifada, from 1987 to 1993,1 which constitutes the golden age of Palestinian resistance towards Israel’s occupation, the Palestinian resistance movement was characterized by a passionate belief in the possibility of a revolutionary transformation. Due to the consistent stalemate and even worsening of the conflict that have followed in the wake of the Second Intifada, from 2000 to 2003, this passionate belief in the realization of a Palestinian state has been replaced by ambivalence toward that ideal. Based on insights from my intermittent fieldwork with families of Palestinian political prisoners from 2004 to 2011, this article suggests that the contemporary ambivalence surrounding the revolutionary project can be meaningfully analyzed using Freud’s notion of melancholia. In Freud, melancholia accounts for the relation between a feeling of indeterminate loss and ambivalent attachment. The notion of melancholia thereby provides anthropology with a concept that can be used to name and explore the frayed attachment to the ideal of a Palestinian state in the context of an ongoing colonial occupation. The passionate politics of the First Intifada enabled a fusing of Palestinian personhood with the overall political project into a subject characterized by active resistance. In contrast, the ambivalent attachment that marks the link between self and state project in the Palestinian territories after the Second Intifada leads to a mood of melancholia. By analyzing the attachment to the political project as an indeterminate loss in the melancholic’s ego, I argue that the Palestinian political project is part of the self and keeps its adherents in a repetitive temporal fold from which they are unable to escape, because they are obliged and compelled to keep fighting for a state that does not seem to materialize. Conceptually, melancholia has the capacity to elucidate the emotional and deeply intersubjective toll it takes to live and aspire to an ideal that seems further from realization by the hour.
The capacity to receive occult messages and look into the future is claimed by individuals in most societies and probably always has been. In Denmark, clairvoyance is a popular service offered at the alternative market for counseling and healing. During my fieldwork among Danish spiritualist mediums in 2007–08, I was often puzzled by the way in which clairvoyants and clients seemed to share the same kinds of problems. This observation steered my interests toward understanding how personal sensations and feelings are exchanged in therapeutic encounters and raised questions about who is doing what to whom. Drawing on Jung’s concept of the wounded healer to highlight the clairvoyant’s role as a channel for societal anxieties and Melanie Klein’s concept of projective identification as a framework for understanding the defense mechanisms at stake in object relations, I argue that psychoanalysis may add an important critical dimension to the anthropology of therapeutic encounters.
In this commentary, I discuss some of the theoretical and methodological issues the contributions to this special issue raise collectively, namely: how do we as anthropologists pick and choose among the many diverse psychoanalytic concepts available to us, especially when these concepts may come embedded in very different, and sometimes contradictory, theoretical assumptions about human behavior? Once we find a psychoanalytic concept that is useful for ethnographic work, can we or should we attempt to relate it to more experience near ethnopsychological terms and assumptions, ones that might seem more understandable and intuitive from a local point of view? How intimately should we know people, biographically or developmentally, before we attempt to apply psychoanalytic concepts to their behavior? And, given that George Devereux is cited as one of the inspirations for this special issue, what role can or should an awareness of countertransference play in ethnographic work, and what are the limits, if any, of psychoanalytic interpretation in an ethnographic context?
The devastating Indian Ocean tsunami of 26 December 2004 caused massive destruction to coastal Aceh, Indonesia, and left countless numbers of people dead or wounded. This article focuses on the embodied narratives of three Acehnese women who survived the disaster and, like many others in Aceh, told their stories ‘through’ their bodies. A detailed ethnographic account of their narratives reveals how the body stretches temporally between the ‘narrated event’ and the ‘narrative event’, both through the representation of the body in narratives and through the embodied performance of narratives. Moving beyond meaning-centred analyses of narratives, I argue that the central accomplishment of these narratives is that they convey poignant bodily experiences to others and thereby create a shared, post-disaster, world. Ultimately, through these embodied narratives of disaster people remake their world, with others, in the wake of its ‘unmaking’.
Inquiring into concerns surrounding death and the afterlife in an underclass enclave in Japan, this article proposes that the politics of survival involves engaging with the enduring relationship between the living and the dead, referred to as ‘necrosociality’. Based on fieldwork carried out in Yokohama, it explores how ‘isolated death’ (kodokushi) and ‘disconnected spirits’ (muenbotoke) have become major concerns in homeless activism and support, giving rise to various necrosocial innovations and practices. The emergent necrosociality in Yokohama conjures up an alternative logic of care that connects people based on the general premise of inevitable decay and decline rather than familial ties and intimate memories. This article suggests that the concept of necrosociality provides a useful framework for analysing how social relations are negotiated, reaffirmed, or negated through bodily remains and graves, effectively shaping the modes of being and care among the living.
Special Focus Section: Comorbidity
Merrill Singer and Nicola Bulled
Based on an assessment of the available research, this article uses syndemic theory to suggest the role of adverse bio–social interactions in increasing the total disease burden of tick-borne infections in local populations. Given the worldwide distribution of ticks, capacity for coinfection, the anthropogenic role in environmental changes that facilitate tick dissemination and contact, evidence of syndemic interaction in tick-borne diseases, and growing impact of ticks on global health, tick-borne syndemics reveal fundamental ways in which human beings are not simply agents of environmental change but objects of that change as well.
This article examines the comorbidity concept in medical anthropology. I argue that the dearth of articles on comorbidity in medical anthropology may result from the rise of syndemic theory. Syndemics recognize how social realities shape individual illness experiences as well as distribution of diseases across populations. I discuss synergistic interactions foundational to the syndemics construct through my research of depression and diabetes comorbidity in vulnerable populations from urban United States, India, and South Africa. I argue that social and economic factors that cluster with depression and diabetes alone and together exemplify the biosocial processes that are at the heart of syndemics. In doing so, I illustrate how social, cultural, and economic factors shape individual-level experiences of co-occurring diseases despite similar population-level trends. Finally, I discuss the relevance of syndemics for the fields of medicine and public health while cautioning what must not be lost in translation across disciplines.
Lenore Manderson and Narelle Warren
Chronic conditions and their resultant difficulties in daily living frequently occur with other health problems, sometimes due to interactions or complications at a biological level, or as a result of common pathogens or risk factors. On other occasions, they develop independently. Drawing on research conducted with Australian women that began in the mid-2000s and is still ongoing, we highlight how chronic structural factors shape the risk factors of “chronic” conditions, influencing health seeking, continuity of care, and health outcomes. Institutional, economic, and other circumstantial factors pertain and impact health trajectories as much in highly industrialized as in resource poor settings. In illustrating how poverty and social exclusion create the preconditions of multiple chronic health problems, and how chronic health problems increase such disadvantages for individuals and their households, we introduce the idea of “recursive cascades” to capture the often inevitable trajectory of increasing ill health and growing empoverishment.
Lesley Jo Weaver
The biomedical definition of comorbidity belies the complexity of its lived experience. This article draws on case studies of women with diabetes and various comorbidities in New Delhi, India, to explore intergenerational transactions surrounding suffering in contexts of comorbidity. The analysis synthesizes sociological theories of chronic disease work, psychological theories of caregiver burnout, and anthropological approaches to suffering and legitimacy to explore how, when, and by whom women’s comorbid sources of suffering become routinized in everyday life. The analysis demonstrates, first, that comorbid suffering is not simply a matter of the addition of a second source of suffering to an existing one; rather, it comprises complex interactions between suffering, disability, family dynamics, and quality of life. Second, it illustrates several social routes through which comorbid suffering can fade into the background of everyday life, even when it is severe. Close attention to how suffering works in cases of comorbidity will be important as comorbid conditions become increasingly commonplace around the world.
Brandon A. Kohrt and Christine Bourey
Our objective was to elucidate how culture influences internal (psychological), external (social), institutional (structural), and health care (medical) processes, which, taken together, create differential risk of comorbidity across contexts. To develop a conceptual model, we conducted qualitative research with 13 female child soldiers in Nepal. Participants gave open-ended responses to intimate partner violence (IPV) vignettes (marital rape, emotional abuse, violence during pregnancy). Twelve participants (92%) endorsed personal responses (remaining silent, enduring violence, forgiving the husband). Twelve participants endorsed communication with one’s husband. Only four participants (31%) sought family support, and three contacted police. Ultimately, 12 participants left the relationship, but the majority (nine) only left after the final IPV experience, which was preceded by prolonged psychological suffering and pregnancy endangerment. In conclusion, comorbidity risks are increased in cultural context that rely on individual or couples-only behavior, lack external social engagement, have weak law and justice institutions, and have limited health services.
In this short essay, I wish to briefly discuss smoking, polypharmacy, the human biome and multispecies relations, and biomedicalization as a means of stretching the common ways we think about comorbidity. My intent is to expand our thinking about comorbidity and multimorbidity beyond the individual as a unit of analysis, to reframe comorbidity in relation to trajectories of risk, and to address comorbid states of our own making when the treatment of one health problem results in the experience of additional health problems. I do so as a corrective to what I see as an overly narrow focus on comorbidity as co-occurring illnesses within a single individual, and as a complement to critical medical anthropological assessments of synergistic comorbid conditions (syndemics) occurring in structurally vulnerable populations living in environments of risk exposed to macro and micro pathogenic agents.
The nation’s fight against fat has not reduced obesity, but it has had other worrying effects. Mental health researchers have raised the possibility that the intense pressures to lose weight have heightened the risks of developing eating disorders, especially among the young. Medical anthropology can help connect the dots between the war on fat and disordered eating, identifying specific mechanisms, pathways, and contextual forces that may lie beyond the scope of biomedical and psychiatric research. This article develops a biocitizenship approach that focuses on the pathologization of heaviness, the necessity of having a thin, fit body to belonging to the category of worthy citizen, and the work of pervasive fat-talk in defining who can belong. Ethnographic narratives from California illuminate the dynamics in individual lives, while lending powerful support to the idea that the battle against fat is worsening disordered eating and eating disorders among vulnerable young people.
Cristina A. Pop
This article locates the symbolic construction of “corrupted purity”—as a key assertion in Romanian parents’ HPV vaccination refusal narratives—within a multiplicity of entangled rumors concerning reproduction and the state. Romania’s unsuccessful HPV vaccination campaign is not unique. However, the shifting discourses around purity and corruption—through which some parents conveyed anxieties about their daughters being targeted for the vaccine—place a particular twist on the Romanian case of resisting the HPV vaccination. Parental discourses took the form of clusters of rumors about state medicine’s failure to provide adequate reproductive health care, additive-laden foods, and exposure to radioactive contamination. In these rumors, corruption becomes literally embodied, through ingestion, consumption, contact, or inoculation. Parental discourses about what is being injected into their daughters’ pristine bodies express their uncertainty around navigating the unsettled post-socialist medical landscape.
This article analyzes informal medical payments that the majority of Lithuanians give or feel compelled to give to doctors before or after treatment. It focuses on how patients and their caretakers encounter, practice, and enact informal payments in health care and how these payments create a reality of health care that is not limited to an economic rationality. Within such a frame, rather than being considered a gift or bribe, it conceptualizes these little white envelopes as a practice of health and care. The article shows how an envelope of money given to a doctor transcends the material patient–doctor transaction and emerges as a productive force for coping with illness, medical encounters, and misfortunes.
