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Science, Medicine, and Anthropology
Mis à jour : il y a 3 heures 29 min

Musings on the Materiality of Health Care by Cristina A. Pop

il y a 7 heures 18 min

Nightstand in a psychiatry hospital from Alba-Iulia, Romania. The picture was taken by Odeta Catana in November 2014, as part of a project initiated by the Center for Legal Resources. Reproduced with permission.

In October of 2014, Romanian mass-media featured the local story of a few dozen citizens—most of them Orthodox nuns—refusing their newly issued state health insurance cards, on the grounds that the term card imprinted on the card would spell, when read backwards, drac—the Romanian word for “devil.” It seemed that the nuns, along with a few Orthodox priests and monks and other laymen, rejected the cards because they saw in them instruments of population control imbued with malefic powers. In their view, anyone who would accept the biometric chip-enabled health insurance card would bear the “mark of the beast,” as prophesied in the Christian Book of Revelation. “The beast” would be the computerized data system of global surveillance, whose ultimate aim is to strip humans of their God-bestowed freedom.

Upon reading this news, I was not necessarily astonished by the fact that a narrow demographic group would express such apocalyptically articulated anxieties when facing the biopolitical regimes of health care provision. In Romania, as elsewhere, fundamentalist Orthodox websites disavow various biomedical procedures—like vaccination—on similar grounds, by equating them with receiving “the mark” and by evoking the millennialist opening of the seals that precede the coming of the Antichrist. What did surprise me was the backwards reading of the word card as drac. Why would someone read anything backwards? And how does one get the idea of reading in reverse in the first place?

I took my own health insurance card in my hands and tried to read it the way the Orthodox nuns might have read theirs. And all of a sudden I was struck by its materiality. While staring at the card, my mind stopped conjuring the entitlements to medical services that it granted. I am unsure if the mental process I underwent qualifies for the status of phenomenological reduction, but I was simply contemplating the rectangular piece of plastic in my hands. My consciousness was ensnared by the card’s material presence, while all my background knowledge about health care and medical insurance was suspended. As a pure object of the phenomenal world, the card had lost its strict spatial attributes and had no up and down, left and right, recto and verso anymore. It had become a polymorph and dynamic thing that I kept rotating slowly between my fingers, until, indeed, “the devil” popped up.

That the nuns had most likely contemplated rather than just embraced the health insurance card seems to make sense when thinking about the fact that they are presumably living in a lifeworld imbued with signs of decay that reveal the coming of the Antichrist. Uncovering the materiality of the health insurance card is a form of taking possession of the card, while questioning at the same time the promise of health care benefits that it bears. In contrast, accepting the card for what it is claimed it represents and completely bypassing its materiality would be letting the world of medical insurance and health care services take over you. By operating a contemplative scrutiny of the actual objects that make access to health care possible the nuns rightfully diagnosed the violence encapsulated in the state-driven system of medical insurance.

We might similarly grasp something of the complicated dynamic of desire and resistance in relation to medical care claims, entitlements, and benefits when allowing our gaze to engage with the materiality of health care, as it unveils to our consciousness. At the 2015 AAA in Denver, Julian Chehirian, a student at American University, who is researching the social history of psychiatry in communist Bulgaria presented a paper about his Excavating the Psyche exhibition —a display of a psychiatric consultation room. In order to really wrap our heads around the already shopworn idea that psychiatry was used as an instrument of political repression, Chehirian invited us to contemplate actual objects, such as the medicine cabinet. The “true force of things”—as Sahlins (1981) once said in reference to what symbols represent—resides in the disquieting presence of the tall and narrow cabinet, with its glass door that reveals and protects its content at the same time. Neatly arranged syringes, small medicine bottles, ampoules, and prescriptions convey order and terror. The order of terror. The severity and the coldness of the cabinet white-painted metallic frame gives the viewer an uncomfortable bodily frisson.

Recently, my gaze was captured by a similar white metal hospital item—the nightstand. I am referring to the type of nightstand that is still common in most Romanian public hospitals. Sometimes, its metallic drawers are pastel-colored in shades of pale pink or faint blue, but—white or pastel—the paint is always chipped on the edges. The hospital nightstand is a liminal object where ambiguities converge. It is a familiar piece of furniture that we know from home, yet it appears so foreign and anonymous in a hospital setting. It divides a patient’s vital space from that of the nearby roommate, but it also connects the individual patients’ personal spaces. It is a functional object whose empty ugliness mobilizes patients, family members, and even medical practitioners sometimes, to tame it and to make it look less like a painful metaphor of the current state of public medical care in Romania.

In a quintessential act of engagement with the materiality of health care, the ritual of domesticating the hospital nightstand starts with drudgingly opening its semi-stuck drawers and covering their rusty bottom with wrapping paper or roll paper brought from home for this specific purpose. Once the drawer is padded, various personal items are placed inside: silverware, plates, cosmetics, towels, and the phone charger. And toilet paper. A nice chocolate box or a bag of coffee for “the gifts” to the doctor and nurses might find their place inside the nightstand as well. Also, a few empty envelopes—in case “the gift” takes a monetary form. Then, the top of the nightstand also gets covered with roll paper, a decorative kitchen towel, or even a small macramé tablecloth. Various items show up on the nightstand—medication, a mug or a glass, a phone, books and magazines, writing utensils, bottled water, and a vase with flowers. Sometimes, a small icon. It is tempting to read patients’ socio-economic profile and personal history through a reading of their customized hospital nightstand. Moreover, by contemplating the hospital nightstand, a trained eye can decode a patient’s diagnosis, the projected length of stay, and maybe even the prognosis.

However, I am mostly interested in the materiality of the hospital nightstand for its potential in exposing the regimes of health care delivery. The nightstand is not only the tangible expression of patients’ past experiences within the realm of state medicine, but also of their expectations and assumptions regarding medical entitlements and benefits. How does the inventory of patient items placed on or inside the nightstand correlate with the quality of hospital services or with the resourcefulness of the system of medical care more generally? Without really addressing such a question or similar ones, Healy et al. (2015) explore the use of nightstands (and over-the-bed tables) and provide interesting data on the kind of items that patients surround themselves with in a rehabilitation hospital in the US. Making a similar inventory in a Romanian hospital would be a starting point for a deeper analysis.

Finally, I would like to consider the hospital bag, as another example of the way citizens attempt to tame their anxieties about the transforming landscapes of medical claims and entitlements in a post-socialist context, by acting upon the materiality of care. Before being an actual bag, the hospital bag is just a checklist of things that an expectant mother packs in preparation of her hospital birth. The internet abounds in video tutorials, advising websites, and chatrooms dedicated to its content. With the hospital bag, the materiality of health care shifts back and forth between the actual experience of giving birth in a maternity clinic and the virtual anticipation of such an event. When looking for online information or asking their peers about what to pack for their upcoming hospital births, future mothers have to face their most terrifying assumptions about the low-quality provision of reproductive care, while mobilizing their most hopeful emotions. Packing the proper hospital bag is a strategy to navigate perceived reproductive vulnerability.

Beyond embodying personal reproductive experiences, the hospital bag can also offer a reading of how people position themselves in relation to the various regimes of medical care distribution. The interminable list of items presumably needed to give birth in a Romanian state maternity hospital includes everything from toilet paper, cotton, diapers, onesies, blankets, and baby wipes to breast pumps and silicone nipple shields, etc. By contrast, those who can afford the expensive care of private birthing clinics boast about their minimalist hospital bag—allegedly containing only a tooth-brush and the bank-card. It seems that not having to deal with the materiality of health care is a consequence of having access to forms of privileged care. The women whose hospital bag is a card have no reason to engage with its materiality as a pure object of the phenomenal world. Their card will always spell an unequivocal card.

In the end, the musings that the contemplation of actual items of health care provision engender—from the overwhelming materiality of the health insurance card, to the anguish-producing hospital furniture and the material volatility of the hospital bag—are in fact about structural violence, biopolitical surveillance, uneven access to medical care and reproductive vulnerability. Yet, as I have sought to show within this brief piece, engaging with the materiality of health care genuinely empowers patients in their attempts to co-produce the emergent meanings of reformed medicine.

 

Cristina A. Pop earned a PhD in Linguistics from Babeș-Bolyai University (Romania) and a PhD in Cultural/Medical Anthropology from Tulane University. Her work scrutinizes the transformations in women’s sexual and reproductive health produced by the post-socialist restructuring of medical care in Romania. Cristina has published articles in Medical Anthropology Quarterly and Culture, Health and Sexuality. She is currently preparing a book manuscript about the Romanian cervical cancer “epidemic.”

 

References

Sahlins, M. 1981. Historical Metaphors and Mythical Realities: Structure in the Early History of the Sandwich Islands Kingdom. Ann Arbor: University of Michigan Press.

Healy, S., Manganelli, J., Rosopa P. J., Brooks J. O. 2015. An Exploration of the Nightstand and Over-the-Bed Table in an Inpatient Rehabilitation Hospital. Health Environments Research & Design Journal. 8(2): 43-55.

Top of the Heap: Paul Rabinow by Hannah Gibson

23 Septembre 2016 - 12:00pm

For this installment of the Top of the Heap series, I spoke with Paul M. Rabinow, who is a Professor of medical and sociocultural anthropology at the University of California at Berkley.

 

Alexander Kluge & Oskar Negt, History and Obstinacy, translated by Richard Langston et.al., edited and with an introduction by Devon Fore, Cambridge: Zone Books, 2014.

Michael Foessel: Le Temps de la Consolation, Paris: Editions du Seuil, 2015.

Marielle Macé, Le temps de l’essai, Histoire d’un genre en France au XX siècle, Paris Belin, 2006.

Tim Blanning, Frederick the Great, King of Prussia, New York: Random House, 2016.

Stephen Parker, Bertolt Brecht, a Literary Life, London: Bloomsbury, 2014.

Ben Ratcliff, John Coltrane, The Story of a Sound, New York: Picador, 2007.

 

As we have long since passed through the moment of the politics and poetics of ethnography, I find my reading still fits into something like the ethics and aesthetics of life. In that light, here are some of the books I have been reading lately.

The Kluge & Negt is the most ambitious as well as the most experimental of the lot. They are (were) well known for their interventions in the public sphere discussions offering a more Marxist interpretation than that of Habermas. This volume is a new English translation of a much longer book in German that the authors collaborated in reducing in size and perhaps increasing in coherence. It is a weird book assembling a heterogeneous range of materials ranging from concept definitions, to German folklore, to a very long term history of capitalism and the micro forms of resistance, “obstinacy” that they claim have always existed. The book is impossible to summarize: Devon Fore provides a lucid and helpful long introduction that is the place to begin.

The Foessel is an essay in the recent French genre that they now call philosophy. It is an intriguing attempt to demonstrate that while once philosophy (and religion) offered forms of consolation, in modernity this salvational hope has become untenable, at least theoretically. The claim is a rich one raising many questions well worth pondering even if the author’s approach and style are too sweeping to be truly convincing. Had the book ever touched ground in an anthropological sense it would have been vastly improved but the clarity of its argument would have been harder to sustain in such epochal and totalizing terms. Still, a very intriguing contribution to contemporary ethics and thought.

The Macé is a much more scholarly (and convincing) treatment of the importance of the essay in France as straddling and at times occupying the liminal zone between art and science. This is an excellent book.