This paper follows the ‘moral life’ of epinephrine auto-injectors, devices that people with food allergies and their caretakers use to administer emergency medication to stop serious allergic reactions, in the United States. These devices are potent signifiers of the seemingly precarious nature of life with food allergies. I follow auto-injectors from their social birth as a commodity object, through how they structure doctor-patient interactions and parenting, to the ways that parents and illness advocates talk about their life-saving properties. At every step of the way, their significance is influenced by the political-economic context of health care in the United States, which places significant burdens of financial cost and responsibility for deciding what constitutes ‘good’ care upon individual patients and caretakers. The moral life of epinephrine serves as a model for thinking about how medical devices take on meaning that is at once practical, moral, and economic as they circulate through manufacturing and distribution channels and into the lives and social worlds of users.
Sara Marie Hebsgaard Offersen, Mette Bech Risør, Peter Vedsted, Rikke Sand Andersen
Woven into the fabric of human existence is the possibility of death and suffering from disease. This essential vulnerability calls forth processes of meaning making, of grappling with uncertainty and morality. In this article we explore the uncertainty and ambiguity that exists in the space between bodily sensations and symptoms of illness. Bodily sensations have the potential to become symptoms of disease or to be absorbed into ordinariness, prompting the question: how do we ascribe meaning to sensations? In the context of middle-class everyday life in Denmark, we show how different potentialities of ambiguous sensations are weighed against each other on a culturally and morally contingent continuum between normal and not normal, uncovering the complex interplay between the body, everyday life, and pervasive biomedical discourses focusing on health promotion, symptom awareness, and care seeking.
Miriam Waltz and Fiona C. Ross
Donated human milk’s status comes into question as it leaves the mother-child relationship and is reconfigured through practices and discursive structures that seek to stabilise it as a specific kind of object. Based on research conducted in Cape Town, South Africa, we examine the crucial role of technologies in aiding the milk’s transformation as milk moves from donors’ homes into the clinical setting where it is received by preterm, low-birth weight newborns. We show that the milk shifts back and forth between being a bodily fluid, food, and medicine in the course of this trajectory. Different techniques foreground milk’s diverse properties as a set of moral decisions converges around saving, securing, and sustaining life, and materialising relationships.
This article critically examines the development and current state of speculative bioethics (bioethics discourse concerned with future technologies) as reflecting an intensifying science fictionality, a cognitive/perceptual mode in which the imagined future begins to exert increasing degrees of influence on the present, culminating in a collapse of distance between the two. Future technologies thereby come to be viewed as generating practical ethical issues that need to be addressed well in advance of their arrival. Although this appears to be a prudent effort, it actually bypasses the present as a site of moral agency and locates ethics within a simulation of the imagined future. A constructive form of speculative bioethics must be able to critically assess visions of technological futures if it is to function as an ethics that is of and for the present.
This article considers differences between the representation of mutation in science fiction films from the 1950s and the present, and identifies distinctive changes over this time period, both in relation to the narrative causes of genetic disruption and in the aesthetics of its visual display. Discerning an increasingly abject quality to science fiction mutations from the 1970s onwards—as a progressive tendency to view the physically opened body, one that has a seemingly fluid interior–exterior reversal, or one that is almost beyond recognition as humanoid—the article connects a propensity for disgust to the corresponding socio-cultural and political zeitgeist. Specifically, it suggests that such imagery is tied to a more expansive ‘structure of feeling’, proposed by Raymond Williams and emergent since the 1970s, but gathering momentum in later decades, that reflects an ‘opening up’ of society in all its visual, socio-cultural and political configurations. Expressly, it parallels a change from a repressive, patriarchal society that constructed medicine as infallible and male doctors as omnipotent to one that is generally more liberated, transparent and equitable. Engaging theoretically with the concept of a ‘structure of feeling’, and critically with scientific, cinematic and cultural discourses, two post-1970s’ ‘mutation’ films, The Fly (1986) and District 9 (2009), are considered in relation to their pre-1970s’ predecessors, and their aesthetics related to the perceptions and articulations of the medical profession at their respective historic moments, locating such instances within a broader medico-political canvas.
Early last year, a non-profit organisation called ‘Limbitless Solutions’ modelled a 3D printed prosthetic arm on a fighting suit that features in the popular superhero film series, Iron Man (2008–2013). In addition, ‘Limbitless Solutions’ resourcefully deployed the fictional character and inventor of the Iron Man suit, weapons specialist and philanthropist, Tony Stark, played by Robert Downey Jr, in a celebrity/superhero endorsed promotional short film, showing ‘Tony’, the ‘real Iron Man’, gifting the futuristic military styled ‘gauntlet’ to Alex, a 7-year-old boy with a partially developed right arm. Engaging with scholarly work on the science fiction of technoscience, prostheses and the posthuman, and disability and DIY assistive technology, I analyse ‘Limbitless Solutions’ use of science fiction in a high-profile media event that problematically portrays an impaired child ‘in need’ of ‘repair’ and subsequently ‘fixed’ by technology. Overall, the aim is to integrate science fiction tropes, such as the wounded hero, the fighting suit and prosthetic arm, with disability studies, to highlight the sustained challenges that emerging theories of disability and technology face as contemporary economic, political and ideological forces endorse and promote militarised images of cyborg assimilation over human variation and physical difference.
Lesley Henderson and Simon Carter
There has been considerable interest in images of medicine in popular science fiction and in representations of doctors in television fiction. Surprisingly little attention has been paid to doctors administering space medicine in science fiction. This article redresses this gap. We analyse the evolving figure of ‘the doctor’ in different popular science fiction television series. Building upon debates within Medical Sociology, Cultural Studies and Media Studies we argue that the figure of ‘the doctor’ is discursively deployed to act as the moral compass at the centre of the programme narrative. Our analysis highlights that the qualities, norms and ethics represented by doctors in space (ships) are intertwined with issues of gender equality, speciesism and posthuman ethics. We explore the signifying practices and political articulations that are played out through these cultural imaginaries. For example, the ways in which ‘the simple country doctor’ is deployed to help establish hegemonic formations concerning potentially destabilising technoscientific futures involving alternative sexualities, or military dystopia. Doctors mostly function to provide the ethical point of narrative stability within a world in flux, referencing a nostalgia for the traditional, attentive, humanistic family physician. The science fiction doctor facilitates the personalisation of technological change and thus becomes a useful conduit through which societal fears and anxieties concerning medicine, bioethics and morality in a ‘post 9/11’ world can be expressed and explored.
[This article originally appeared in Limn, Issue No. 7, “Public Infrastructures / Infrastructural Publics”.]
For the past several decades, Flint, Michigan, has staggered under waves of deindustrialization, disinvestment, and abandonment that have left the city depopulated, its built environment in shambles, and its remaining residents reeling from high unemployment and crime rates, a decimated tax base, and dwindling municipal services. While grim, Flint’s decline is by no means unique in a region whose cities have become synonymous with the booms and busts of twentieth century American manufacturing. Nor is the degree of its decay unusual. Aficionados of ruin will find crumbling infrastructures arresting and aplenty in most any “Rust Belt” city. What is singular, however, is the attention that Flint’s contaminated water has received in recent months, an attention that is now amplifying ongoing debates concerning America’s ailing and aging infrastructures. That amplification is especially apparent in variations of a phrase that has recently echoed through local, regional, and national media and activist circles: “We are all Flint.”
With every disclosed email, alleged wrongdoing, and denial of responsibility, the course of Flint’s contamination grows as murky and foul as the water that began flowing from its taps in 2014. In April of that year, the city switched its water source from Lake Huron to the Flint River. The switch unfolded amid a climate of intense fiscal austerity in which state-appointed emergency managers pushed Michigan’s most financially beleaguered cities to cut costs. In Flint, part of this push included a proposal to bypass Detroit’s Water and Sewerage Department as the city’s water supplier, and to instead source cheaper water through a newly constructed pipeline into Lake Huron. Yet until that pipeline came on line in 2016, the city would draw directly from its river. Decades of heavy industry, pollution, and salted roads meant that more than water rolled through that river. Bacteria, chloride, and chlorine-based disinfectants transformed Flint’s treated river water into a highly corrosive soup that ate into aging copper, iron, and lead pipes. Heavy metals then leached from the service lines that connected individual homes, schools, businesses, and factories to Flint’s broader water infrastructure.
Flint’s residents complained almost immediately about the rank, rust-colored water that tasted strange and sickened them. Local water workers and state environmental monitors, however, repeatedly brushed off these complaints, even as they failed to combat pipe corrosion. According to recent criminal charges, some even went so far as to tamper with tests and readings that would have confirmed the heavy amounts of lead in Flint’s water system (State of Michigan Attorney General 2016). Pressure mounted throughout 2015 as residents clamored for action, and as researchers and medical professionals documented high lead levels in Flint’s water alongside a spike in cases of children with elevated levels of this potent neurotoxin in their blood.
“Flint’s Katrina,” as some activists and politicians have taken to calling the contamination, might seem an isolated event born of the catastrophic convergence of emergency management, shifting water chemistry, aging pipes, and failed governmental oversight. After all, what makes an event a disaster is its ability to rupture everyday life, expectations, and routines. Yet “We are all Flint’s” traction in local, regional, and national media suggests something else. Doctors, journalists, and activists have all invoked the phrase when pointing to the ongoing presence of lead in Americans’ everyday lives, especially within the water systems of older cities. If “We are all Flint” is a rallying cry, exactly who and for what does it rally?
In the face such a question, it’s tempting to argue that there is something universalizing about water because it is a substance that all humans depend on. Consider comments made by Erin Brockovich, an environmental activist known for her legal advocacy. In Brockovich’s recent article “We Are All Flint” (2016), the city emerges as just one entry in a list of municipalities afflicted by a common denominator: tainted water. Water is “the one thing that sustains us all,” Brockovich writes, and for that reason, contaminated water doesn’t “see any boundaries of rich or poor, black or white, Republican or Democrat” (Brockovich 2016). Flint is unusual only because it is “the perfect storm” of pollution and government inaction that might just cause “everybody else to wake up” to the presence of toxins in all our lives and bodies (Brockovich 2016). Here, our biological dependence upon water collapses social boundaries, drawing us into a universal political body with a shared stake in clean water.
In the face of such universalisms, it’s also tempting to underscore that not every American navigates tainted water in the same way. After all, it is not just any city being poisoned through its degraded and neglected infrastructures, but an impoverished Black city. Take a recent column by New York Times journalist Nick Kristoff titled “America Is Flint.” “Today the continuing poisoning of half a million American children is tolerated,” Kristoff writes, “partly because the victims often are low-income children of color” (Kristoff 2016). Kristoff’s column does not back away from the sentiments undergirding “We are all Flint.” It merely qualifies them by pointing out the ubiquity of lead in Americans’ lives alongside the uneven distribution of its risks. A more pointed critique might suggest that were “we” to foreground that that unevenness, we might be forced to recognize that if “America is Flint,” it is not because of the ubiquity of lead in our water infrastructures. It is because like Flint, America is a place built on profound, longstanding, and enduring racial and economic inequalities that continue to waste some but not all of its citizens’ bodies and communities. From this perspective, the sentiments that undergird “We are all Flint” bear more than a passing resemblance to those associated with “All Lives Matter.” They gesture to enduring inequalities at the same time they blunt any serious criticism of those inequalities by diluting them in a wash of misdirected solidarity. Here, “We are all Flint” isn’t just hogwash: it’s whitewash.
While American society’s enduring inequalities are troubling, they are not exactly news. News commentary surrounding Flint in fact dwells on how racial animus directed against residents of this “majority minority” city might have driven the neglect and disregard that ushered in its contamination. “We are all Flint’s” power then rests not on the phrase’s affirmation or denial of social inequalities, but on its capacity to summon a “we,” an expansive group comprising countless Americans concerned with “our” aging municipal water infrastructures. In the process, a down-at-the-heels, Black city in a down-at-the-heels state has become emblematic of the dangers that infrastructural degradation poses to all Americans. The question that “We are all Flint’s” traction raises then is not whether this “we” actually includes those Americans most at risk from lead poisoning. It is rather about the kinds of risks that a far-flung group of citizens can recognize as shared, and thus worthy of collective concern and action, and those that will, despite their ubiquity, seem isolated events that will never break the surface of widespread attention. Scholars of mass media in liberal democratic societies have a term for such groups: publics.
Publics form when strangers consume media forms, like newspapers, newscasts, and novels. As they respond to these forms, and imagine countless others throughout their cities, states, or nations doing the same, they constitute themselves as a political whole (Calhoun 1998; Habermas 1991; Warner 2002). Members of publics come to imagine themselves as part of much larger wholes capable of voicing collective interests and making collective demands upon entities tasked with protecting those interests. Publics emerge through speaking, listening, and reading. As such, they are discursive formations. Yet those formations are never divorced from a material world. Brockovich’s readers have no trouble imagining a “we” indignant at tainted water precisely because they have spent lifetimes opening and closing their own taps, lifetimes filling glasses, tubs, and pots with the water that comes gushing out, and lifetimes expecting that water to be clean. And they have spent lifetimes expecting that their taxes supported the care that fellow citizens took with protecting important collective goods such as water. Yet it’s not every infrastructure that raises a public able to make demands about the soundness of the collective goods it delivers. Consider, for instance, the relative silence that surrounds lead’s presence within another major infrastructure: housing.
Housing does not often show up in conversations about infrastructure, but it should. When understood as a thing that draws other entities into relation, an infrastructure need not be limited to the pipes, wires, or roads that so often come to mind whenever we utter the term (Larkin 2013). We can also understand it as a thing that facilitates flows, standardizes distributions, and extends political projects (Anand 2017; Chu 2014; Collier 2011; Joyce 2003; von Schnitzler 2016). Beginning in the 1930s, subsidized housing in both its public and private guises became a premier infrastructure of the American welfare state. On the one hand, public housing, at least in its earliest years, delivered sound shelter to working- and middle-class Americans shut out of housing markets on account of their limited means or the color of their skin. On the other hand, federally guaranteed mortgages allowed many Americans in the middle class—and those who aspired to join its ranks—to stabilize their housing costs by spreading them over several decades. They obtained, on extremely favorable terms, a major asset that they could then leverage to finance things a household’s members might need, or just want: educations, retirements, second homes, business ventures, enough accrued wealth to pass onto children. The trappings of middle-class security became bound up in the mortgaged home and the orientations to time, place, saving, and spending that it disciplined among mortgage holders. But as much as this welfare infrastructure facilitated the expansion and distribution of financial and economic wellbeing, it was also a thing in its own right. And in the course of older American cities, that thing became thoroughly leaded.
By the early twentieth century, lead was common in the pipes that snaked through growing industrial cities and in the soils of areas that surrounded smelters and foundries. When lead became a common additive in gasoline in the 1920s, lead particles in the air and soil became even denser (Shea 2007). Yet it was lead’s presence in house paint that threw—and continues to throw—American children most directly into its path. Consumer tastes for colorful domestic interiors grew in the 1920s. The electrification of cities meant that consumers no longer needed their house paint to cover soot from coal- and gas-burning lamps, and thus dark, oil-based paints fell out of fashion. Lead paint made the surfaces it covered bright, durable, and easy to clean, adding to consumers’ conceptions that it was the most hygienic way to treat surfaces (Markowitz and Rosner 2002; Warren 2000). As lead paint was more expensive than other paints, consumers tended to save it for surfaces that would see more wear and tear, such as baseboards, windowsills, doors, and stairs. And so the very surfaces small children gravitate toward for ballast as they learn to stand up and walk around became covered in a thin, metallic layer. Without regular maintenance, those surfaces could break down and release leaded dusts. Small children easily ingested these dusts because they explore their worlds as much with their mouths as they do with their hands. During the middle decades of the twentieth century, doctors and researchers gradually tied such ingestion to a host of ailments, including lifelong cognitive impairments, behavioral problems, stunted growth, and in severe cases, death (Markowitz and Rosner 2013). More recently, researchers have suggested that lead-poisoned children afflicted with behavioral problems can age into erratic, aggressive, even criminal behavior (Nevin 2007).
By the 1950s, physicians understood that deteriorating paint had ushered in a lead poisoning epidemic among children, especially among impoverished children living in the dilapidated housing stocks of aging industrial cities. They clamored for regulations, and two strategies emerged. The first called for eliminating lead from American life, and a total ban on its circulation. The second, considered far more cost effective, focused on limiting individual instances of exposure (Markowitz and Rosner 2013). Federal regulations finally emerged in the late 1970s that prohibited the use of lead in paint destined for residential uses. Even so, many leaded homes would remain leaded: to this day, health professionals advise homeowners and landlords that aging lead paint poses little risk when neatly sealed with a layer of clean paint, tile, drywall, or wallpaper, and when dust is contained during renovation. The main public health intervention is to direct those who own homes built before 1980 to make sure that lead paint is properly contained, that renovations are properly conducted, and that children avoid suspect surfaces. In short, lead paint still lingers in all manner of homes financed and delivered through governmental subsidies and programs. Yet in a society that takes homeownership aspirations for granted, and treats the responsible mortgage holder as an exemplar of citizenly virtue, it is difficult to parse the lead layered in one’s walls and windowsills as a collective matter that warrants widespread attention and concern. There is no “we” here; there are only individual homeowners and landlords who act more and less responsibly when grappling with the residues of bygone building practices, homeowners and landlords who are more or less able to safeguard the health of both their investments and the people who live within them. This ethos of individual responsibility is in fact so strong that it has come to govern even obsolete housing infrastructures and their disposal.
Consider here the serious effort that another financially beleaguered Michigan city has recently undertaken to mitigate the hazards posed by the vacant houses that litter its landscape. In 2014, Detroit embarked on an ambitious, federally funded plan to take down 40,000 derelict structures. Those coordinating the demolitions put in place measures to suppress the spread of demolition dust, which typically comprises a range of heavy metals, including copper, manganese, iron, and lead. Coordinators have concerned themselves especially with lead. Like many cities in the region, Detroit has struggled with high childhood lead poisoning rates: although rates have fallen in the past decade, they are still nearly twice the national average (Bienkowski 2013). Adopted measures included requiring contractors to forgo the wrecking ball in favor of equipment and procedures that release less dust, to wet down houses and the resulting debris piles as they demolish houses and cart them off to the dump, and to distribute materials to neighbors that offer tips for avoiding dust. While federal regulators have lauded these steps as a “best practice,” they have not required Detroit to undertake any of them. Were this “best practice” to fall by the wayside under mounting criticisms about rising demolition costs and dwindling federal funds to cover them, nothing apart from personal vigilance would stand between a resident and her exposure to potentially hazardous dusts.
Now compare this situation with that of Flint. Federal regulations phased out lead pipes, paint, and gasoline around roughly the same time. And like leaded housing, many leaded water infrastructures have remained leaded because remediation strategies have likewise centered on containment instead of removal. This is where the similarity ends. Federal regulations in place since the early 1990s require water utilities to take standard corrosion control measures (U.S. Environmental Protection Agency [EPA] 1991). Adding phosphates to water during the treatment process coats pipes in ways that inhibit lead and copper from leaching into water from a utilities’ own aging and outmoded piping, but also from consumers’ aging and outmoded piping. This second point is crucial: regulations exist governing the disposal of leaded paint in occupied buildings, but they target the actions and inactions of individual property owners. The responsibility for lead mitigation within water infrastructures is neither localized nor localizable. Instead, the service provider must assume responsibility for the health of water distributed throughout the entire network. As such, it must mitigate leaching risks in the houses of private homeowners by making sure that the water it sends into those houses will not cause aging pipes and fixtures to leach lead. This is the step that water workers failed to take in Flint, and the step that state and federal regulators failed to enforce. In the process, they set off a public health emergency that has captured national attention. Federal and state governments are heavily involved in providing and regulating the goods of shelter and water. Yet in contrast to water, Americans do not generally consider shelter to be a collective good, as evinced by that fact that its provision, maintenance, and regulation is in most instances not centrally administered. Publics raised through water infrastructures can make demands of public entities that publics raised through housing infrastructures generally cannot. This means that heads can and will roll for toxic water in a way that they have not and cannot roll for physically and financially toxic housing.
Once airborne, demolition dusts can circulate beyond the point of their origin. In this respect, they resemble the expansive reach of flowing water. Yet even though dust generated by the demolition of homes poses public health hazards in cities across the United States, we are not all Detroit. Just as we are not all Baltimore, Chicago, or Milwaukee, all cities that have, courtesy of leaded house paint, struggled with epidemic lead poisoning rates. Flint is an entirely different matter because Americans have come to conceive of water and its delivery in an entirely different fashion. Water infrastructures may send water flowing through an individual home, but they are not ultimately of that home. They tap deep into investments in a good whose care seems utterly beyond the reach of any single individual. And these investments float the stuff not just of collective imagination and identification, but also of collective administration and related demands for collective protection. So while “we” might all be at risk for ingesting toxins, some of us can spit back the lead soup that leaches from “our” pipes, even as others must swallow the lead dust that flakes off “our” walls.
Catherine Fennell is an anthropologist at Columbia University whose work examines the social and material legacies of housing in the urban Midwest.
Anand, Nikhil. 2017. The Hydraulic City. Durham, NC: Duke University Press.
Bienkowski, Brian. 2013. “Good News for Detroit: Lead Poisoning of Kids Drops 70 Percent since 2004.” Environmental Health News, February 28. link
Brockovich, Erin. 2016. “We are all Flint: How America’s Moms are Leading the Battle for Clean Drinking Water.” Huffington Post, March 18. link
Calhoun, Craig. 1998. “Community with Propinquity Revisited: Communications Technology and the Transformation of the Urban Public Sphere.” Sociological Inquiry 68(3):373–397.
Chu, Julie. 2014. “When Infrastructures Attack: The Workings of Disrepair in China.” American Ethnologist 41(2):351–367.
Collier, Stephen. 2011. Post Soviet Social: Neoliberalism, Social Modernity, Biopolitics. Princeton, NJ: Princeton University Press.
Habermas, Jurgen. 1991. The Structural Transformation of the Public Sphere. Cambridge, MA: MIT Press.
Joyce, Patrick. 2003. The Rule of Freedom: Liberalism and the Modern City. New York: Verso.