The Banning is a magisterial account of Frederick the Great, for once not concentrating at length on his encounter with Bach or the thoughts of Kant on the Enlightenment. Rather, if one wants to get a richer, detailed and situated account of what the emergence of bio-power and bio-politics looked like in the eighteenth century, this is a good place to start. It offers a remedy for the vast outpouring of necrophilic accounts of what Foucault had in mind when he coined the terms. Further, it turns out that Frederick was a flamboyant gay, organizing his court to suit his tastes.

The Parker is another magisterial biography, this time of Bertolt Brecht. The deeply appreciative yet complexly nuanced account of this brilliant modernist and the political shoals he had to navigate his whole life from the Americans to the Communists. The presentation of his theater and poetry is helpful if not exactly an introduction; it should serve as a stimulus. Brecht’s domestic practices and his gender politics will not please everyone but are worth knowing about.

The Ratcliff, perhaps most like the Macé in this grouping, is a telling account not so much of John Coltrane the man (although there is some of that and it is done well with great economy) but of his “sound.” Ratcliff, a journalist jazz critic, provides a compelling account of a short period of time (mid to late 1950s until Coltrane’s death in 1967) of his transformations in sound and style. Coltrane practiced relentlessly perfecting his technique and testing his body; he was a far ranging intellectual with a quiet if voracious curiosity. His search for the outer frontiers of modern music and the institutional setting and racial as well as the critical obstacles he had to face are well told. Coltrane said at the end of his short life (he died at age 40) that he wanted to be remembered as a saint. Food for thought for anthropologists.

Professor Paul M. Rabinow received his Ph.D. (1970) in anthropology from the University of Chicago, and is currently Professor of Anthropology at the University of California at Berkeley where he has taught since 1978. He has taught in France, Brazil, Iceland and is co-founder of the Berkeley Program in French Cultural Studies. He was named Chevalier de l’Ordre des Arts et des Lettres by the French Government in 1998. He received the University of Chicago Alumni Association Professional Achievement Award in 2000. He was awarded the visiting Chaire Internationale de Recherche Blaise Pascal at the École Normale Supérieure for 2001-2.  STICERD Distinguished Visiting Professor- BIOS Centre for the study of Bioscience, Biomedicine, Biotechnology and Society, London School of Economics (2004), Sir James Frazer Lecturer (Cambridge) 2008, Mosse Distinguished Lecture (Berlin) 2010.

Special Issue! Private, the Public, and the Hybrid in Umbilical Cord Blood Banking by Aaron Seaman

22 Septembre 2016 - 6:39pm
The current issue of New Genetics & Society is a special issue, entitled “Private, the Public, and the Hybrid in Umbilical Cord Blood Banking.” As Margaret Sleeboom-Faulkener and Hung-Chieh Chang write in their opening editorial, the five articles that compose the issue have two aims:

“First, it critically examines the dichotomy between public and private cord blood banks, and shows that the mechanism and network of cord blood banks is far more complex than indicated by the dichotomy of the public and the private. …

“Second, there is an increased interest in the social, ethical and political aspects of cord blood banking as a location where scientific, economic, governmental and personal expectations converge. Cord blood banking attracts various actors with common, and competing, interests, including regulators, scientists, business people, medical staff, donors, patients and customers. Although academic publications have appeared on some of the contested values and discourses around UCB banking, such as waste, gift, hope, insurance and venture…, there is still little we understand about the collaborations, alliances and competition among these actors and stakeholders, as the processes involved in cord blood banking remain opaque. This special issue brings together the perspectives of midwives, managers in cord blood banks, parents, scientists and policymakers in different countries. Their standpoints highlight various perspectives on cord blood banks, as well as how a panoply of opinions and actions come about in their specific socio-cultural, economic and political context.”

As such, the articles’ abstract are below. Enjoy!

Hybrid practices in cord blood banking. Rethinking the commodification of human tissues in the bioeconomy

Christine Hauskeller and Lorenzo Beltrame

The STS and bioethical literature on umbilical cord blood (UCB) banking nowadays discusses the field as divided into opposite institutional arrangements, public versus private banking. Public banks represent a model-sharing economy; private banks represent a market economy that capitalizes hopes and tissues, and new hybrid forms that are emerging. We challenge that this distinction is analytically valuable for understanding the various forms of marketization, commodification and biovalue production that mark the UCB economy. Our analysis of current UCB banking practices, especially hybrid ones, and their inherent visions of the future, shows that hybrid UCB banking criss-crosses the different economic models and concepts of commodification. The private, public, hybrid distinction is thus inadequate for a critical analysis of the complex UCB bioeconomies. Drawing on the perspective of social welfare systems analysis, however, the tripartite distinction emphasizes an important ethical and biopolitical commitment to equality in current and future health care.

The multiple roles of cord blood banks in Taiwan: competition and collaboration

Hung-Chieh Chang

In Taiwan, as in many countries where national cord blood donation programs are not available, cord blood donation and banking services are provided by non-governmental sectors. This article discusses: (1) the various cord blood banking models to critically examine the public and private binary; and (2) the collaboration and networking between cord blood banks and other institutions as strategies in response to strict governance and fierce competition. This article, based on fieldwork in Taiwan, gives an overview of cord blood banking models in Taiwan and shows the interdependent relationship among different stakeholders in the generation of stem cell knowledge. The concept of “bionetworking” is drawn upon to analyze the networks that cord blood banks establish with various stakeholders. I argue that, through analyzing networks and activities that cord blood banks engaged in and their relation with science, our understandings of stem cell knowledge and therapies production can be deepened.

Following the banking cycle of umbilical cord blood in India: the disparity between pre-banking persuasion and post-banking utilization

Prasanna Kumar Patra and Margaret Sleeboom-Faulkner

To address critique of the rare uptake of umbilical cord blood (UCB) in private banks, hybrid-banking models would combine the advantages of “public UCB banking” and private UCB banking by responding to both market forces and public needs. We question both by following the cycle of UCB banking in India: the circulation and stagnation of UCB as waste, gift, biological insurance, enclaved good, source of saving lives and commodity through various practices of public, private and hybrid UCB banking. Making the journey from “recruitment,” “collection” and “banking” to “research” and “therapy” allowed us to identify concerns about the transparency of this cycle. Drawing on archival research and fieldwork interviews with different stakeholders in UCB banks in India, this article shows how private/hybrid cord blood banks are competing for their market share and its implication for the circulation of UCB: speculation, stagnation and opacity.

Contested expectations: the cord blood economy in South Korea

Yeonbo Jeong

Stem cells from umbilical cord blood are now being actively used in transplants, as well as for a wide range of other medical, research, therapeutic, and commercial purposes. In this incipient stage of stem cell treatments and products, however, expectations about the benefits, use, and distribution of cord blood stem cells vary significantly among relevant companies, scientists, donors, patients, and governments. Focusing on the use of cord blood in South Korea, this paper examines the contested expectations that exist among the parties involved with the donation and use of cord blood, and how the distribution of cord blood stem cells reflects these disparities. The emergence of cord blood economy has been accompanied by contested expectations related to an array of issues, including altruism, motherhood, wealth, nationalism, sharing, and ethical justification. Although donors often remain interested in the prospective use of the biomaterials, their concerns and expectations have been overlooked.

The collection of “quality” umbilical cord blood for stem cell treatments: conflicts, compromises, and clinical pragmatism

Laura L. Machin

Incentives have been proposed to National Health Service (NHS) hospitals to encourage the collection of “quality” umbilical cord blood (UCB) to treat people with blood disorders. As UCB is collected immediately after a woman has given birth, maternity practices have come under scrutiny. Sixty-two interviews were conducted between 2009 and 2010 with those working on maternity wards, and in UCB collection and banking. Ethical approval was granted by the university institution and the NHS Research Ethics Committee. Participants perceived a conflict between acquiring a “quality” UCB sample for blood disease sufferers and concerns for maternal and neonatal health. Options to overcome the conflict were compromises that demonstrated that those most powerful in the debates are those conducting maternity practices, whilst those involved in the banking of UCB have less influence perhaps as a consequence of the lower priority of “quality” UCB collection in relation to maternal and neonatal health.

Maurizio Meloni’s “Political Biology: Science and Social Values in Human Heredity from Eugenics to Epigenetics” by Alan Goodman

21 Septembre 2016 - 12:00pm

Political Biology: Science and Social Values in Human Heredity from Eugenics to Epigenetics

Maurizio Meloni

Palgrave MacMilllan, 2016, 284 pages

 

In Political Biology, Maurizio Meloni, one of our most insightful social theorists of contemporary biology, guides us through heredity from the second half of the nineteenth century, through the twentieth “century of the gene” (Keller, 2000) and into the twenty-first century and the epigenetic present. Meloni expertly maps the consolidation of the paradigm of “hard heredity” that dominates most of the twentieth century. The book invites us to explore the surprising postgenomic world: that is, the world of science that begins roughly after the completion of the Human Genome Project, a period marked by the everyday sequencing of genomes and, of most significance, the opening up of the genome and an increasing appreciation of the complexities by which genetic sequences relate to phenotypes.

Meloni, Senior Research Fellow in the Department of Sociological Studies at the University of Sheffield (UK), examines, on one level, how biological heredity “became modern” when the notion of the gene as controlling fundamental biological processes cemented into the dominant paradigm of biology. On a second level, Meloni investigates the implications of the rise, transformations, and potential decline of hard heredity for social life and political thought. He asks “What sorts of citizenship, personhood, politics and governmentality” are to be found with hard and soft heredity? (ix). What are the connections between views of heredity (and degrees of determinism) and political systems? And on a third level, Meloni highlights the epistemological split between the natural sciences and the social sciences that also became institutionalized during the twentieth century.

Meloni questions the structures of knowledge—particularly the separation of genetics from the social sciences—and the ways in which genetics pulled biology and medicine from the social sciences and social inquiry. He explores “the reconfiguration of the border between life and social sciences following the rise and fall of certain scientific views of human heredity.” (6). “[P]olitical biology,” he writes, “reopens closed connections between certain scientific statements and political values, connections that have been chopped off under the weight of historical stratification. This reopening seems particularly important right now, as a particularly neglected view of science—soft heredity—is being renewed” (17).

Meloni calls for a new social biology, a call I find particularly exciting and that readers of Somatosphere may as well.

In the first chapter, “Political Biology and the Politics of Epistemology,” Meloni outlines his goals. His book is a sort of archaeology of genetics, and here he explains his interest in heredity and the working distinction between hard and soft heredity. Briefly, hard heredity is the notion that genetic inheritance is a closed system, passed with fidelity from parents to their offspring. Soft heredity is less deterministic and predictable, and most important, allows for the possibility of environmental influences, from Lamarckian inheritance to epigenetic mechanisms. Hard heredity and soft heredity stand in for strong nature and strong nurture—that is, a closed genetics system as fundamental to human nature and a biology that is open to social influences.

One of the strengths of Meloni’s treatment is that it provides a wide historical and philosophical view of the separation of two realms of inquiry: the biological and the social. In a sense, Political Biology is a strong and urgent appeal for a social biology, a concept Meloni has taken up in articles and shorter writings (2014). He urges us to consider that if biology is influenced by the unfolding of life events, early life and even the experience of one’s relatives, as epigenetics suggests, how might this change our ideas about health and the body? What might be the political implications and the implications for rethinking human biology?

Chapters two through seven, the core of the book, present the history of heredity in an approximately chronological order.