Kristoff, Nicholas. 2016. “America is Flint.” New York Times, February 6. link
Larkin, Brian. 2013. “The Politics and Poetics of Infrastructure.” Annual Review of Anthropology 42(1):327–343.
Markowitz Gerald, and David Rosner. 2002. Deceit and Denial: The Deadly Politics of Industrial Pollution. Berkeley: University of California Press.
———. 2013. Lead Wars: The politics of Science and the Fate of America’s Children. Berkeley: University of California Press.
Nevin, Rick. 2007. “Understanding International Crime Trends: The Legacy of Preschool Lead Exposure.” Environmental Research 104:315–336.
Shea, Edward. 2007. Lead Regulation Handbook. Lanham, MD: Government Institutes.
State of Michigan Attorney General. 2016. “Schuette Charges Three with Multiple Felonies in First Stage of Flint Water Crisis Investigation” [press release], April 20. link
U.S. Environmental Protection Agency (EPA). 1991. Lead and Copper Rule. Washington, DC: EPA, Office of Water.
von Schnitzler, Antina. 2016. Democracy’s Infrastructure: Techno-politics and Protest after Apartheid. Princeton, NJ: Princeton University Press.
Warner, Michael. 2002. Publics and Counterpublics. Cambridge, MA: MIT Press.
Warren, Christopher. 2000. Brush with Death: A Social History of Lead Poisoning. Baltimore, MD: Johns Hopkins University Press.
Book Forum––Science, Reason, Modernity: Readings for an Anthropology of the Contemporary by Todd Meyers
Science, Reason, Modernity: Readings for an Anthropology of the Contemporary is many things — a carefully curated selection of classic texts ranging from Immanuel Kant’s “An Answer to the Question: ‘What is Enlightenment?’” and Max Weber’s “Science as a Vocation,” to Georges Canguilhem’s “The Question of Normality in the History of Biological Thought” and Paul Rabinow’s “Anthropos Today: Reflections on Modern Equipment”; a critical intervention aimed at the core of science studies; an exacting, plowing thesis on the anthropology of the contemporary; and a pedagogical resource crafted for those seeking paths through the briar of scientific method and biological thought (and their historical, social, and philosophical registers). We hope you enjoy a provocative and engaging set of commentaries.
Mediated Experiences: 1-7
Bradley Dunseith + Sean Miller + Antoine Przybylak-Brouillard + Meg Stalcup
University of Ottawa
Canguilhem: the mutual purpose of ethics and science
Goldsmiths, University of London
The Rabinowian Program
University of Liege
Forging Links, Surveying Rifts
University of Pennsylvania
In the Folds of the Contemporary
Gaymon Bennett, Lyle Fearnley & Anthony Stavrianakis
Arizona State University, Singapore University of Technology and Design, CNRS
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On Deanthropologizing Anthropology — An Essay on Tarek Elhaik’s “The Incurable Image” by Tobias Rees
“Are cultural anthropologists ready to shed their habit of using society and culture? (…) No, I don’t feel so. (…) It seems to me that many anthropologists wish to keep the human (…). There is a tricky problem here: concentrating around the human could mean either maintaining this character apart from other entities — the former beings of ‘nature’ defining by contrast what could be called the ‘humanistic’ position —, or it could mean accepting that, as soon as you take the human into consideration, it is suddenly redistributed (not disintegrated, that’s the whole point, but redistributed) in many other roles and connections that make its earlier figurations unrecognizable.”
Could one deanthropologize anthropology? Is it possible to differentiate anthropology, science of the human, from the figure of ‘Man’ as it emerged in the 18th century and made anthropology possible (Foucault 1966)?
At first these questions may sound bizarre — and an anthropology journal an odd choice for asking them. However, the will to leave the human behind is a prominent feature of what one could call contemporary anthropologies of nature. The reference here is largely to the so-called ontological turn (for reviews see Kohn 2015; Boellstorff 2016) and multi-species anthropology (Helmreich and Kirksey 2010; Kirksey 2014).
Admittedly, I find the writings of the multi-species anthropologists and the ontologists — the two groups are best kept separate, precisely insofar as many of the former are not actually ontologists at all — hugely fascinating: I find myself intrigued by the effort to break free from ‘the human.’ I find it fascinating to read anthropology books on mushrooms (Tsing 2015) and cheese (Paxson 2012), on rocks (Povinelli 2016), water and waves (Helmreich 2009; 2015), pigeons (Jerolmak 2013), and insects (Raffles 2010) — to read them as an effort to imagine anthropology as independent from the concept of the human that has historically made anthropology possible. How can one imagine anthropology differently? What could an anthropology of the animal — or the mushroom — look like?
But then, I also find many of the anthropologies of alternative ontologies or multi-species assemblages sobering. Leaving the human behind, whether in substance or in form, seems much more difficult than anticipated. For example, most works in multi-species anthropology happily reproduce the very genre of anthropology from which they seek to depart. Like classical modern ethnographers studied strange and exotic others — the ‘primitive,’ the ‘savage,’ with their seemingly inexplicable rituals —, multi-species anthropologists study strange and exotic animals and their seemingly inexplicable (but endlessly curious) behavior. And like the ‘primitive’ was once invented — or instrumentalized — by ethnographers to put the taken-for-grantedness of our own, Western life style in question, so today the animal is used to question our self-description as human. What is more, just like once every anthropologist had her tribe (Shilluk, Trobrianders, Zulu, Aranda), so each multi-species anthropologists has her animal or plant.
There might be a focus on animals rather than on humans, but in a curious — and at times problematic — turn, animals (or plants) often seem to assume the role formerly reserved to ‘the primitive:’ as a moralizer of the (Western, modern concept of the) human.
Ontology has comparable issues (e.g., Kohn 2007; Viveiros de Castro 2004; Holbraad 2009; Holbraad et al. 2014; Descola 1996a, 1996b, 2013, 2014). The vast majority of ontologists directly or indirectly seem to rely on Latour’s problematization of modernity understood as the separation of nature and culture — and to then argue that the ‘primitive’ has never made that mistake in the first place (Latour 1996). More often than not this argument is offered in form of a critique of modernity that is reminiscent of the 19th century romantic conception of nature (of which the formerly premoderns are the guardians) — a setup that evokes the moral authority of nature in the face of the violent (human) destruction of the environment.
Much of ontology, thus, appears to be a curious inversion of the philosophy of history that has been constitutive of modernity: it is contingent on the very argument it sets out to leave behind.
At least two sets of questions emerge from the sobering effect that emerges from readings in ontology and multi-species anthropology. The first is quite simply this, how to really break free from ‘the human?’ How to decouple anthropology of the figure Michel Foucault called ‘Man’ without immediately reintroducing the vocabulary that stabilized ‘Man’ from within and without simply inversing the nature/culture relationship?
The second set of questions emerges from the, let’s say, ‘narrow’ focus of most of the works that ask the first one: the actual empirical focus of those interested in breaking with human exceptionalism is almost exclusively on nature, on human-animal relations, on bacteria, plants, mushrooms, soil, environments. A bit as if nature or the possibility to establish a human/nature continuum is the only possible point of departure, the only hopeful remedy against ‘the human.’ Indeed, one is occasionally left with the impression that any attention to the human is retrograde, a conservative remnant of a modernist past. This, well, morally charged focus on nature provokes me to ask: Couldn’t one envision an anthropology ‘of’ the human but after ‘the human?’ That is, an anthropology still interested in things human but not ready to assess human things in terms of ‘Man?’ Differently asked, could it be that one venue for deanthropologizing the human could be found not in nature but in the emergence of human affairs that escape the vocabulary that surrounds ‘the human?’
It is in the face of these questions that The Incurable Image, a book by Tarek Elhaik, an anthropologist and curator, gains its significance; it provides an unanticipated, fieldwork-based answer to both of the above questions.
In the early 2000s, Elhaik, left to conduct fieldwork among contemporary artists and curators in Mexico City. Prior to attending University, Elhaik — a native of Morocco — had been a curator of Arab film festivals. While immersed in cinema, he found himself intrigued by the overlap between the themes explored by the films he curated and questions that surfaced in various anthropological projects of the 1990s: questions of decolonialization, of the possibilities and pitfalls of a postcolonial identity, of the figure of the migrant, of cultural differences, of alternative modernities, of the possibility of a — non-Western-based — cosmopolitan politics.
In school (working with Paul Rabinow) Elhaik built an imaginaire that revolved around a clearly defined set of references (think of it as an echo of the 1990s): (1) the sense of play defined by what Marcus and Fischer in 1986 called ‘the experimental moment in the human sciences;’ (2) the critique of western epistemologies today largely (if not quite correctly) associated with Writing Culture and Public Culture; (3) what Jim Clifford described as Ethnographic Surrealism (the overlap of avant-garde, literary modernism, painting, and anthropology especially in the 1920s and 30s); and (4) by Georges Marcus’ exploration of the significance of the cinematic technique of montage for post-Writing Culture ethnographies.
Equipped with this imaginaire as well as with the questions he had fostered since his days as film curator — question of non-Western modernities, postcolonial identity, art, and cosmopolitanism —, Elhaik left, in the early 2000s, for Mexico City.
He was curious what a contemporary, politically as well as epistemologically oriented formation of Ethnographic Surrealism in Mexico City would look like. What if one replaced ‘classical modern ethnography’ with ‘contemporary anthropology’ and ‘classical modern art’ with ‘contemporary art’ (art after the conceptual turn, in the age of media art)?
Mexico seemed an ideal site for posing these kinds of questions. The country has a long — indeed, a spectacular — history of encounters between art and anthropology, between the search for political form and film. Beginning in the 1920s anthropologists and avant-garde artists (Mexican as well as international) came together to invent emblems for a national culture for revolutionary Mexico. Quite literally, anthropology — science of ethnos — was charged with the task to provide accounts, together with artists, film makers, writers, of Mexican culture (Elhaik has many pages on the significance in particular of Eisenstein’s Que Viva Mexico for this collaboration between art, avant-garde, anthropology and revolutionary politics).
Elhaik found himself intrigued by the adventure of exploring what the latest configuration of this interplay of art, politics, and anthropology in contemporary cosmopolitan Mexico City would look like? What new configuration of modernity, of cosmopolitan — but non-Western — politics would emerge?
It seems like the first thing that emerged was, well, a tragic disenchantment with his own set of questions. The reason for this disenchantment — for this intellectual tragedy — was what Elhaik calls his encounters with ‘the post-Mexican scene.’
Only a few years before his arrival, the anthropologist Roger Bartra had published Blood, Ink, and Culture, a volume of essays, several of which can be read as a deconstruction of the collaboration of anthropologists and artists in the invention of a national culture for revolutionary Mexico (from the emblematic cactus landscape to pre-Colombian figurines to the hacienda to the pelado, the disenfranchised urban poor).
Bartra argues that contemporary Mexico has outgrown the images of Mexicaness that anthropologists and artists once constructed — and he shows the indebtedness of the images of Mexicaness to European genealogies. The dream of Mexico was a European dream, a nightmare that configured humans through substantive humanist conceptions of culture, society, the nation, territory.
How to come to terms with Mexico after — Mexico?
It is this question that critically defined the arts scenes in which Elhaik arrived. Many of the most active art and curatorial groups of Mexico City — Curare, SEMFEO, Teratoma, InSITE, and Laboratorio 060 — understand their work as attending to the Post-Mexican moment, a moment which they attend to in terms borrowed from pathology (Elhaik, noticing the close relation between critique and a clinical language often refers to Deleuze’s Essays Critical and Clinical).
To give an example, Elhaik quotes from a curatorial statement written by a member and co-founder of Teratoma:
“Teratoma is a site of encounters, debates, exhibitions, residencies, pedagogy, dialogues, archiving of textual, visual, physical and virtual information in order to allow production, debate and reception of the various cultures to come in our continent. For now, we have decided to adopt TERATOMA as a provisional name for our group. As some of you may already know, the name comes to us from pathology: it is a denomination that refers to a type of tumor that has the nasty particularity to generate all kind of cell types, but without organization. As a result of a failure in the cellular reproductive mechanism, often due to the latency of embryonic cells or to genetic disorder, Teratoma has the tendency to grow in the body by combining, in a quasi-monstrous way, neuronal tissue with pelvic bones, semen with mammal glands, and so on Teratoma appears like a double of the affected body, perfectly identical to it, yet acting as its twin, without top or bottom, left or right, or distinction between function and localization. Teratoma is a metaphor that stands for the rejection of at once the ideal architecture of culture and the evolutionist imaginary. It is the illness of a regression to chaos by a colony of cells that acts parasitically towards the symbolic apparatus.”
Another feature (next to the blurring of the critical and the clinical) of many of the art projects Elhaik studies is that they symbolically use anthropology — science of nations small and large, of territorially imagined societies that are culturally identical with themselves — to bring the sickness of the ethnos-configuration of the human into view.
The exemplary reference here is to Eduardo Abaroa’s La Destrucción Total del Museo de Antropología (2012), an installation of pieces of debris from a symbolically destroyed national anthropology museum.
In Mexico City, thus, Elhaik begins to recognize — and this recognition process is a critical feature of his Erkenntnisprozess — that many of the elements that framed his research when he left for the field were ultimately still refractions of ‘Man.’ He discovers, not without shock, that, ultimately, even the postcolonial, cosmopolitan critique of the West or the search for alternative, ‘culturally’ differently configured modernities (or ontologies, for that matter) is bound to the territorial, the national, the social, the cultural (Deleuze and Guattari). What, after all, becomes of multiple modernities if one takes away the territorial and cultural references so critical for, say, Appadurai’s appropriation of Eisenstadt?
Or take the figure of the migrant as the unsettling cultural other: isn’t this still a reflection of a territorialized culture concept of the human?
The question, of course, is how Elhaik — the anthropologist — responds to his interlocutors’s destruction of anthropology? What form does an anthropology in the moments of its impossibility take?
Elhaik’s takes up this challenge by making his major fieldwork based discovery the object of his book: in eight essayistic chapters he traces how — with what tools, with what concepts — contemporary Mexican curators, media and film artists expose anthropology. However, these chapters are not representations, as if Elhaik were simply saying ‘this is what contemporary artists in Mexico do.’ Were they representations, he would reproduce the form that he — his friends — so vehemently critique. Instead of a representation, Elhaik designed his book as an ‘installation’ book — a book that is as much art as anthropology, that blurs the artists’ exposure of anthropology with the anthropologists’ interest in finding a form of anthropology in the moment in which anthropology as we know it has become impossible.
While Elhaik explores various installation forms, two emerge as most prominent from his research, curation and the incurable.
What is the incurable? It is a metaphor taken from the realm of the clinical to indicate the post-Mexican condition — a situation in which Mexico has already broken with Mexico and still is trapped by the image of Mexico it once has itself fabricated. It is the impossibility of letting go a form even when this form has become impossible — the form composed of an assemblage made up of the revolution, of politics, ethnos, the nation, culture, society, anthropology, art. What is sick — incurable, even untreatable — is as well anthropology. The incurable allows to bring into view a Mexico (an anthropology) that can never be anything but an escape, a discrepancy, a pain, a disease. Like his interlocutors, Elhaik here grounds his work in a language partly borrowed from pathology, partly from existentialist philosophy: he speaks of the incurable, of metastases, of pathology, and — often — of ‘endurance’ (as if all that is left to do is endure the untreatable).
And curation? Curation is first and foremost a form of care, a form of attending to the incurable, the untreatable — which also is to say a form of exposing disease. It is through the broken figure of the incurable image — the image of Mexico, the image of the human, the subject, the migrant, the postcolonial, the cosmopolitan, etc. — that Elhaik attends to the contemporary (im)possibility of Mexico, of anthropology.
For Elhaik, riffing of Abaroa’s total destruction of the national museum of anthropology, the anthropologist today is left with attending — with care, with pain, but also with a certain relief — to debris, with scattered bits and piece no one can put together again into something whole.
It is the rupture with ‘the human,’ that makes anthropology possible (as an attention to the dispersed, the scattered, the fragment).
The Incurable Image is also a book of critique — a critique that emerges from the debris that Elhaik studies. One of the principle objects of the critical energy of the book is alliance of anthropologists and artists around what Hal Foster in 1996 called the “ethnographic turn.”
Elhaik’s intervention is twofold. On the one hand, he writes with vehemence against artists who naively reinstate anthropology as the science of ‘cultural alterity.’ On the other hand, he fiercely turns against those anthropologists who embrace the artist’s suggestion that anthropology is somehow the guardian of the wisdom conserved by the premodern. The climax of this critique is when Elhaik exposes the emergence of a sensory ethnography (the reference here is to Lucien Castaing-Taylor’s sensory ethnography lab).
The background to the ‘turn’ to the sensory, Elhaik explains, is the suggestion by critiques of modernity that ‘the culture’ of ‘the West’ has privileged ‘vision’ over the other four senses; it has thereby established a hegemony of one mode of relating to the world — a mode of observation, of representation, of the cognitive, ultimately of thought and reason. The implication of this critique is that the non-Western — the premodern as documented by ethnographers — has had a sensually more diverse, indeed ‘holistic’ relation to the world. The non-Western world, the story goes, has preserved a haptic way of being enmeshed in the (natural) world through smell, touch, hearing, smell, and also through vision. The implication is as well that the sensory turn in anthropology and in art is a critical exposure of the shortcomings of modernity, of what the West has forgotten.
With verve Elhaik mocks the image of the ‘holistic man’ that emerges from sensory ethnography, mocks the very idea that anthropology is the guardian of the holism that has been preserved among ‘the primitive’ (a story that strangely reflects the turn to social suffering that has made much of medical anthropology a moral science). What is more he exposes the naïve conception of humanity that distinguishes between the West/modern and the rest/premodern and thereby repeats a philosophy of history that has so severely been critiqued by the Writing Culture generation. Some of his sentences are worth being quoted at length.
“Alas, rather than opening new vistas and problematizations, [sensory ethnography] implicitly returns us to a place that still distinguishes between West and non West, and from which we have to choose between conceptual abstract and sensorial material modes of conducting life and research.”
“Of course, it is important to remind ourselves, as Jonathan Crary, Laura Marks, and others have astutely done, of the imperial primacy of vision in Western modernity’s capture of the world and its attendant neglect of the haptic, the aural, and so on. But, it is unclear why and how a sensory ethnographic orientation would enable, simultaneously, the decolonization of the categories of the ethnographic turn, the poststructuralist desire to unseat the sovereign subject and the question of the author, and the geopolitical reconfiguration of artists’ and anthropologists’ mise-en-scene. It is simply unclear why and how, today, the value of the sensory should be the order of the day and the ethical mode framing the relationship between art and anthropology.”
“The sensory mis-en-scene will always be haunted by two ghosts that are ultimately two sides of the same coin: it will claim the so called non-Western, subaltern, and sub cultural practices as occupying a more multisensorial, less ocular centric subject position while attempting, in the same gesture, to search for and redeem, in the present, a pre-visual, communal and artisanal state of affairs which the West has allegedly lost.”
To Elhaik, the ethnographic turn of art — and its reflection in sensory ethnography or the ontological turn — ultimately is a reification of the naive modern primitivism of the 1920s and 30s. With one difference though, “Tragedy the first time, farce the second.”
What makes The Incurable Image a most interesting book is — that it is one the most successful attempts at deanthropologizing anthropology that I know of. What makes the book so compelling, even if this may sound strange, is that it is an intervention in a discussion its author never meant to contribute to: The beauty of the book is that it revolves around questions its author never set out to address. Indeed, it is precisely that — and how — Elhaik’s initial project fails, the perplexity that emerges from this derailment, and, eventually, the effort to find possibilities to conduct anthropology in the moment of its becoming impossible that is so compelling and refreshing.
For Elhaik, the departure from the configuration of the human in terms of culture, society, territory was nothing he had hoped for or planned. On the contrary, it was an (at first) unwelcome, fieldwork based, unanticipated discovery that came in form of a shock. How shocking indeed this discovery has been — how painful (endurance) — emerges from every page of his book.
The consequence of this shock — of the encounter with unanticipated that dissolved his initial project — is that there are no grand arguments in The incurable Image. No universal theories; no ontologies; no declarations of epochal errors (the destructions of nature wrought about by the moderns); no grand alternatives or replacement approaches (what comes after culture or society?). What is more, the book is free from allocation of blame, free from moral judgments (no celebration of the moral authority of nature, the non-moderns, animals, or plants).
Instead of writing in the tone of someone who has broken through to the truth, or of someone who knows what’s wrong, Elhaik offers hesitant fragments — uncertain, honest, perplex probings. Collectively, his probings amount to a broken inventory of possibilities (plural) of practicing anthropology in the moment in which it can’t rely on ‘the human’ anymore. An inventory specific — singular — to his site of research.
The Incurable Image is a subtle, a complex book — many shades of grey, rather than black and white. Indeed, this is one of the most powerful insights that emerge from Elhaik’s book, that in the aftermath of the falling apart of the human (of ethnos) that he documents all (human) generalities may fail: if the ‘the’ human is gone, all there is are scattered bits and pieces, are inchoate venues that don’t add up, differences instances of an elsewhere that remain incommensurable to one another. Call it the joy that emerges from the painful liberation of the grandiose — epochal stories, universal forms, general theories, etc.
The true? The good? Elhaik debunks all those who hold on to these concepts — that is, the good, the truth — as hopeless. To substitute nature for culture is as futile — as damaging — as substituting the animal for the primitive.
Of course this is impossibly provocative! But then, when have you last read an anthropology book that intellectually aroused you? That left you passionate, that radically opened up the question what anthropology is or ought to be?
Coda (no book review without critical comments, however minor). Although I tremendously enjoyed reading the book, I initially came away from The Incurable Image with a mild sense of unease. Elhaik’s language of pathology — the grounding of the critical in the clinical — seemed to be partly owed to a holding on to a form in the moment of the impossibility of this form. Couldn’t one, I wondered, explore the space that opens up after ‘the human’ (after ethnos) more positively? Without “endurance” and instead with a certain joy?