In chapter two, Meloni outlines the rise of “heredity before hard heredity” and focuses on three key scholars: Francis Galton, August Weismann and Wilhelm Johannsen. He shows how hereditarian ideas based on a mixture of nature and nurture, as developed by Erasmus Darwin and Herbert Spencer, took definitive shape, even before the biomechanics of heredity were determined. However this soft hereditarianism was replaced by a complete separation of heredity and environment in which the seed was seen as more important than the soil, the key lesson of Galton and partly so of Weismann (43).

The dominant belief in seed over soil was key to the intellectual climate that allowed for the widespread acceptance of eugenics (chapter 3). What makes for fascinating food for thought is the juxtaposition of the expected connections between authoritarian politics and deterministic hereditarianism on the one hand (chapter 3) and examples that go against the grain on the other hand (chapter 4). Just as there are politically left Lamarckians and right Mendelians, Meloni tell us about their opposites: right Lamarckians and left Mendelians (94). The utter separation of heredity and environment had an unexpected emancipatory potential (both in terms of politics and knowledge-production) that we might perhaps understand only today when the legacy of this separation is once again challenged by epigenetics.

Alfred Kroeber, one of the founding fathers of cultural anthropology, provides an excellent example of left hereditarianism. Kroeber follows Franz Boas, his mentor, in his separation of culture from biology. Kroeber formulates the idea that culture is above biology, or “super organic.” Although culture emerges from the organic (biology), it occupies a different domain or sphere, largely independent in rules and regulations from the organic, not reducible to the organic, and requiring a separate science. Here Meloni gives me an appreciation of what Kroeber was trying to do in freeing culture from biology, but as an anthropologist I would have loved to read more about Boas and his earlier struggles to integrate biology and culture.

Boas’s (1912) anthropometric work on immigrants and their offspring showed that types could change—they were plastic, thus providing an early example of soft inheritance. Working in the dominant paradigm of hard heredity, however, and at a time in which human biology could not be separated from race and type, Boas opted to separate the science of culture from the science of biology. It is noteworthy that he helped to open up heredity (against a tide of racism and eugenics) but ultimately moved politically to save culture and ceded biology to the hard hereditarians. Boas, some suggest, was the last biocultural anthropologist.

In chapters five and six, Meloni discusses the field of heredity after 1945 and the Second World War to the end of the twentieth century, a period marked by an ever-increasing pace of research in the new field of genetics. Beginning in the 1950s the gene, understood as a string of nucleotide sequences, takes on a physical reality and the central dogma of genetics—that information travels in one direction from DNA to RNA to proteins—is established. Toward the end of this period of study, the ambitious Human Genome Project (HGP) gets under way and full genomes of humans and other organisms are successfully sequenced. Questions remain, however, as to what genes mean and what genomes do.

At the press conference in June 2000 to announce the first successful sequencing of a human genome, Craig Venter and colleagues took the moment to announce that race is genetically meaningless. Still, scientists and writers today are far from uniform about whether “race” is to be found in the genes.[1]  UNESCO statements on race go forward and back. Whereas first William Boyd (1950) and others assumed that difficulties of defining races based on flexible phenotypes would be overcome by hard genetic information, Lewontin (1972) burst that bubble by showing that almost all known genetic variation is within so-called races. That race is not found in genetic differences raises questions about the sociopolitical roots of race (and class) differences in health and wealth. If differences exist—as they do—and they are not genetic, what is their cause? In other words, how does living in a racial and racist world get under the skin, and even into the genome? Instead of reducing culture to biology, culture is seen to cause biological differences.

Meloni welcomes us to postgenomics in chapter seven. Indeed, it is an exciting period and an unexpected (and welcome?) turn of events. As some predicted, the most difficult scientific work was to come only after the three billion letters of the genome, that “blueprint of life,” were revealed. How does the genome fold? What is the importance of all of those base pairs that do not code for proteins? And what activates and inactivates the mechanisms by which gene sequences are transcribed?

The author, one of our chief chroniclers of epigenetics, walks us through the postgenomic present. Meloni outlines five ways of understanding postgenomics, all of which “decenter” the genome. He wonders how this opening up of the genome harks back to more than a century ago, the last period during which soft heredity was dominant. Indeed, epigenetics provides a modern molecular mechanism to show that early life events, and even events that were experienced by ancestors, can turn genes on and off. Meloni asks what the implications will be of the reopening of the genome to life experience.

In his last chapter, Meloni does not tell us what the future will hold. Instead, he offers a series of provocations. He interprets the signs that epigenetics might lead to a more social biology. It is less easy, however, to predict the politics of this more social biology. It could, for example, lead to a deterministic view of racial differences in health. Politics, Meloni shows us, affect the science of heredity and the science affects the politics, but the influences in both directions are only partial. Meloni writes: “Science and knowledge are the plastic objects of power, but so is politics the plastic object of scientific facts and expert claims. Therefore, power and truth, matters of fact and matters of concern, loop back to each other” (13).  The relationship between political beliefs and systems on the one hand and the hereditarian perspectives on the other, Meloni says, has both an underlying pattern and a distinct flexibility and complexity. And perhaps this is a core lesson of Meloni’s important book: we should be aware of both the pattern and the breaks with the pattern.

This book should become a fundamental resource. It is of necessity a dense work and the reading can at times be slow (a copy editor knowledgeable about genetics could have made the writing more linear), but to break up the text, Meloni has incorporated some lovely declarative sentences. Meloni’s text references are utterly thorough: the bibliography of works cited takes up forty-three pages! Not surprisingly, his copy editors left out some references in the extensive ending bibliography. My last quibble is the hefty price tag. Let us hope that Palgrave sees the wisdom of issuing Political Biology in a more affordable paperback edition.

I have great admiration for what Meloni has achieved in Political Biology. His breadth of research and his depth of understanding are impressive. The scope is a huge one—the history of genetics—but even more important, Meloni presents a thoughtful analysis of the codeterminations of genetics and politics.

Political Biology may stand as a key moment not only in chronicling but also in helping to bring together genetics and social science and reconfiguring the border between the life sciences and the social sciences.

 

Alan Goodman is professor of biological anthropology at Hampshire College in Amherst, Massachusetts. He teaches and writes on the health and nutritional consequences of political-economic processes including poverty, inequality and racism. Goodman is the editor or author of seven books including Building a New Biocultural Synthesis (University of Michigan Press, 1998) and Genetic Nature/Culture (University of California Press, 2003)He is a past President of the American Anthropological Association. 

 

Works Cited

Boas, Franz. (1912) Changes in the Bodily Form of Descendants of Immigrs. American Anthropologist 14:530-562.

Boyd, W. (1950) Genetics and the Races of Man. Boston, MA: Little, Brown and Company.

Keller, E. F. (2000) The century of the gene. Cambridge, MA: Harvard University Press.

Lewontin, R. (1972) The apportionment of human diversity. Evolutionary Biology, pp 381-398.

Meloni, M. (2014) How biology became social, and what it means for social theory. Sociol Rev, 62(3): 593–614.

Wade, N. (2014) A troublesome Inheritance: Genes, race and human history. New York: Penguin Books.

 

Notes

[1] The publication and responses to Nicholas Wade’s A Troublesome Inheritance (2014) is an eye-opening example of just how alive the debate around race and genetic remains.

Infant Topography: Baby Body Mapping in Maphisa, Zimbabwe by Min'enhle Ncube

19 Septembre 2016 - 12:00pm

Nomsa, her sixteen month old son Nathi and I met early one morning at the entrance to the open cast mine in Mafuyana, Southern Matabeleland, Zimbabwe. Nathi safely secured on her back, a shovel in one hand and a plastic bag with bread and water in the other, Nomsa hurried me along: “We must walk quickly, the earlier I start working, the earlier I can knock-off. This little one gets irritated when hungry, plus he has a bit of flu in this cold”. We walked briskly through the maze of thorny acacia and mopane bush for about thirty minutes—some three kilometres. Despite the absence of trails, Nomsa navigated the landscape well. We passed several abandoned deep vertical shaft gold mines before we arrived at the open cast mine pits where she worked with two other women, extracting ore. She sat Nathi down in the shade and began work, digging the rocky ore from one side, piling it on the other. Intermittently, she breastfed Nathi, usually when he became irritable. The women worked hard, pausing only for tea until mid-afternoon, when they packed up and we returned to Maphisa, the new development zone where they lived.

Nomsa lived in a single room shared with her husband and two children. The room was dim; there were no curtains or lights. The small room was crammed with a double bed, a chipped wooden wardrobe, and a kitchen unit. The floor was cemented concrete, uneven, unrefined and dusty. Nomsa’s room was part of a larger housing unit that comprising a toilet and kitchen (without either water or electricity) and a bedroom on either side. Her neighbour, Mhlophe, lived in the second room. The two families cooked outdoors. The home, although small in size, presented a rich space for exploring infants’ topographies in Mafuyana. The physical and emotional characteristics the home contained contributed largely to the formations of childhood.

This vignette introduces my investigation of the intersections of ‘urban’ development and early childhood. It forms part of the research of the First Thousand Days research programme at the University of Cape Town. Over eight weeks of summer 2016 I worked with infants and caregivers in Mafuyana, a new ‘urban’ township on the northern periphery of a growth point, Maphisa, in Southern Zimbabwe.[1] Mafuyana forms part of Zimbabwe’s nationwide Operation Garikai[2] project (Operation Live Well), which followed the Operation Murambatsvina[3] campaign (Operation Clean-Up/Restore Order). Mafuyana was built for those dispossessed during Operation Murambatsvina and for others who had never owned a house. There were many young children and babies in Mafuyana. This community, mostly comprised of young adults, valued having children in their lives. Children were considered a life investment and caregivers hoped to be cared for by their children in their old age. However, infant care posed numerous challenges in Mafuyana where, as we have seen in the opening vignette, limited economic opportunities and poor ‘urban’[4] infrastructure posed daily challenges to infant care and well-being.

My work is concerned with the ecologies that surround infant health and child loss in a developing context. In Zimbabwe, the high infant mortality rate is attributed to AIDS, dysentery, malaria, diarrhea, skin conditions and nutritional deficiency. The Zimbabwe National Child Survival Strategy Report (2010–2015) states that these deaths are mostly preventable. Risk factors include unsafe and unhygienic delivery environments, delays in seeking skilled medical care, home deliveries, poor antenatal surveillance and poor postnatal care. In Mafuyana, poor housing and a chronic shortage of employment opportunities contribute to these risk factors. Fieldwork interviews and home visits demonstrated the extent to which the new housing settlement was hazardous to raising infants. Frail housing was prone to invasion by burglars, pests and bad weather. In the absence of clean running water, residents used contaminated water sourced from Antelope Dam[5]. Familial relations within and between homes also influenced the wellbeing of infants. It is easy to describe these material topographies but I was interested to explore more; to find ways to access how people understand infant bodies and well-being in Mafuyana. Standard biomedical descriptors such as ‘fontanelle’ or ‘heart’ were inadequate to the task; I soon discovered they did not get me to the heart of knowledge I sought. I therefore developed a methodology I term ‘baby body mapping’. This is a visual mapping technique that gains more access to people’s perceptions of their babies’ bodies in relation to the houses sheltering them and the geographies formed around them.