Perhaps Elhaik would agree. In any case, if one reads the few essays he has written after The Incurable Image, one can see the emergence of a response to my critique. In his most recent writings the existentialist trope of ‘endurance’ and the clinical concept of ‘incurability’ seem to recede, and a more positive form of inquiry emerges, one that displays a calm indifference.
I find it fascinating to see how Elhaik now turns to questions of solitude, of beauty, virtue, care, ultimately to the possibility of philosophical life by way of turning to the broken figures of ‘solitude,’ ‘beauty,’ ‘virtue,’ ‘care,’ and the ‘philosophical life.’
Instead of attending to the incurable, he now turns to “Antonioni’s artificially colored landscape, Fatmi’s installations and essays on Levi-Strauss’ voyages, Gruner’s films and sculptures with volcanic stones, Smithson’s entropic earthworks, and Ruiz’s hallucinatory dreamscapes.” “In these minimalist art practices,” Elhaik writes, “human geography and the human figure is rarefied,” is being “dis-figured” and “left behind.” And what interests him is not only that these “de-morphed” humanity “is unlikely to be repairable through ‘sensory’ ethnography.”
What interests him as well is the liberating joy that emerges from these fragments.
That I know of, Elhaik’s The Incurable Images is to date the most interesting and most successful attempt at deanthropologizing anthropology. Not least because it achieves this departure not by turning to nature as non-human but by attending to, well, the human.
Tobias Rees is Associate Professor of Social Studies of Medicine in the Faculty of Medicine at McGill University and a Fellow of the Canadian Institute of Advanced Research (CIFAR). His expertise lies at the intersection of anthropology, art history, the history of science, and the philosophy of modernity and concerns the study of knowledge/thought. More specifically, he is interested in how categories that order knowledge mutate over time –– because of humans, microbes, snails, the weather, or other events –– and in what effects these mutations have on conceptions of the human/the real.
Deleuze, Gilles. 1993. Essais Critique et Clinique. Paris: Edition de Minuit.
Descola, Philippe. 1996a. Constructing Natures: Symbolic Ecology and Social Practice. In Nature and Society: Anthropological Perspectives. Philippe Descola and Gisli Pálsson, eds. Pp. 82–102. Routledge.
Descola, Philippe. 1996b. In the Society of Nature: A Native Ecology in Amazonia. Cambridge: Cambridge University Press.
Descola. Philippe. 2013. Beyond Nature and Culture. Chicago: The University of Chicago Press.
Descola. Philippe. 2014. Modes of Being and Forms of Predication. HAU: Journal of Ethnographic Theory 4(1): 271–280.
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Haraway, Donna. 1990. Primate Visions: Gender, Race, and Nature in the World of Modern Science. New York: Routledge.
Haraway, Donna. 1991. Simians, Cyborgs and Women: The Reinvention of Nature. New York: Routledge.
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Helmreich, Stefan. 2009. Alien Ocean. Berkeley: University of California Press.
Holbraad, Martin. 2009. Ontology, Ethnography, Archaeology: An Afterword on the Ontography of Things. Cambridge Archaeological Journal 19(03): 431.
Holbraad, Martin, Morten Axel Pedersen, and Eduardo Viveiros de Castro. 2014 The Politics of Ontology: Anthropological Positions — Cultural Anthropology. https://culanth.org/fieldsights/462-the-politics-of-ontology-anthropological-positions. Accessed March 8, 2016.
Kirksey, Eben (eds). 2014. The Multispecies Salon. Durham: Duke University Press.
Kirksey, S. Eben, and Stefan Helmreich. 2010. The Emergence of Multispecies Ethnography. Cultural Anthropology 25(4): 545-576.
Kohn, Eduardo. 2007. How Dogs Dream: Amazonian Natures and the Politics of Transspecies Engagement. American Ethnologist 34(1): 3–24.
Latour, Bruno. 1993. We Have Never Been Modern. Cambridge, Mass: Harvard University Press.
Latour, Bruno. 2004. Politics of Nature –– How to bring the Sciences into Democracy. Cambridge: Harvard University Press.
Latour, Bruno. 2014. Distinguished Lecture at the AAA Meeting in Washington, D.C.
Marcus, George E., and Michael M. J. Fischer. 1986. Anthropology as Cultural Critique: An Experimental Moment in the Human Sciences. Chicago: University of Chicago Press.
Paxson, Heather. 2012. The Life of Cheese: Crafting Food and Value in America. Berkeley: University of California Press.
Raffles, Hugh. 2010. Insectopedia. New York: Vintage Books.
Rees, Tobias. 2010a. To Open up New Spaces of Thought: Anthropology BSC (beyond Society and Culture). Journal of the Royal Anthropological Institute 16(1): 158–163.
Rees, Tobias. 2010b. On the Challenge – and the Beauty – of (contemporary) Anthropological Inquiry: A Response to Edward Dutton: Correspondence. Journal of the Royal Anthropological Institute 16(4): 895–900.
Tsing, Anna. 2015. The Mushroom at the End of the World: On the Possibility of Life in Capitalist Ruins. Princeton University Press.
Viveiros de Castro, Eduardo. 2004. Metafísicas Canibais. São Paulo: Cosac & Naify.
 The beginnings of the contemporary efforts to depart from ‘the’ human can be traced back to the works of Bruno Latour and Donna Haraway (I stress contemporary because there were, of course, previous projects of problematizing the human, just think of structuralism or post-structuralism). On the one hand, the reference is to Latour’s 1993 We Have Never Been Modern and his thought-provoking problematization of European modernity (see as well his search for political alternatives in Latour 2004). On the other hand, the gesture is to Donna Haraway’s troubling of the category of nature in Primate Vision (1989) and Simians, Cyborgs, and Women (1991), and specifically to her argument that “we have never been human” in the Companion Species Manifesto (2003) or When Species Meet (2008).
At least in retrospect, it was largely (of course not exclusively) through these works, that, over the course of the 1990s, the condition of the possibility of a non-human centric anthropology emerged. Latour’s suggestion that the mistake of the self-declared moderns is that they remained blind to the natureculture continuums led (some) anthropologists –– today referred to as ontologists –– to suggest that the supposed ‘primitives’ indeed never made the mistakes of the moderns. And Haraway’s turn to dogs has encouraged others to conduct anthropologies of insects (Raffles 2010) and mushrooms (Tsing 2015), of oceans (Helmreich 2009) and bacteria (Paxson 2012) –– publications today grouped together under the heading multi-species anthropology (Helmreich and Kirksey 2010; Kirksey 2014).
 This is not meant as wholesale critique. There are most excellent works that reflect on –– or subversively play with –– these inversions/relations, see for example Povinelli 2016, Tsing 2015, Helmreich 2009 or Raffles 2010.
 Aside, when ontologies are ‘socially constructed,’ and each ‘society’ has its very own ontology, then I am not sure where the rupture with the anthropocentric epistemology of European modernity has actually occurred: society, after all, is a genuine European concept, born in the France of the first half of the nineteenth century, introduced among other things to set the human apart from the animal, to argue that there is an irreducible human reality, a reality sui generis that needs to be understood in its own (social) terms (see, e.g., Descola 1996b, 2013, Holbraadt et al. 2014 or Viveiros de Castro 2004).
Beyond Miracles: How Traditional Chinese Medicine Establishes Professional Legitimacy in Post-colonial Macau by Loretta I.T. Lou
[Editor’s Note: An earlier version of this article appeared in Imponderabilia: The International Student Anthropology Journal (2014). This piece is updated with new data and photos collected between 2015 and 2016.]
In Search of Reclusive Doctors (xunzhao yin shi yishu) was the first Chinese TV documentary about medical miracles “made” by doctors of traditional Chinese medicine (TCM). When it was first broadcasted in 2001, it evoked great public interest in the Pearl River Delta region. In exalting the Chinese doctors’ miraculous power to save people on their deathbeds, the documentary paradoxically placed great emphasis on the scientific validity of TCM and folk medicine. In line with this, Mei Zhan’s ethnographic study of TCM doctors in Shanghai and San Francisco also found that the legitimacy of traditional Chinese medicine is built upon its ability to treat difficult cases (Zhan 2001:454). She argues that TCM doctors have used “miracle-making” to “craft a niche for traditional Chinese medicine within a biomedicine-centered health care system. The everyday practice and discourse of traditional Chinese medicine has come to be a site for the ‘production of the extraordinary’” (Ibid).
In an environment where TCM is in fierce competition with biomedicine, it is understandable that some TCM practitioners feel they have to establish their legitimacy through miracle-making. However, my research in Macau suggests a different story. A former colony of Portugal (1557-1999), Macau was returned to the People’s Republic of China in 1999 and is now a Special Administrative Region (SAR) of the PRC. Although Macau had the first Western-style hospital in Asia, it was not until 1984 when the Macau-Portuguese government finally reformed its health care system and established a public health network composed of a government hospital and a dozens of community health centers. As of 2015, there are three major hospitals and 708 primary healthcare premises in Macau, most of which are privately operated.
Official recognition of TCM in Macau
Without doubt, Macau’s medical landscape is shaped by its colonial legacy. While TCM doctors in the PRC were endowed with “a clear-cut professional identity” as early as in 1955 (Farquhar, 1994:12), in Macau, it was not until 1998, a year before the city’s handover to China, that the Macau-Portuguese government began to regulate the licensing of private health care services and the qualifications required for entering the profession of Chinese medicine (Decree-Law no. 84/90/M). In terms of the number of practitioners, by 2012, there were 353 registered TCM doctors (zhong yisheng; recognized through an accredited degree) , 204 TCM practitioners (zhongyi shi, recognized by a professional TCM committee), 13 massage therapists, and seven acupuncturists in Macau.
Prior to 1999, Chinese medicine was not a part of the public health service (Serviços de Saúde) in Macau. Centro Hospitalar Conde de São Januário (CSCHJ), Macau’s only public hospital, still does not have a dedicated department for traditional Chinese medicine. The two TCM hospital departments in Macau are run by two private hospitals—the University Hospital and Kiang Wu Hospital. Yet things started to change after the handover in 1999. Not only has Serviços de Saúde begun to run a TCM outpatient service in some of its primary health centers, the government has also made clear its ambition to promote and industrialize the Chinese medicine sector in Macau. This move is closely related to Mao’s successor Deng Xiaoping’s determination to “rejuvenate the nation through science education” (kejiao xingguo), a development strategy to make science and technology (keji) a national priority. This is a significant departure from some of Mao’s earlier policies, which deemed progress as something to be achieved through self-reliance, revolutionary virtue, and mass mobilization rather than Western science and technology (Kirby 1989:24).
When I started this research in 2005, “make Chinese medicine great again” was all talk and no action. But over the past 10 years, the Macau government has made significant progress towards making Macau a “national hub” of traditional Chinese medicine. Local officials are keen to use it as an opportunity to express their patriotism. They also hope that the industrialization of Chinese medicine would help diversify the economy of Macau, which has always been heavily dependent on its gambling industry. Since 2011, Macau has been an active member of the World Health Organization (WHO) Collaborating Centre for Traditional Medicine. Yet the biggest breakthrough was the recent joint venture to construct the Guangdong-Macau Traditional Chinese Medicine Science and Technology Industrial Park (GMTCM Park)—a gigantic, state-of-the-art business park set in Hengqin in the south of Zhuhai, Guangdong province.