Body mapping has emerged as a useful method serving to connect the understandings of biological and social processes of the infant’s body. Andrea Cornwall (1992 and 2002) has used body mapping to examine women’s knowledge about reproduction and their interpretations of non-indigenous contraception in Mazvihwa, a rural area in Zimbabwe. This technique offered a bridging space between the biomedical and local understandings of the female reproductive anatomy. Hayley MacGregor (2008) analyses the use of body mapping in Khayelitsha, South Africa, as an educational tool that promotes the understanding of social and political aspects of HIV and AIDS. Baby ‘topography’ is a term derived from Geetha Ramani and colleagues’ (2010) investigation of babies’ self-awareness of their body shape and spatial configuration. Ramani states that neonates begin learning about their own bodies as newborns and can determine whether the hand caressing their cheek is their own or someone else’s. Furthermore, self-awareness of one’s topography increases with age and is associated with traditional measures of reflective self-awareness. Caregivers’ descriptions gave insight to the complex geographies—physical, economic, emotional, social and spiritual—that shape infant lives. Baby body mapping facilitated a less directive interviewing style which produced people’s own classifications and visual descriptions that were used as a basis for discussion.

I implemented the baby body mapping exercise at the end of my research, during a focus group discussion I held with care givers who had been part of the project. By then I had a clear idea of the challenges infants and caregivers faced, such as those described in the opening vignette. Together, we drew a large sketch of a baby. When the mapping exercise began, caregivers were reluctant to share their ideas, but I reminded them that as a childless woman, I had much to learn from them. Each individual described parts of the body and meanings associated with them. Eventually, we produced a topographical map. This was the first time the participants had visualised their babies through a drawing. I was surprised by some of my informants’ perceptions, and had to overcome my own assumptions on what contributes to the making of a baby’s body. Given the context of precarious labour, and unemployment in the mining township, it is hard not to focus on infancy as a period configured by economic and physical constraints. I came to realise that I had placed an overwhelming focus on the physical and economic aspects of infancy, overlooking the spiritual, symbolic and emotional experiences.

The body mapping exercise led to stimulating discussions about the women’s different perspectives on infants’ bodies. They described for example, ukwetheswa inkanda (‘strengthening’ a baby’s fontanelle), a ceremony performed after the umbilical cord has fallen off. This serves to protect the baby from any evils he or she encounters when introduced to the world for the first time. Approaches to the ceremony differed. Some wafted herbal smoke over the child; others used parts of animals believed to embody great strength, such as the honey badger and the elephant. However, they lamented no longer being able to use these animal parts due to inaccessibility. Another practice was tying a cord that had been blessed by a church pastor around a baby’s waist. This had the dual function of providing protection and serving to gauge the infant’s growth. Twins were perceived more problematic in comparison to singletons. Memory, a mother of six month old twin girls, was advised by her neighbours to roll them in the ash pit behind her house in order to calm their bouts of excessive crying.  This practice is known as ukubhuqa emlotheni (rolling in ashes). Nomsa described having bathed her baby in a basin of water and soil scooped from a common public area in the belief that exposing her baby to ‘public’ soil would acclimatise him to the world. In these ways, caregivers sought to treat and protect children while exposing them to the complexities of the world.

The topography of infancy in Mafuyana was more complex than it seemed. Although national policy seeks to protect children from preventable disease and death, caregivers spoke also of the need to protect children from social and metaphysical dangers. Their commentary on such dangers and their efforts to protect children in a context underpinned by economic hardship and limited opportunity suggest that it is critical to investigate local understandings of well-being. Examining infancy topographically and geographically through the body mapping technique provides a useful alternative to conventional interviews, which sometimes overlook underlying perspectives. The method shifted my perspective considerably. For example, whereas I had thought that children should be protected from dirt, I learned that dust and ash could be a necessary part of exposing the child gradually to the dangers of the world and in so doing, offering protection. Unlike structured interviews, infant body maps facilitate discussion and reflection on the ways parts of the body are perceived and treated. Infant topography produced by drawing a baby body map opens a space for deeper discussions that formulate infant geographies and the practices (and limitations) of care that surround them.

 

Min’enhle Ncube is a Master’s student in Anthropology at the University of Cape Town and part of the First Thousand Days of Life research group. Her research interests in medical and developmental anthropology lie in early childhood and its interaction with the developmental and political space in Matabeleland South, Zimbabwe. This article is based on her current Masters research underway, which examines the development of infants in a developing urban-rural township.

 

References

Cornwall, A. 1992. Body mapping in health RRA/PRA. International Institute for Environmental Development. Issue 16, pp.69–76. London

Cornwall, A. 2002. Body Mapping: Bridging the Gap between Biomedical Messages, Popular Knowledge and Lived Experience in Realizing Rights: Transforming Approaches to Sexual and Reproductive Wellbeing, 2002 (eds. Andrea Cornwall & Alice Welbourn). pp. 219–231. Zed Books. London

Gasper, A. 1988. Rural Growth points and rural industries in Zimbabwe: Ideologies and Policies, Development and Change 19(3) 425–66.

Government of Zimbabwe. 2005. Response to the UN Special Envoy’s Report on Operation Murambatsvina. Harare

Kesby, M et al. 2006. Theorising other ‘other childhoods’: Issues emerging from work on HIV in urban and rural Zimbabwe. Children’s Geographies. Vol 4:2. pp185–202

MacGregor, H. 2008. Mapping the body: tracing the personal and the political dimensions of HIV/AIDS in Khayelitsha, South Africa. Anthropology and Medicine. Vol 16:1. p85–95

Mlalazi, A. and Conyers, D. 1989. Is There A Future For Regional Planning In Zimbabwe? Paper Presented At the 1989 Conference of the Department Of Physical Planning, Masvingo.

Ncube, M. 2015. ‘Posted Home’: The Impact of Tuberculosis on Early Childhood and Beyond in Maphisa. University of Cape Town. (Unpublished B.SocSci Honours Dissertation.)

Nyathi, P. 2005. Zimbabwe’s Cultural Heritage. ‘amaBooks. Bulawayo

Nyathi, P. 2001. Traditional Ceremonies of AmaNdebele. Mambo Press. Gweru

Potts, D. 2006. ‘Restoring Order’? Operation Murambatsvina and the Urban Crisis in Zimbabwe. Journal of Southern African Studies. Vol 32:2. [Online]. Available: http://www.jstor.org/stable/pdf/25065092.pdf  Accessed: 18 July 2015

Ramani, G et al. 2010. The Head Bone’s Connected to the Neck Bone: When Do Toddlers Represent Their Own Body Topography? Child Devlopment. JStor. Vol. 81: 3, p797–810

UNICEF. 2013. Zimbabwe Annual Report. [Online]. Available: http://www.unicef.org/zimbabwe/Annual_Report_Webpages_layout_2014.pdf  Accessed: 10 October 2015

UNICEF. 2010-2015. Zimbabwe National Child Survival Strategy Report. [Online]. Available: http://www.unicef.org/zimbabwe/Young_Child_Survival_Doc-Complete.pdf Accessed: 3 August 2016

 

Notes

[1] ‘Growth point’ denotes settlements which are earmarked for economic and physical development in Zimbabwe.

[2] The follow-up exercise did little to alleviate the country’s self-inflicted humanitarian crisis.

[3] A large-scale Zimbabwean government campaign, which started in 2005, to forcibly clear ‘informal’ structures across the country.

[4] Relative to the Maphisa rural community, this was classified as urban, regardless of its deprivation of electricity, underground piping to supply water and robust housing.

[5] Also known as Gulameta Dam

Arguing with Justice: Brexit and Biomedicine by Rosalind Williams

16 Septembre 2016 - 12:00pm

The aftermath of the UK’s recent referendum on European Union (EU) membership, which culminated in a decision for Britain to leave the EU, reminds us of Britain’s bleak history of racism, and should prompt us to reflect upon the political visions of justice that underlie current constitutions of biomedicine.

For many, the outcome of the ‘Brexit’ referendum was justice turned on its head. After the Leave vote won with a 52% majority, social commentators argued that Brexit is an injustice to Britain’s youth—those who will live the longest with the outcome of the referendum wanted to remain in the EU, which bears out in the early retrospective analysis of voter demographics. But the Leave campaign also appealed to justice by arguing that the EU had morphed into a force for “social injustice” as Brussels turned its back on “economic common sense”. The most toxic claims came from those who appealed to a kind of natural right, couched in English nationalism, about who belonged in the UK.

In the wake of these claims on justice, it is, we suggest, time that scholars working at the intersection of science and medicine argue with justice. Similar to other recent arguments about science and justice, we choose these words deliberately. Arguments are often made by using justice (for example, by mobilising the language of “social injustice” to argue against the EU). But scholarship doesn’t as freely spend time arguing with justice—interrogating this unwieldy but thoroughly seductive motif.

At this intersection between Brexit, science and health, it comes clearly into relief that biomedicine is about much more than patients and clinicians, or research participants and investigators. It is about the legal and institutional frameworks that shape our daily lives and our access to healthcare and medicines. Such issues of inclusion, health and wellbeing are matters of justice. With fundamental societal changes looming ahead, Brexit means we must argue with justice.

Such reckoning with justice is critical because what we have seen with Brexit is a heredity redux—an explicit revival of imperial attention to biological and genealogical propriety, marked by the dilation of hierarchy as ordering mechanism. An overt return to much older and never fully forgotten nationalist, biological and xenophobic sentiments about who belongs and is entitled to receive provisions of justice, like health care and access to medicines.

During the June 2016 lead-up to the EU referendum vote, the Official Leave campaign made the funding of Britain’s National Health Service (NHS) a central component of its movement. Notoriously, campaign buses touring the country were emblazoned with: ‘Let’s give our NHS the £350 million the EU takes every week’. One of the most powerful pieces of propaganda released by the Leave campaign (which was also immediately rescinded by Leave campaign politicians on their victory), this statement tapped into long-standing frustrations. The NHS, ushered in with sweeping post-war welfare reforms, is in the midst of apparent debt crisis, a veritable black hole sucking in precious funds to meet the health demands of a growing (and aging) population. All this against the backdrop of funding cuts imposed by EU ‘enforced austerity’, by shrinking State economic support and the slow creep of privatisation through which the famous NHS logo is itself now being used by private companies.

In the media, blaming the non-national—asylum seekers, refugees and migrants—has been explicit. In the most amusing analysis, migrants into Britain are simultaneously lazy social welfare/healthcare users and job-stealing (summed up perfectly by the Schrödinger’s immigrant meme). In more nefarious moments, asylum seekers are set to overwhelm the country’s beleaguered health service.

Where does the EU sit in all of this? As a key EU report, entitled ‘Evaluating Care Across Borders’, pointed out, discussions of the then European Economic Community in the 1970s concluded that “the principle of free movement of people was meaningless if it applied only to those in full health”. Accordingly, we see the legislative enshrinement of what the EU calls cross-border care. in the European context, far right political energy has reached a peak and this comes starkly into relief in the context of Brexit. Preoccupation with indigeneity to the United Kingdom manifested in the week after Brexit with a fivefold increase of race hate incidents nationally. The day after the result, English National Front protesters were out in Newcastle, carrying a poster demanding “STOP IMMIGRATION. START REPARTRIATION”.

Such vitriol highlights the more pernicious articulation of the increasingly complex relationship between race, geography and national identity in which claiming citizenship through jus soli has undergone systematic erosion in various nation-state contexts, not least via the British Nationality Act 1981 in which statelessness is the default for British-born children of non-British parents. But the vitriol doesn’t answer the question it begs of us—what makes one British? This question carries such weight because of the benefits of Britishness—of existing in a country built on colonial exploitation, of existing in a country where feelings of deservedness, of a right to access health and wealth are deeply embedded. But such a question (really, a basic question of justice) of who belongs in a polity is one not easily answered.

Health provision, biomedical research and technology are deeply impacted through these changing post-colonial iterations of what being British means, along with who has the right to belong and benefit from state institutions, such as the NHS. In addition, biomedical technologies are increasingly playing a public role in answering questions of who is part of a polity. The proliferation of genetic ancestry testing and national biobanking are testaments to the multiple and contradictory ways genetic and biological evidence of belonging becomes enmeshed in national debates. This is not just evident in the UK as Senator Elizabeth Warren’s debunked claim to Native American heritage highlights. As we have seen with Brexit, being able to say that one person is more British than another is a dangerous ability.

The political shifts signalled by the Brexit vote present a profound departure from the idealistic sentiment of universalism we usually imagine when we think about justice. Porous borders, and the postcolonial push and pull of bodies through them, tested ‘justice’ and the capacity of communitarian caring. Now we are compelled to think about the grammar of justice.

 

Rosalind Williams is a Research Associate in Sociology at the University of Sheffield. She is currently working on a Leverhulme funded project, ‘Tracking Ourselves?’, focusing on everyday practices of self-monitoring. She’s written for Life Sciences, Society and Policy and New Genetics and Society.

Amy Hinterberger is an Assistant Professor of Sociology at the University of Warwick. Her work has been published in Public Culture, Theory, Culture and Society and Science as Culture. She is currently working on a Wellcome Trust funded project entitled ‘Blood and tissue as human research subjects’ which investigates transformations in definitions and practices of what constitutes a human research subject in the context of data-intensive biology.

This piece was inspired by discussions had at ‘Arguing with Justice’, an Early Career Researcher workshop held June 2016 at the University of Warwick’s Sociology department and attended by keynote Jenny Reardon from UC Santa Cruz and discussant Maria Puig de le Bellacasa from University of Leicester.

Special Issue! Nonsecular Medical Anthropology by Anna Zogas

14 Septembre 2016 - 8:34pm

Ian Whitmarsh and Elizabeth F. S. Roberts have edited a Special Issue of Medical Anthropology called “Nonsecular Medical Anthropology.”  Here is an excerpt from their introduction to the issue, along with the abstracts of its commentary and six articles.  Enjoy!

Nonsecular Medical Anthropology (open access)
Ian Whitmarsh & Elizabeth F. S. Roberts

A nonsecular medical anthropology insists on the ways medicine and science have constituted ‘the secular’ itself through the ‘secular self’—how medical knowing has been used to craft the secular political subject. As James Boon noted, too often in social theory, “religion gets safely tucked away—restricted theoretically to ‘meaning’ rather than power” (1998:245). The authors of the six articles in this special issue ‘untuck’ religiosity from within the norms and numbers of medicine itself, and examine how ‘secular’ medicine has relied on religious traditions to produce political secularity. These articles demonstrate that ‘secular’ medicine relies on religious others whose exclusion bespeaks latent religious commitments of citizenship in the modern political realm of health.

In the past few decades, anthropologists of religion and secularity have provided a vigorous critique of the liberal political subject constituted through the distinction between the secular and the religious (Asad 2003; Mahmood 2005). Meanwhile medical anthropologists have developed tools to examine how medicine constitutes the human. With this special issue, we draw together insights from both these literatures to query the relationship between the secular and health, medicine, and the body.

Gods, Germs, and Petri Dishes: Toward a Nonsecular Medical Anthropology (open access)
Elizabeth F. S. Roberts

This commentary calls on medical anthropology to become programmatically non-secular. Despite recent anthropological critiques of secularity, within and outside of anthropology, most contemporary medical anthropologists continue to leave deities and religiosity out of their examinations of healing practices, especially in their accounts of biomedicine. Through a critical, relational constructionist lens, which traces how all entities are both constructed and real, a non-secular medical anthropology would insist that when deities are part of medical practice, they are integral to analysis. Importantly then, within the symmetrical nature of this same constructionist lens, biomedical entities like germs and petri dishes need to be accounted for just as much as deities.

All Eyes on Egypt: Islam and the Medical Use of Dead Bodies Amidst Cairo’s Political Unrest
Sherine Hamdy

Using dead bodies for medical purposes has long been considered taboo in Egypt. Public health campaigns, physicians’ pleas, and the urgings of religious scholars all failed to alter public opinion regarding the donation of dead bodies either for instructional material or for therapeutic treatments. Yet in 2011, amid revolutionary turmoil in Egypt, a campaign was launched for people to donate their eyes upon death; this time, people readily signed up to be donors. Focusing on mass eye trauma that occurred in Egypt amid the political uprisings of 2011, I raise questions about when and why Islam can explain people’s attitudes and behaviors, particularly toward death and medicine. The case of mass eye trauma in Egypt and citizens’ reformulations of questions once jealously controlled by state-aligned doctors, politicians, and religious scholars unsettles the boundaries between ‘religion’ and ‘secularism’ in medical practice.

Medical Eschatologies: The Christian Spirit of Hospital Protocol
Jean M. Langford

If much has been written of the forms of bodiliness reinforced by hospitals, less attention has been paid to the medicalization of the soul. The medical management of death institutionalizes divisions between body and soul, and matter and spirit, infusing end-of-life care with latent Christian theological presumptions. The invisibility of these presumptions is partly sustained by projecting religiosity on those who endorse other cosmologies, while retaining for medicine a mask of secular science. Stories of conflict with non-Christian patients force these presumptions into visibility, suggesting alternative ethics of care and mourning rooted in other understandings. In this article, I explore one such story. Considering the story as an allegory for how matter and spirit figure in contemporary postmortem disciplines, I suggest that it exposes both the operation of a taboo against mixing material and spiritual agendas, and an assumption that appropriate mourning is oriented toward symbolic homage, rather than concern for the material welfare of the dead.

Cosmic Experiments: Remaking Materialism and Daoist Ethic “Outside of the Establishment”
Mei Zhan

In this article, I discuss recent experiments in ‘classical’ (gudian) Chinese medicine. As the marketization and privatization of health care deepens and enters uncharted territories in China, a cohort of young practitioners and entrepreneurs have begun their quest for the ‘primordial spirit’ of traditional Chinese medicine by setting up their own businesses where they engage in clinical, pedagogical, and entrepreneurial practices outside of state-run institutions. I argue that these explorations in classical Chinese medicine, which focus on classical texts and Daoist analytics, do not aim to restore spirituality to the scientized and secularized theory of traditional Chinese medicine. Nor are they symptomatic of withdrawals from the modern world. Rather, these ‘cosmic experiments’ need to be understood in relation to dialectical and historical materialisms as modes of knowledge production and political alliance. In challenging the status of materialist theory and the process of theorization in traditional Chinese medicine and postsocialist life more broadly speaking, advocates of classical Chinese medicine imagine nondialectical materialisms as immanent ways of thinking, doing, and being in the world.

“The Tools of Your Chants and Spells”: Stories of Madwomen and Indian Practical Healing
Sarah Pinto

A longstanding trope in Indian psychiatry, and in popular representations of it, involves the efficacy of incantations and exorcism in healing afflictions of the mind, notably hysteria. In many accounts, from nineteenth century medical journals to twenty-first century popular films, a medicine deemed at once ‘Western’ and universal is granted the ability to diagnose neurotic afflictions, but rendered incapable of curing them, while bodily techniques referred to as ‘Indian’ are granted efficacy. In this article, I explore the subtleties and implications of this recurrent knowledge paradigm. I argue that a particular arrangement—one in which difference is established through equivalence—undergirds the terms by which medicine comes to be viewed as a cultural encounter. As these progressive formulations are often founded on stories about women’s madness, I ask, what are the implications of an arguably pragmatic ethos founded on an uneven—and deeply gendered—resolution to postcolonial knowledge problems?

Secular Redemptions: Biopolitics by Example
Cristiana Giordano

In this article, I analyze the practices of a group of Catholic nuns who run shelters for ‘victims of human trafficking’ in Italy, and are thus involved in state-funded rehabilitation programs for former foreign prostitutes. This case shows how the state and the Church are deeply implicated in each other’s projects of redemption and the creation of new forms of life. In Italy, the legal model for rehabilitating foreign prostitutes is avowedly secular yet also deeply shaped by a Catholic impetus to purify sinners. At the same time, however, the nuns themselves develop an understanding of redemption as a secular life-saving project in line with the state’s project of recognition, and thus inscribe their practices within the biopolitical effort to transform lives. Ultimately, I argue, leading by example becomes a specific Catholic instantiation of biopolitics that characterizes both the state’s and the Church’s approach to foreigners.

Entangled Bodies: Jews, Bedouins, and the Making of the Secular Israeli
Na’amah Razon

Taking Israel’s National Health Insurance Law as a point of entry, in this article I probe how notions of equality and citizenship, secularism, and religion become entangled in the experience of Negev/Naqab Bedouins, who are Palestinian citizens of Israel. Drawing on ethnographic and archival research, I show how Jewish citizens have come to represent the secular and modern citizens in the region, while Bedouins, although mandated and claimed by policy and providers to be the ‘same’ and ‘equal,’ are always already imagined and characterized as other. Universal health care and the daily manner in which biomedicine is practiced in southern Israel provides an avenue for examining the Jewish valences medicine carries in southern Israel, Israel’s boundaries of inclusion, and the connection between biomedicine and secularism.

Tarek Elhaik’s The Incurable Image: Curating Post-Mexican Film and Media Arts by Christopher Fraga

14 Septembre 2016 - 12:00pm

The Incurable-Image: Curating Post-Mexican Film and Media Arts

by Tarek Elhaik

Edinburgh University Press, 2016, 198 pages

 

Tarek Elhaik’s first book—an ethnographic examination of multi-media artists, curators, and fellow anthropologists loosely centered around Mexico City—is a bold, highly theoretical effort to revive something of the experimental ethos of Writing Culture (Clifford and Marcus 1986) and the works that followed in its wake. Rather than experiment with textual form, however, Elhaik seeks to formulate a new vocation for contemporary anthropology, one that is both “critical and clinical.” Drawing liberally on the vitalist philosophy of Gilles Deleuze, Elhaik aspires to reconceptualize anthropology as a kind of “symptomatology”: that is, as a means of diagnosing cultural ailments and of identifying pathways to other, more salubrious “forms of life.”[1] The Incurable-Image consists of a collection of interconnected essays that identify the symptoms of a “post-Mexican condition” (Bartra 1992, 2002) before drawing lessons from contemporary efforts to “curate” it. Medical anthropologists and scholars working in science and technology studies will find here a complex reconceptualization of film and media arts as twenty-first-century forms of care.

The 1980s saw Mexico grow increasingly permeable to transnational flows of capital in its various forms, a cultural and economic process that reached a new plateau in the mid-1990s with Mexico’s participation in NAFTA. This new permeability was accompanied by the country’s so-called “transition to democracy” after the single-party rule of the Institutional Revolutionary Party was fundamentally (albeit not irrevocably) shaken.[2] Together, these political and economic developments posed an insuperable contradiction to nationalist narratives of Mexican exceptionalism, deeply undermining the unitary national identity that had been forged in the early twentieth century by a coalition of politicians, artists, filmmakers and anthropologists. According to fellow anthropologist Roger Bartra, with whom Elhaik is in dialogue throughout his book, public mourning for the loss of this collective Mexican identity risked tipping into a pathological “melancholia” (82-86). Elhaik builds on Bartra’s account by examining how “post-Mexican” cultural producers have continued to grapple with this loss in the early twenty-first century. Focusing primarily on multi-media artists, filmmakers, and curators, Elhaik diagnoses a “malaise” in contemporary curatorial and moving-image culture (62, 128), the most critical symptom of which consists of a concept of Elhaik’s own creation: the “incurable-image.”