It’s “science”, not miracles
Despite the hopeful future, the delayed recognition of TCM within Macau’s legal-medical framework has caused a lot of anxiety among the TCM doctors there. Unlike practitioners in San Francisco and Shanghai, TCM doctors in Macau feared of being further marginalized as the “miraculous healers”. Dr. Tam, a key interlocutor of mine, was really irked by people who think Chinese medicine is a medicine good at making miracles. He complained loudly: “They think Chinese medicine can cure everything? That’s ridiculous! We’re doctors, not deities! To ask us to clean up the mess is to look down on us! A death case is a death case!” Indeed, most TCM doctors that I spoke to in Macau corroborated that miracles are not easily “made”, if they are something that can be “made” at all. So even though miracle-making is an “unmistakable sign of professional accomplishment” for some TCM doctors (Zhan 2001:453), for others the stereotype implied unscientific practices, which they took offence at. Also, since the majority of TCM doctors survive without the halo of miracles, it is imperative to find out other ways of “doing” Chinese medicine.
When Dr. Tam urged me to let my American colleagues have a look at the TCM syllabuses used in the University Hospital, he wanted to make the point that TCM doctors are superior to their Western counterparts. Not only did he stress that modern TCM doctors are no longer trained within the family or through an apprenticeship, which he considered an unprofessional tradition, he also emphasized that nowadays TCM students are required to study both TCM and Western medicine. The following excerpt from The Journal of Chinese Medicine Doctors in Macau accurately captured Dr. Tam’s points:
The scope of Chinese medicine is very wide. It involves literature and history, animal physiology and plant ecology, meteorology and astronomy, geography and geology, chemistry and genetic engineering. Chinese medicine is a holistic discipline that involves much high science and technology. Every Chinese medicine practitioner should be proud of our nation. We are responsible for exalting our nation’s traditional medicine. To achieve this, we should make use of modern science and research new ways of improving our field.
Looking at illnesses together
Besides nationalism, the professional legitimacy of Chinese medicine was reinforced by the practice of “looking at illness” (kanbing) together with patients (Farquhar, 1994:2) rather than producing miracles on deathbeds. The fact that both TCM practitioners and their patients were involved in producing the medical norms (Ferzacca, 2000:30) has greatly contributed to the legitimatisation of TCM in Macau. When I was doing fieldwork in small TCM clinics, I came to realize that many TCM patients were extremely knowledgeable about their conditions. They were able to use TCM jargons such as “fire in the bones” (gu huo), “depleted fire” (xu huo), “cold cough” (han hai), “hot cough” (re hai), “dry” (gan), “wet” (shi) to describe their states of health. They called this jiubing chengyi, which means when you have to cope with an illness for a long time, you will eventually become your own doctor. Indeed, many TCM users said they are able to interpret their own prescriptions.
“Licorice root is yaoyin,” Mrs. Lam analyzed her doctor’s handwritten prescription for me while we were sitting in the waiting room.
“How do you know?” I asked.
“I’ve been eating Chinese medicine for many years now. Jiubing chengyi.”
“Do you think you would be able to read the Western medicine prescription?”
“How could I?” Mrs. Lam laughed. “I’ve only had five years of primary school education. I don’t know English or Portuguese! How could I read it?”
TCM users are also proactive in self-diagnosis. When Mr. Chan was diagnosed with Sciatica, he was sure that his medical doctor got it wrong. “I am pretty sure that it is rheumatism. I felt so much better after drinking the herbal tea you prescribed me last night.” Mr. Chan told his TCM doctor. “Xiyi (doctors of Western medicine) only know to give me pain killers!’
Similarly, when Mr. Lee was diagnosed with mental disorder (jing shen bing) by his doctor in the government hospital, he came to Dr. Tam’s clinic with a short article cut from the newspaper, titled “The Ancient Ways to Cure dian (epilepsy)”. He urged Dr. Tam to give him the treatments mentioned in the article because he seemed to suffer from the same symptoms. “Well, not all dian are the same”, Dr. Tam rejected his request. Mr Lee was so disappointed that he got agitated in the consultation room. “The hospital people said I have mental disorder! I don’t! I just have numb fingers!” Mr. Lee protested as Dr Tam tried to calm him down, “I believe you! I believe you! The hospital is very wrong in prescribing you those drugs.” After Mr. Lee left, Dr. Tam sighed: “Whenever a patient can’t speak clearly, doctors of Western medicine would prescribe him psychotic drugs. Alas, even if he wasn’t crazy, he certainly would be after taking those medications for such a long time!”
In Macau, the legitimacy of Chinese medicine is not built upon miracle making. Instead, it is achieved through a celebration of cultural tradition rejuvenated with discourses of nationalism and modernity, and through the mutual constructions of medical references between doctors and patients. In the TCM circle, the term “science” was used synonymously with ‘modern’—and being “modern” is considered a good thing. The shared cultural references used in TCM also make it possible for both parties to contribute to the conceptualization of health and illnesses. The knowledge of Chinese medicine is thus owned not only by the doctors but also by the patients. Unlike doctors of Western medicine who sometimes feel the need to shift to another identity when they are on duty (Good 1993), TCM doctors tend to speak the language of their patients and are not afraid of showing the more personal side of themselves. Indeed, it warmed my heart that my 70-year-old TCM doctor still remembered I like to have haw flakes with my bitter herbal tea. It is this human touch that helps Chinese medicine keep its strength even in the absence of miraculous treatments.
Dr. Loretta Ieng Tak Lou is a Postdoctoral Associate at the Institute of Social and Cultural Anthropology (ISCA), University of Oxford. Her doctoral research is an ethnographic study of “green living” and its implications for self-knowledge, social relations, ethics, and political mobilization in post-handover Hong Kong. Her research interests lie in the areas of environment, health, science and technology studies, re-enchantment, and social movements in East Asia.
Barnes, Linda L (2007). Needles, Herbs, Gods, and Ghosts: China, Healing, and the West to 1848. Harvard University Press.
Brown, Melissa J (2010). Changing authentic identities: evidence from Taiwan and China. Journal of the Royal Anthropological Institute. 16(3): pp.459-473.
Decree-Law no. 84/90/M. (2005). Translated by U Wan-Ian from Portuguese. Retrieved from the Internet. <http://www.imprensa.macau.gov.mo/bo/i/98/20/declei20.asp>.
Farquhar, Judith (1994). Knowing Practice: The Clinical Encounter of Chinese Medicine. Boulder: Westview Press.
Farquhar, Judith (1994). ‘Eating Chinese Medicine.’ Cultural Anthropology, Vol. 9, No. 4, 471-497.
Ferzacca, Steve (2000). “‘Actually I don’t feel that bad’: Managing diabetes and the clinical encounter.” Medical Anthropology Quarterly. 14(1): pp.28-50.
Good, Byron J. (1993). Medicine, Rationality and Experience: An Anthropological Perspective. Cambridge University Press.
Kleinman, Arthur (1998). The Illness Narratives: Suffering, Healing & the Human Condition. Basic Books.
Kirby, William, C. (1989). “Technocratic Organization and Technological Development in China: The Nationalist Experience and Legacy, 1928-1953. Science and Technology in Post Mao China. Cambridge: Harvard University.
Zhan, Mei (2001). “Does It Take A Miracle? Negotiating Knowledges, Identities, and Communities of Traditional Chinese Medicine.” Cultural Anthropology. 16(4): pp.453-480.
 Any Macau residents with a university degree in Chinese medicine can apply for a TCM license from the Serviços de Saúde. There is no licensing examination.
 Statistics obtained from Serviços de Saúde.
 Admittedly, many other factors may have contributed to the professional legitimacy of traditional Chinese medicine in post-colonial Macau, such as accessibility, price, and public policy. However, in this short article, I want focus on how TCM doctors establish their legitimacy on nationalism and their shared cultural references with their patients.
 Yao yin is also known as yao yin zi. In Chinese Medicine, yao yin serves as a conduit for certain medicines to reach their targeted organs, arteries or veins.
 See Farquhar 1994.
 The word Dian deserves further analysis. Dian literally means ‘insanity’, but it can also refer to epilepsy.
A well-known quote from Hamlet is “Something is rotten in the state of Denmark.” This, of course, refers to the illegitimate and immoral reign of the fictional King Claudius, Hamlet’s uncle. So, while there is plenty of current relevance related to the political and social turmoil hinted at by this line, instead let’s talk about another aspect that I find particularly fascinating — the connection of scent and odor to ideas of morality, good, and evil.
In an odd turn of events, I recently found myself trying to explain to some chemistry students why a quote saying that someone “smells of sulfur” means that they are diabolical, hellish, or somehow antichrist-like. Why sulfur? No, there is really no connection to sulfur’s having an identical number of valence electrons to oxygen, though that would make an interesting story. Some explanation of the history of sulphurous scent as diabolical can be found here: The Smell of Hell: Does Satan Smell of Rotten Eggs? Connections between scent and good and evil actually abound. Fragrantica has a number of excellent articles about the historical and cultural meanings of scent, including Elena Vosnaki’s A Diabolical Whiff: Scents of Hell:
It was sorcerers during the Middle Ages who, suspected to be in cahoots with the devil, were considered to be sulphurous smelling themselves. Given that these were often “wise women” dealing in pharmacopoeia, of which sulphurous materials did make a part, wouldn’t it be evident that handling them would lend them that odor? Try to prove it to the ecclesiastical courts!
And the counterpart, A Saintly Aroma: Scents of Heaven:
In Biblical times, the link between germs and diseases hadn’t been made (it had to wait till the 19th century), so the logical leap that foul smells, entering the body at once with one’s breath, could carry disease isn’t far fetched… Using incense materials, resins and gums high in purifying molecules such as Verbenone (a ketone) or Trans-verbenol (an alcohol), which they collected spending much time and effort, they fought foul odors with pleasant, “clean” ones… Since these aromatic resins burn without residue, symbolizing the heavenly spirits to whom they ascend to when burnt, and since essential oils represent the very spirit of a plant, could they not be the answer to a prayer against the inavoidability of corruption?
These associations of scent and danger have not disappeared with the advent of germ theory. An antiseptic scent has many associations of its own. Perceptions of morality are also marked by purity of scent, and immorality by malodor. As attributions of moral behavior are deeply cultural, it also makes sense that “When two people smell the same thing, they can have remarkably different reactions, depending on their cultural background” (Sniffing Out Cultural Differences). There are also theories that our senses of disgust, perhaps forged in the evolutionary times of high microbial pathogenesis, have now become embedded as an internalized form of social control: “Our ancestors reacted to parasites with overwhelming revulsion, wiring the brain for morals, manners, politics and laws” (Disgust made us human). So, it may be that humanity is a creature of disgust, and that our social institutions are vestiges of our co-evolution with microbial parasites. (I can’t help but wonder, if the web had an odor, what would it be?)
Additional miscellanea of potential interest:
- Scent related:
- Meet the Woman Who Is Preserving the Smell of History (Atlas Obscura)
- Scientists search for death’s aroma and Zombie Apocalypse Survival Chemistry: Death Cologne. (Both from the American Chemical Society.)