The clearest illustration of this concept comes in the essay that takes it as its title. Taking his lead from the French philosopher and art historian Georges Didi-Huberman, Elhaik interprets the first two shots of Rúben Gámez’s experimental film La fórmula secreta (1965) as a Pathosformel, that is, as a “visible expression of [a] psychic state that had become fossilized, so to speak, in the images” (Didi-Huberman, cited on 59). The first shot of Gámez‘s film shows what appears to be an inverted bottle of Coca-Cola dripping into an intravenous tube, the end-point of which lies off-screen, withheld from view; Elhaik reads it as a symbol of U.S. cultural imperialism. The second shot follows the shadow of a zopilote (the American black vulture, Coragyps atratus) as it frenetically surveys the Zócalo, Mexico City’s main square and the political and ecclesiastic heart of the country; Elhaik notes the zopilote’s symbolic displacement of the golden eagle (Aquila chrysaetos) that adorns the Mexican flag. Taken in sequence, these two shots stage the Mexican body politic as terminally ill, its death-by-Coca-Cola foretold by the carrion-eater circling ominously overhead.

Elhaik insists that this “defiguration” does more than simply disrupt the symbolic order of Mexican nationalism.[3] It “releases an incurable-image,” which he takes as “the sign of a more profound mutation in Mexican visual culture and the point of departure for the production of another anthropological unconscious“ (ibid). By highlighting the incurability of such images, Elhaik does not mean to suggest that they should be withdrawn from display. Rather, he asserts that they call for a new, “postclinical form of curation still to come” (64), one that would “require us to think of other forms of collectivity through a different deployment of images” (67). Additional examples of incurable-images illuminate what such a deployment might entail, and its potential therapeutic value. For instance, Elhaik posits Roger Bartra’s ironic choice of the axolotl (Ambystoma mexicanum), an amphibian common to central Mexico, as “an incurable-image of Mexicanism” (81). This playful, humorous mode of repetition reveals some of the remedial possibilities of incurable-images, which Elhaik conceptualizes in terms of “fugas.” As Bartra explains over the course of a transcribed conversation with Elhaik, the Spanish word fuga encompasses several distinct meanings: it translates the musical term “fugue,” with its use of multiple melodies in counterpoint, but it also refers to flight (in the Deleuzean sense of a “line of flight”) and to leakage (as in a gas leak or a water leak) (97-98).

Another essay describes Elhaik’s own efforts to curate a film series called Soy México (111-114) in 2011. Part of this project involved bidding an “affirmative farewell” to the maguey plant (Agave spp.) as an incurable-image of Mexicanist aesthetics by programming the climactic sequence from Sergei Eisenstein’s unfinished masterpiece ¡Que viva México! (1931) alongside Rubén Gámez’s little-known animated short Magueyes (1962) and Olivier Debroise’s experimental documentary Un banquete en Tetlapayac (2000). Maguey plants feature prominently in all three of these films, and Elhaik’s series sought to weave these images into a kind of cinematic counterpoint. Observing that this international group of filmmakers had to “crisscross the political, affective and aesthetic landscapes of so-called alternative modernities” (117) before reaching the Mexican countryside and its stately agaves, Elhaik presents Soy México as a “post-Mexican fugue” of his own making.

In “The Incurable Park,” Elhaik continues to follow some of the practical pathways that have been illuminated by his concept of the “incurable-image,” this time by considering “pedagogy as a form of curation” (131). This essay offers the clearest example of how his alternative conception of anthropology departs both from conventional methods of ethnographic fieldwork on the one hand, and from the socially oriented forms of artistic practice that have characterized the “ethnographic turn” in contemporary art on the other. Leading a small seminar at the Escuela Adolfo Prieto in Monterrey, an industrial city in northern Mexico (129), Elhaik trained his students to see a nearby public park, Parque Fundidora, as symptomatic of what Deleuze has characterized as “societies of control.” Taking his notion of the incurable as their point of departure, they sought out the blockages and impasses that shape the Parque Fundidora. Elhaik incorporated the results of this exercise into a more experimental mode of textual production that is indeed quite reminiscent of the Writing Culture era: a collaboratively authored text comprising eight short diagnoses written up by the participants in Elhaik’s seminar (all of whom were professionals connected in some way or other to the Monterrey art scene).

Several features of Elhaik’s collection of symptomatological essays merit highlighting. As he warns in the Introduction, his book will “not quench the reader’s thirst for things Mexican” (6). He completely eschews not only the genre conventions of ethnographic writing, but also the foundational concept of ethnos as such. Responding to the (post-)Mexican artist Eduardo Abaroa’s complex installation The Total Destruction of the National Museum of Anthropology (2011), Elhaik casts aside the notion of a geographically delimited field site populated by individual human subjects. (Indeed, as far as Elhaik is concerned, Abaroa’s fantasy of destroying Mexico’s National Museum of Anthropology “is the destruction of anthropos, tout court” [45].) Instead, he insists on situating his work in what he identifies as a “post-Mexican assemblage” with nodal points in Mexico City, Monterrey, Tijuana, and the southern border town of Frontera, as well as Los Angeles and San Diego. He regards this assemblage as being populated by a dynamic cast of “conceptual personae” (see Deleuze and Guattari 1994), consisting primarily of “the artist,” “the curator,” and “the anthropologist.” The actual biographies of the physical human bodies that host these personae are irrelevant to his purposes; what matters are only the “vital anecdotes” (idem, 72-73)—like that of Bartra’s ironic engagement with the axolotl, or Gámez’s recourse to hungry zopilotes and warring magueys—that enable Elhaik to produce his design for a post-human, post-social, post-cultural anthropology.

Elhaik’s commitment to conceptual experimentation is commendable, as is his Nietzschean attempt to conjure some of anthropology’s “untimely futures” into being. This is a highly sophisticated book, steeped in an eclectic blend of cutting-edge anthropology, continental philosophy, and contemporary art theory. More to the point, however, these essays raise a deeper set of epistemological and methodological questions for our discipline. If Eduardo Abaroa was successful in destroying anthropos tout court, if “we are the hinterlands of images, nothing more and nothing less” (72), as Elhaik rather polemically asserts, if indeed we are none too human after all, what would be the place of science in the anthropology of images still to come? If assemblage-work is now preferable to fieldwork (34 and passim), how are we to map the geo-spatial contours of such assemblages with any empirical rigor? In consistently advocating for the creation of concepts, conceptual personae, and “curatorial thinking” over empirical description, human informants, and cultural practices, Elhaik seems to be espousing something like a philosophical disenfranchisement of anthropology (to adapt an expression from Arthur Danto). Many of us will no doubt be reluctant to abandon our existing commitments and conceptual repertoires in favor of Elhaik’s newly minted design for a contemporary anthropology, but his book nevertheless offers a welcome reminder that even our most cherished concepts can go rancid and turn poisonous if we go too long without dusting them off and reexamining them.

 

Works cited

Bartra, Roger. The Cage of Melancholy: Identity and Metamorphosis in the Mexican Character, translated by Christopher J. Hall. New Brunswick: Rutgers University Press, 1992.

———. Blood, Ink, and Culture: Miseries and Splendors of the Post-Mexican Condition, translated by Mark Alan Healey. Durham: Duke University Press, 2002.

Clifford, James and George E. Marcus, eds. Writing Culture: The Poetics and Politics of Ethnography. Berkeley: University of California Press, 1986.

Deleuze, Gilles. Nietzsche and Philosophy, translated by Hugh Tomlinson (New York: Columbia University Press, 1983).

Deleuze, Gilles and Félix Guattari. What Is Philosophy?, translated by Hugh Tomlinson and Graham Burchell (New York: Columbia University Press, 1994).

Smith, Daniel W. ““A Life of Pure Immanence”: Deleuze’s “Critique et Clinique” Project,” in Gilles Deleuze, Essays Critical and Clinical, translated by Daniel W. Smith and Michael A. Greco, xi-liii. Minneapolis: University of Minnesota Press, 1997.

Sparks, Simon. “Editor’s Introduction: Politica ficta,” in Philippe Lacoue-Labarthe and Jean-Luc Nancy, Retreating the Political, translated by Simon Sparks, xiv-xxviii. New York: Routledge, 1997.

 

Notes

[1] As Deleuze puts it in his reading of Nietzsche’s philosophy, “the sciences are a symptomatological and semiological system” (1983, 3; cf. 75). See Smith (1998) for a cogent overview of Deleuze’s own “symptomatological method,” and his critique et clinique project more broadly. Nietzsche is another key philosophical interlocutor throughout these essays, though Elhaik does not make this very explicit.

[2] See Bartra (2002) for a more detailed explanation of how these changes gave rise to a “post-Mexican condition.”

[3] Elhaik’s elliptical invocation of “defiguration” (58) comes from an exchange between philosopher Jean-Luc Nancy and psychoanalyst Philippe Lacoue-Labarthe, quoted in English translation in Sparks (1997, xxi-xxii). See Elhaik (2016, 73n.2 and 73n.5).

 

Christopher Michael Fraga is Assistant Professor of Anthropology at Swarthmore College. His research focuses on cultural change in Mexico since the 1980s, particularly in the plastic arts. He is currently developing a new project on the cultural and political implications of U.S. drug policy, past, present and future.

 

Pricing the EpiPen: Drug Prices, Corporate Governance, and the Financialization of Biomedicine by Danya Glabau

12 Septembre 2016 - 12:00pm

Why does Mylan’s EpiPen cost so much?

That was a question many parents of food allergic children found themselves asking this past August, as a flurry of news reports revealed that the standard two-pack now costs patients as much as $600 out of pocket. The device, a type of epinephrine auto-injector, looks like an oversized marker. Inside is a mechanism that pops out a short needle and delivers epinephrine in three seconds or less when it is pushed firmly against one’s body (preferably the outer, upper thigh). Epinephrine – a hormone also known as adrenaline – is the preferred substance for halting and reversing a severe allergic reaction, called anaphylaxis. Originally created as a tool for delivering emergency nerve gas treatment on Cold War-era battlefields, the device is now considered a necessity for people with food allergies.

The EpiPen pricing controversy is one of many events that have drawn attention to the escalating price of medical objects and procedures in the past year. Turing Pharmaceuticals’ Daraprim pricing scandal beginning in the fall of 2015 (about which I’ve written previously for Somatosphere) and Theranos’ meltdown earlier in 2016 on the news that the high-priced tests they performed were not as advertised has kept the issue of high drug prices in the public eye. In the EpiPen pricing case, many journalists and members of the food allergy community have critiqued the credentials and motives of Mylan CEO Heather Bresch. From analyses of her possibly fraudulent MBA to critiques of her compensation to her political connections via her US Senator father, her rise to corporate stardom on the strength of EpiPen revenue has been put under the microscope.

One thing that sets these scandals about the costs of medical care apart from previous debates (such as those surrounding the cost of health insurance in the wake of the Affordable Care Act) has been the attention paid to specific pharmaceutical companies and their specific pricing strategies. In each instance, the CEO of the company has been placed in the spotlight, portrayed as both the representative for the complex goings-on within their companies which generate such pricing strategies and an avatar for corporate greed in healthcare. Yet while blaming the CEO satisfies the forensic itch of reporters and congresspeople, it obscures some important structural issues at play in healthcare today. In particular, the methods now used to raise operating capital and bring new products to market have made healthcare CEOs increasingly beholden to a new set of actors with new expectations for company conduct and performance: shareholders, debt-holders, and various types of private investors.

An increasingly important part of research and development for most pharmaceutical companies in the past several years has been to outsource much of the clinical development and manufacturing research to smaller pharmaceutical, biotechnology, medical device, and health technology companies. Small companies conduct the early stages of research and development before their successful “assets” (as new products are called) are scooped up by larger ones via partnerships or acquisitions. These transactions reduce a pharmaceutical company’s infrastructural investment at earlier stages where technologies are more prone to failure due to rocky transitions to use in humans or persistent difficulties in producing the actual drug substance or device. By relying on investors and financiers in new ways to acquire so-called “de-risked” technologies, companies seek to reduce their exposure to the risks of conducting research on and designing products for unruly human bodies.

To attempt such transactions, companies need access to capital, and there are two ways for them to get it: sell more products, or sell them at a high enough price to generate revenue quickly and have cash on hand; or (as Karen Ho (2009) has also explained in her ethnography of investment banking) raise the stock price, which raises the financial valuation of the company (also known as the market capitalization, or market cap), which the company can then borrow against through investment banks and shadowy private equity firms. Mylan’s August 2016 quarterly financial statement bears witness to this strategy, showing that the company raised over $6 billion in capital through debt and stock issuance – essentially borrowing from investors against the promise of future stock price growth – between August 2015 and August 2016. This was almost the precise amount needed for the $6.6 billion takeover of Swedish pharmaceutical company MEDA and associated transaction costs.

EpiPen pricing policies were undoubtedly a crucial lever that enabled this particular transaction. The value provided to a company like Mylan by a device like the EpiPen is not only the value of the revenue collected to date, but also the demonstration of the company’s ability to continue to increase revenue through price increases and increased sales into the future. The promise of increasing revenue draws in new investors as the strategy is demonstrated to work in successive quarters, increasing the company’s stock price and thereby increasing the company’s access to borrowed capital. For modern pharmaceutical companies, this promissory function of pricing is an important aspect of company strategy that enables the pursuit of other activities and transactions.

This episode concerning EpiPen prices – a snapshot in my larger, three-year project on food allergies in the United States – underscores the importance for anthropologists and STS scholars to do more rigorous research on the relationship between medicine and finance. (Notable, Somatosphere has already begun to feature such work in progress.) A number of scholars in what is often referred to as the social studies of finance have now studied how Wall Street-style investment banking gets done in practice (Mackenzie 2006, Riles 2011) and the distinctive cultural attitudes towards risk and reward these practices produce (Ho 2009). Meanwhile, medical anthropologists have written extensively about the construction of consumer and provider markets for pharmaceuticals (Dumit 2012, Greene 2014) as well as how clinical research is strategically designed to provide evidence for lucrative indications for prescribing (Petryna 2009, Jain 2013) and providing hands-on care (Kaufman 2015). What is missing in these literatures as they stand today is an in-depth understanding of the financial practices of healthcare companies and the effects they have on patient care.

These practices matter because they undermine what most assume to be the social role of pharmaceutical companies to be: the development of reasonably priced, high-quality medications for very ill patients. They do so by reinforcing the alignment of management with investors who are interested in making products with large markets that can quickly generate revenues that increase quarter after quarter, thereby generating revenue, increasing share price that can be leveraged as debt in exchange for more capital, or both. In the wake of the shareholder revolution and the widening acceptance of Wall Street financial governance models in healthcare-related businesses, the CEO’s role in pharma has been redefined as one of keeping investors satisfied by assuring them that they will receive their anticipated returns. CEOs who fail at this can be removed by their company boards, as it is not uncommon for the majority of a pharmaceutical company’s board seats – especially those of smaller or new companies – to be populated by representatives of their largest shareholders. The company must be aligned with investor expectations from the top down for the work of making medicines to even begin.

I argue that it is a dead end to try to understand pharmaceutical company behavior – from pricing schemes to early-stage R&D strategies – based on the assumption that drug makers are primarily motivated by a desire to expand access to necessary care. This assumption, which I call the “care thesis of biomedicine,” makes pricing controversies seem contradictory, immoral, even irrational to observers (also see Dingwall 2016 for the impact this has within the medical profession). Understanding the financial entanglements of the modern pharmaceutical company with the financial sector, however, casts a different light on these controversies: they are perfectly rational when measured by the standards of the actors who control the purse strings. In other words, like any actors in ethnographic research, pharmaceutical companies make more sense when apprehended on their own terms. And it is those very terms – what I refer to as the logic of finance capital – that set companies down the path of what many analysts, reporters, and members of the public see as bad behavior that inflicts harm on patients.

 

Danya Glabau recently received her PhD in Science and Technology Studies (STS) at Cornell University. Her dissertation examined the culture of food allergy activism in the United States and drew on over two years of multisited ethnographic research. She is currently Faculty at The Brooklyn Institute for Social Research and has worked with three New York-based biotechnology companies in the allergy space. You can check out her blog to learn more about her research, upcoming class at the Brooklyn Institute, and other events. You can also follow her on Twitter at @allergyPhD.

 

Works Cited

Dingwall, Robert. 2016. “Why Are Doctors Dissatisfied? The Role of Origin Myths” 21 (1): 67–70. doi:10.1177/1355819615589425.

Dumit, Joseph. 2012. Drugs for Life: How Pharmaceutical Companies Define Our Health. Durham: Duke University Press.

Greene, Jeremy. 2014. Generic: The Unbranding of Modern Medicine. Baltimore: Johns Hopkins University Press.

Ho, Karen. 2009. Liquidated: An Ethnography of Wall Street. Durham and London: Duke University Press.

Jain, Sarah Lochlann. 2013. Malignant: How Cancer Becomes Us. Berkeley: University of California Press.

Kaufman, Sharon. 2015. Ordinary Medicine: Extraordinary Treatments, Longer Lives, and Where to Draw the Line. Durham, NC: Duke University Press.

Mackenzie, Donald. 2006. An Engine, Not a Camera: How Financial Models Shape Markets. Cambridge, MA: MIT Press.

Petryna, Adriana. 2009. When Experiments Travel: Clinical Trials and the Global Search for Human Subjects. Princeton: Princeton University Press.

Riles, Annelise. 2011. Collateral Knowledge: Legal Reasoning in the Global Financial Markets. Chicago: The University of Chicago Press.

 

 

Book Forum––Robert Desjarlais’ Subject to Death: Life and Loss in a Buddhist World by Todd Meyers

9 Septembre 2016 - 12:00pm
    Robert Desjarlais’s Subject to Death is like stepping onto a train already in motion. Its momentum isn’t fierce but there’s no time to ease in––from its first pages, as readers we find ourselves in the midst of death and life and loss as they take and are given form. At the risk of overusing the term, there is great care in this book, and the five commentaries that follow are reflections of this care, not owing to an expected attitude or comportment towards life and death, but attending to what is required by the invitation Desjarlais makes to readers, made between author and subject and reader, as we are brought into a conversation rather than relegated only to eavesdrop. It is a great honor to present this forum on Robert Desjarlais’s Subject to Death.   Living with Dying Anand Pandian Johns Hopkins University   Insider’s Note Karma Gyaltsen Lama   You are here. Sarah Pinto Tufts University   Life in Death Summar Said Wayne State University   Making Death: A Narrative Medicine Exploration Marsha Hurst
Columbia University   Writing Anew Robert Desjarlais Sarah Lawrence College

Download the PDF:

Subject to Death Book Forum

Special Issue! Practical Anthropology for a Global Public Psychiatry by Anna Zogas

6 Septembre 2016 - 7:32pm

A very exciting special issue of Transcultural Psychiatry has just been published: Practical Anthropology for a Global Public Psychiatry: Provocations and Future Directions is edited by Neely Myers, Rebecca Lester, and Kim Hopper. Here are the abstracts!

Reflections on the anthropology of public psychiatry: The potential and limitations of transdisciplinary work
Neely Myers, Rebecca Lester, and Kim Hopper 

Transcultural psychiatry and anthropology have long championed the comparative study of emotional distress to better understand how people experience, interpret, and manage extraordinary mental events and emotional quandaries around the globe. This special issue brings together practitioners, scholars, and experts from both disciplines working at the intersections of the community and the clinic, the personal and the social, the local and the global, to ask: where does this effort currently stand? We hope this collection of articles will serve as a bellwether selection of provocations and future directions for transdisciplinary research in psychiatric anthropology.

Much research on the mental health system in the US, at least, skirts the sprawling, fragmented, poorly mapped terrain of “de facto” services—a motley array of institutional arrangements claiming to offer custody and care, such as jails, prisons, detention facilities, residential institutions for teenagers, homeless shelters, and a variety of quasi-institutions for the deaf, blind, and elderly. Rather than avoiding these settings, the researchers contributing to this issue reflect on the challenging work of engaging intimately with interlocutors living with these conditions. We use the term “public psychiatry” to refer to this ad hoc, patch-worked, and ill-monitored system. Unlike “public health,” as we use the term here, public psychiatry encompasses not populations but structures: state, private, and informal configurations of care, the surrogates of care and the default options offered when care is unavailing. Understood in this way, we can reflect on both public psychiatry in the US and the global variations of public psychiatry familiar to readers of this journal.

Recovery stories: An anthropological exploration of moral agency in stories of mental health recovery
Neely Anne Laurenzo Myers

Moral agency has been loosely defined as the freedom to aspire to a “good life” that makes possible intimate relationships with others. This article uses ethnographic research to further the discussion of the role of moral agency in mental health recovery. This article attends to the ebb and flow of moral agency in the life stories of three people diagnosed with a serious psychiatric disability at different stages in their individual recoveries to illustrate particular aspects of moral agency relevant for recovery. From these, a more complex notion of moral agency emerges as the freedom not only to aspire to a “good life,” but also to achieve a “good” life through having both the intention to aspire and access to resources that help bring one’s life plans to fruition. Each storyteller describes an initial Aristotelian peripeteia, or “breach” of life plan, followed by an erosion of moral agency and sense of connection to others. The stories then diverge: some have the resources needed to preserve moral agency, and others attempt to replenish moral agency that has been eroded. In these stories, the resources for preserving and nourishing moral agency include the ability to cultivate the social bases of self-respect, autobiographical power, and peopled opportunities. These stories cumulatively suggest that without such resources one’s attempts to preserve or nourish the moral agency needed for recovery after the peripeteia, which is often perpetuated by the onset and experience of serious mental illness, may fall short.

Violence, addiction, recovery: An anthropological study of Mexico’s anexos
Angela Garcia and Brian Anderson

Informal, coercive residential centers for the treatment of addiction are widespread and growing throughout Latin America. In Mexico these centers are called “anexos” and they are run and utilized by low-income individuals and families with problems related to drugs and alcohol. This article draws on findings from a 3-year anthropological study of anexos in Mexico City. Participant observation and in-depth interviews were used to describe and analyze anexos, their therapeutic practices, and residents’ own accounts of addiction and recovery. Our findings indicate that poverty, addiction, and drug-related violence have fueled the proliferation of anexos. They also suggest that anexos offer valuable health, social, and practical support, but risk exacerbating the suffering of residents through coercive rehabilitation techniques. Emphasizing this tension, this article considers the complex relationship between coercion and care, and poses fundamental questions about what drug recovery consists of in settings of poverty and violence.