- An interesting piece on the meanings of evidence, expertise, and flossing one’s teeth: Flossing and the Art of Scientific Investigation
- Is Physical Law an Alien Intelligence? Because, why wouldn’t it be?
- “The ancient Japanese art of flower arranging was the inspiration for a groundbreaking technique to create tiny “artificial brains” that could be used to develop personalized cancer treatments.”
- And, for a few additional thoughts about science, medicine, and magic in all their intertwined and uncleanly complexity: Found in the Eyes of Rams: The Bezoar and its Powers. “A bezoar is a mass of undigested or inedible material found in the GI tract…Whatever the origins of the belief in curing poison, bezoars were popular in the Middle Ages and into the 17th century as antidotes. They were carried as charms, included as decor or attached to drinking and eating vessels to protect the diner, and tests were even designed to detect fakes –the selling of which was a punishable offense.”
by David S. Jones
The Johns Hopkins University Press, 2013, 336 pages.
My first encounter with David S. Jones’ Broken Hearts was in April of 2016. I had packed it in my carry-on luggage as on-plane entertainment while traveling to Minneapolis, MN for the eighty-ninth annual meeting of the American Association for the History of Medicine (AAHM). How fitting, I thought, to read about the history of heart disease in the “cradle of cardiac care,” a city that transformed America’s medical enterprise by developing many innovative inventions and techniques in the field of cardiology.
And fitting it was. The conference was teeming with allusions to the University of Minnesota’s cardiac legacy. Not only was there an exhibition on the history of cardiac disease epidemiology developed by the university’s School of Public Health, but there was also a guided tour of the Visible Heart Project, a research laboratory dedicated to reanimating mammalian hearts to gain insight into the organ’s physiology. The overarching theme of both the exhibit and tour was one of progress, as both of these special presentations emphasized how far we have come in terms of gathering accurate information about the human heart. Whereas the exhibit referenced the “exponential growth” that the field of cardiac epidemiology has made in terms of understanding the risk and protective factors associated with heart disease, members of the Visible Heart Laboratory claimed that their research had provided unprecedented insight into the functional anatomy of the beating heart. Over half a century after University of Minnesota surgeon Dr. C. Walton Lillehei preformed the first open heart surgery, and, with the help of Earl Bakken, developed the first battery-powered wearable pacemaker, I left Minneapolis thinking that the city continued to be at the forefront of cardiac care. Within the walls of the University of Minnesota, researchers were still developing innovative inventions and techniques that were transforming medical practice and saving lives.
The idea that unprecedented progress in cardiology has been made over the course of the last sixty years is not unique to researchers at the University of Minnesota. Many medical professionals believe that we now know more about the human heart than ever before, and that research conducted over the past sixty years has given us a deeper understanding of cardiac diseases and their causes. However, this black-and-white picture of medical progress is not as straightforward as these AAHM special presentations would have us believe. In spite of the mantra that health science researchers are “conquering cardiovascular disease,” physicians still face many challenges in developing theoretical frameworks for heart attacks, and producing definitive knowledge about the safety and efficacy of cardiac treatments.
One of the first scholars to draw attention to some of these challenges is David S. Jones. His new work, Broken Hearts: The Tangled History of Cardiac Care, unpacks the complex history of how medical professionals have understood ischemic heart disease over time. By examining how American cardiologists have interpreted and responded to heart disease during the mid-late twentieth century (and beyond), Jones reveals the ambiguities and inconsistencies that persist at the core of cardiac surgery, and traces how these uncertainties underpin the development and evaluation of modern medical interventions. Using the history of heart disease as a lens through which to examine the challenges associated with making health choices, Jones presents a fascinating analysis of how the complexities associated with medical decision making influence the way that cardiac care is administered in the twenty-first century.
In order to explore this tangled history of medical knowledge production, Jones divides his book into three sections. In his first section, Jones examines how heart disease has been conceptualized by medical professionals from the early twentieth century to the present day. He starts the section off with the brief and simple statement: “while the heart, at a basic level, is one of the easiest organs to describe, it has been one of the hardest to understand, especially when it comes to coronary artery disease.” The omnipresence of ischemic heart disease, and physicians’ willingness to perform medical interventions like coronary angioplasty, bypass surgery, or prescribe pharmaceuticals like statins and platelet inhibitors (even on a preventative level) suggests the medical establishment’s unwavering confidence in how cardiac care should be administered. However, Jones points out that there has been ambiguity about heart diseases’ underlying etiology since the early twentieth century, and that this uncertainty raises questions about the efficacy and safety of modern methods of treatment.
Providing archival evidence from thousands of medical journal articles, Broken Hearts reveals that, from 1910 onwards, medical professionals have debated the cause of heart attacks. Although most pathologists agreed that arteriosclerosis underpinned coronary thrombosis, many disagreed on the finer details of this process. Whereas some pathologists argued that thrombosis was the result of the rupture of an unstable plaque in the coronary artery (thus triggering a dangerous blood clot), others believed that myocardial infarctions stem from the progressive obstruction of the coronary arteries, which ultimately prevents blood from flowing through the vessel. Uncertainty over the diseases’ etiology has continued to circulate in medical communities up until the early twenty-first century. In fact, the inability of researchers to establish a stable evidence base for and reaching consensus on a particular theory of heart disease is one of the reasons why the ISCHEMIA trial was launched by the U.S. National Heart, Lung, and Blood Institute of the National Institutes of Health in 2011. By assessing whether revascularization reduces the risk of heart disease or death in patients with angina, this trial hopes to resolve whether the theory of progressive obstruction or unstable plaques underpins ischemic heart disease “once and for all”.
After tracing the history of debates surrounding the underlying causes of cardiac disease, Broken Hearts moves on to consider how this theoretical ambivalence on the underlying cause of coronary thrombosis has influenced how cardiac interventions have been developed and assessed. In the book’s second section, Jones looks at the historical development of coronary angioplasty, bypass surgery, statins and platelet inhibitors, and chronicles medical discussions over which one of these methods provides the best treatment for patients. By showing that the popularity and use of medical treatments is predicated on a multitude of factors besides disease etiology, including ideas about cost, convenience, and effectiveness Jones challenges the popular and professional belief that the benefits of cardiac intervention always outweigh its risks. By arguing that doctors devote more energy to proving that treatments work than they do ascertaining complications—thus producing an asymmetrical knowledge base more focused on efficacy than patient safety. This can be seen in the example of bypass surgery as, in their attempt to demonstrate the validity of this revascularization technique in the face of theoretical ambivalence, cardiac surgeons neglected the cerebral complications that often arose as a result of the procedure.
In his last section, Jones raises the issue of geographic and racial variations in medical practice by showing how cardiac care is not practiced in a uniform way across cities, states or populations.
Through looking at how factors like race and place influence how a doctor will identify and respond to cases of ischemic heart disease, Broken Hearts illustrates the often-equivocal nature of cardiac care and the messiness of medical decision making more general. Although Jones doesn’t offer any hard and fast solutions to these problems, he highlights the need to integrate patient and physician priorities, values and preferences into account when developing new models of medical decision making. He also emphasizes the importance of acknowledging the complex social dynamics that underpin “the diseases we suffer, the treatments we can access, the outcomes of those treatments, and our knowledge of those processes.”
All in all, Broken Hearts is a captivating study of the history of cardiology. By moving away from the longstanding tendency to frame the history of cardiology as a progress-narrative, this book makes a great addition to the emerging body of literature that adopts a critical stance towards cardiac care, including Anne Pollock’s Medicating Race , and Janet Shim’s Heart-Sick.  Although this book is definitely geared to an academic audience, because it unsettles contemporary ideas about the coherence of cardiac care, the soundness of medical treatments, and the logic underpinning medical decision-making, I think that Broken Hearts has important lessons for the lay reader as well. Especially for people who are currently undergoing treatment for coronary artery disease.
Jennifer Fraser is a fourth year PhD student studying the history of medicine at the University of Toronto. Her dissertation charts the history of Canadian cancer epidemiology, focusing specifically on how cancer control campaigns were advertised and applied to Indigenous communities during the mid-twentieth century.
“About.” Heart Attack Prevention: A History of Cardiac Disease Epidemiology, Department of Epidemiology; University of Minnesota. 1 May 2016. http://www.epi.umn.edu/cvdepi/about/
“About the Lab.” The Visible Heart Laboratory, Department of Surgery; University of Minnesota. 1 May 2016. http://www.vhlab.umn.edu/about.html
“Conquering Cardiovascular Disease.” National Heart, Lung and Blood Institute. 27 October 2016. https://www.nhlbi.nih.gov/news/spotlight/success/conquering-cardiovascular-disease
Pollock, Anne. Medicating Race: Heart Disease and Durable Preoccupations with Difference. Durham: Duke University Press, 2012.
Shim, Janet K. Heart-Sick: The Politics of Risk, Inequality an Heart Disease. New York: New York University Press, 2014.
Smith, Monica M. “Medical Alley: Tight-Knight Community of Tinkerers Keeps Hearts Ticking, Minnesota (1950s).” In Places of Invention, edited by Arthur P. Molella and Anna Karvellas, 86-110. Washington: Smithsonian Institution Scholarly Press, 2015.
 Monica M. Smith, “Medical Alley: Tight-Knight Community of Tinkerers Keeps Hearts Ticking, Minnesota (1950s),” in Places of Invention, eds. Arthur P. Molella and Anna Karvellas, 86-110 (Washington: Smithsonian Institution Scholarly Press, 2015), 86.
 “Conquering Cardiovascular Disease,” National Heart, Lung and Blood Institute, 27 October 2016. https://www.nhlbi.nih.gov/news/spotlight/success/conquering-cardiovascular-disease
 David S. Jones, Broken Hearts: The Tangled History of Cardiac Care (Baltimore: Johns Hopkins University Press, 2013), 3.
 Jones, Broken Hearts, 96
 Jones, Broken Hearts, 228.
 Anne Pollock, Medicating Race: Heart Disease and Durable Preoccupations with Difference (Durham: Duke University Press, 2012).
 Janet K. Shim, Heart-Sick: The Politics of Risk, Inequality an Heart Disease (New York: New York University Press, 2014).
Somatosphere invites readers to submit to “Aftermath,” a new series examining the consequences of recent nationalist political turns throughout the world, including the US election. We are particularly interested in pieces which reflect on how these events intersect with the thematic concerns of the site – health, medicine and science, broadly construed. We especially welcome pieces which draw on original empirical materials or which bring conceptual materials from anthropology, history, sociology, STS, public health, cultural psychiatry and related disciplines to bear on the current situation. In the interest of cultivating vital discussion and circulating ideas quickly in response to a rapidly changing political environment, we encourage submissions that may seem sketchy, drafty, or unpolished. Potential topics might include but are in no way limited to:
- Possible effects of the 2016 election on the Affordable Care Act
- Mental health and the aftermath of the election
- Health-related dimensions of the Brexit vote and the upswing in nationalist political movements throughout Europe
- The changing politics and science of:
- abortion and reproductive technologies
- climate science
- evidentiary practices surrounding racial and ethnic categories
- threats to disabilities policies
- Resources for teaching about the current political condition, particularly as it affects health, medicine and science
- Strategies for activist academics in the current political climate
Please send your suggestions for pieces, completed pieces, or inquiries to email@example.com