Shifting blame: Buprenorphine prescribers, addiction treatment, and prescription monitoring in middle-class America
Sonia Mendoza, Allyssa S. Rivera-Cabrero, and Helena Hansen 

Growing nonmedical prescription opioid analgesic use among suburban and rural Whites has changed the public’s perception of the nature of opioid addiction, and of appropriate interventions. Opioid addiction has been recast as a biological disorder in which patients are victims of their neurotransmitters and opioid prescribers are irresponsible purveyors of dangerous substances requiring controls. This framing has led to a different set of policy responses than the “War on Drugs” that has focused on heroin trade in poor urban communities; in response to prescription opioid addiction, prescription drug monitoring programs and tamper-resistant opioid formulations have arisen as primary interventions in place of law enforcement. Through the analysis of preliminary findings from interviews with physicians who are certified to manage opioid addiction with the opioid pharmaceutical buprenorphine, we argue that an increase in prescriber monitoring has shifted the focus from addicted people to prescribers as a threat, paradoxically driving users to illicit markets and constricting their access to pharmaceutical treatment for opioid addiction. Prescriber monitoring is also altering clinical cultures of care, as general physicians respond to heightened surveillance and the psychosocial complexities of treating addiction with either rejection of opioid dependent patients, or with resourceful attempts to create support systems for their treatment where none exists.

God in the brain: Experiencing psychosis in the postsecular United States
Nev Jones, Timothy Kelly, and Mona Shattell

There is a growing literature on what contemporary cultural theorists have broadly termed the “postsecular”: the abandonment of clear-cut boundaries between the secular and nonsecular in the industrialized West and an embrace of a complex understanding of what is real that neither accepts nor rejects the supernatural. These new cultural currents may affect not only philosophers and theologians, but also the ways in which individuals with psychosis make sense of their experiences. This paper reports on the key findings of an in-depth qualitative analysis of 19 interviews of individuals diagnosed with psychotic disorders. The majority of participants described ongoing and self-conscious struggles to demarcate their experiences as the products of the real world or a “crazy” mind. With equal frequency, participants weighed and debated competing secular and supernatural explanations, often juxtaposing and blending different explanatory frameworks. We found that this syncretic process affected not only the content of psychotic experiences—what delusions or hallucinations are about—but also the type of arguments or logics used to justify particular interpretations. We discuss the implications of these observations with respect to clinical practice and the broader phenomenology of psychosis, challenging often oversimplified discourse on “insight” and suggesting that polarization(s) between “biomedical” and “psychosocial” explanations may be of less relevance to patients’ real-world experiences than is often assumed.

Signing on for dirty work: Taking stock of a public psychiatry project from the inside
Leah G. Pope, Lauren Cubellis, and Kim Hopper

As applied anthropologists used to working at arm’s length from public psychiatry, we step out of the daily grind to take stock of the challenges of taking on ethnography entrained–harnessed to the implementation of a new program. These include the loss of critical distance, the struggles to negotiate locally viable forms of authority and relevance, the necessity of sustaining a Janus-faced relation with principal players, the urgency of seeing time-sensitive information converted into corrective feedback, and the undeniable attraction of being part of “committed work” with game-changing potential. In so doing, we rework the terms of witnessing and revive an old alternative: that documentary dirty work be reclaimed as a variant of public anthropology, one that transforms the work of application from mere afterthought to integral part of the original inquiry.

 

Top of the Heap: Matthew Kohrman by Hannah Gibson

5 Septembre 2016 - 12:00pm

[For this instalment of the Top of the Heap series, I spoke with medical anthropologist and Associate Professor Matthew Kohrman from Stanford University.]

Summer has arrived in North America. Catching up on academic reading is not my first priority at the moment. May it be yours! If so, here are a few texts among the many that have been beckoning me, some for far too long. I will be on sabbatical academic year 2016-2017, so my justifications for reading these texts in the months ahead will be perilously few.

Works in medical anthropology that I hope to be perusing soon and which you too may wish to consider are Harris Solomon’s Metabolic Living: Food, Fat, and the Absorption of Illness in India, Vincanne Adams’ Metrics: What Counts in Global HealthCheryl Mattingly’s Moral Laboratories: Family Peril and the Struggle for a Good Lifeand Charles Briggs and Clara Mantini-Briggs’ Tell Me Why My Children Died: Rabies, Indigenous Knowledge, and Communicative JusticeNo less alluring are a few books that colleagues and students have been recommending to me, including Sara Ahmed’s The Promise of Happiness, Carlo Caduff’s The Pandemic Perhaps: Dramatic Events in a Public Culture of Danger, Saskia Sassen’s Expulsions: Brutality and Complexity in the Global EconomyDeborah Cowen’s The Deadly Life of Logistics: Mapping Violence in Global Trade, and two books by Brad Evans and his co-authors, Resilient Life: The Art of Living Dangerously and Disposable Futures: The Seduction of Violence in the Age of Spectacle.

Thinking forward to a new project of mine that will speak to topics in health and the environment, on my must-read list are also Barbara Ellen Smith’s Digging Our Own Graves: Coal Miners and the Struggle over Black Lung Disease and Michelle Murphy’s Sick Building Syndrome and the Problem of Uncertainty: Environmental Politics, Technoscience, and Women Workers.

I was born spring 1964, two months after the civil rights icon and NFL star, Jim Brown, helped my hometown claim a sports championship and enjoy a victory lap of masculine self-celebration.  Fifty-two years onward, after waves of feminist transformation worldwide and a half century of racial and economic turmoil in Northeastern Ohio, two texts free of academic airs that tug at me for immediate consideration are Mike Freeman’s Jim Brown: The Fierce Life of an American Hero and Scott Raab’s infelicitously titled, The Whore of Akron: One Man’s Search for the Soul of LeBron James.

And then there is China. To my interests there, books that are top of the pile include Petrus Liu’s Queer Marxism in Two ChinasPeter Ho and Richard Edmonds’ China’s Embedded Activism: Opportunities and Constraints of a Social Movement, and Elanah Uretsky’s Occupational Hazards: Sex, Business, and HIV in Post-Mao China.

Stitched together this seems like a sizable list. If I get through even half of it – okay, even if I don’t get that far – I intend to enjoy some Asia-inspired graphic novels along the way, including Guy Delisle and Helge Dascher’s Shenzhen: A Travelogue from China and Pyongyang: A Journey in North KoreaMy fellow Californian, Gene Luen Yang, was recently named a National Ambassador to literature, so perhaps I’ll also find time for his celebrated works, like Boxers and Saints and the Avatar series. Hey, if nothing else, I can always tell myself that I’m bringing his eye candy home to encourage my 14-year-old son to read.

Matthew Kohrman is an Associate Professor at Stanford University. With a research focus on the Republic of China, he engages various intellectual terrains such as governmentality, gender theory, political economy, critical science studies, narrativity, and embodiment. In particular, he explores how culture, health and politics are interrelated. Recently, Prof. Kohrman has been involved in research aimed at analyzing and intervening in the biopolitics of cigarette smoking among Chinese citizens. This work expands upon heuristic themes of his earlier disability research and engages in novel ways techniques of public health, political philosophy, and spatial history.

Photo: Vintage Library

Web Roundup: Controversy and Commerce by Sara M Bergstresser

4 Septembre 2016 - 8:53pm

There have been many controversies about substantial and sudden jumps in pharmaceutical prices, the most memorable/infamous surrounding Martin Shkreli, the [widely despised and thoroughly unrepentant] former CEO of the drug company Turing, and the 5000% increase in the price of a drug used by many AIDS patients. Similar questions of impropriety have been raised by the practices of Valeant Pharmaceuticals, which has become known for the practice of bypassing research and development by buying up smaller companies and then jacking up the prices of their existing drugs.

The newest pharma pricing outrage involves the Epipen emergency allergy device, and the CEO antihero of the moment is Heather Bresch of Mylan. “Mylan has raised the list price of EpiPens more than 450 percent since 2004, after adjusting for inflation, according to Elsevier’s Gold Standard Drug Database. A pack of two EpiPens cost about $100 in today’s dollars in 2004, but the list price now tops $600.” (STAT news). The controversy now includes inquiries from the Senate about Mylan’s drug pricing, descriptions of how Mylan prevented Teva from manufacturing a generic version, frustrations with coupon and discount programs, and questions about the validity of Bresch’s MBA and the role of her being the daughter of a US Senator. Bresch’s statement that “No one’s more frustrated than me” (about the price increase) drew widespread ire, particularly from parents of children with severe allergies.

Josh Freeman of the blog Medicine and Social Justice clearly explains how these events are a symptom of the larger problems of health care in the US, which driven by commerce rather than health. The Wall Street Journal also agrees that Epipen pricing is a byproduct of larger systematic forces. Shkreli has even piped in, voicing his support for Mylan (though one has to wonder how much anyone wants his “help” these days). At least some relief from the stress of the situation may be possible, by playing the satire game “Epipen Tycoon.”

Another embattled (female) biotech CEO has also been in the news: Elizabeth Holmes of Theranos, who was once hailed as a visionary, and later banned from lab operations for two years by US regulators. Theranos has recently announced its intent to appeal the sanctions.

And finally, battles over who really invented CRISPR bring the question of gender more explicitly into view. The latest grinding of the gears in the machinations of science, law, and commerce involve a patent dispute over CRISPR and its broader echo in the social world. On one side of the fight, the widely recognized pioneers Jennifer Doudna at UCLA and Emmanuelle Charpentier of the Helmholtz Center for Infection Research in Germany. On the other, Eric Lander of MIT and Harvard’s Broad Institute, who wrote a piece in Cell featuring the Broad Institute’s Feng Zhang as the main protagonist. The response to this article was far from positive: Jesebel reported on: “How One Man Tried to Write Women Out of CRISPR,” and STAT news described “Why Eric Lander morphed from science god to punching bag.” As it progresses, this ongoing drama promises to become an excellent case study of how science is indeed a human endeavor.

Additional related topics and resources:

And unrelated recent topics of interest:

Global Health Education: When (and How) Global Health Issues Should Be Introduced to Youth by Emily Mendenhall

2 Septembre 2016 - 12:00pm

How do we foster empathy in our children? (Particularly empathy for people living in poverty – both in countries far away and neighborhoods closer to home?) We ask this question as parents and professors who are dedicated to global health research and education. As college professors, we are deeply invested in cultivating well-rounded global citizens who not only think about inequity in their backyard but also think about what inequity looks, feels, and tastes like in other cultures and places. Why is this important? We see value in this understanding because we feel that without connecting with the suffering of others, it is easy to ignore others’ suffering, how that suffering came to be, and the obligation of global citizens to do something about it. We believe that global health issues should be introduced to children in order to promote empathy at a relatively early age – late elementary school, middle school and high school. Because of this Emily has edited a series of books containing global health narratives for youth; this project has been ongoing for nearly a decade.

What is the pivotal moment that cultivates a moral obligation to recognize and do something about the suffering of others? Emily remembers sitting on a train in the Copper Canyon of Mexico as a middle schooler and thinking about why her life in rural Iowa looked so differently than that of the young Tarahumara girl she had interacted with earlier that day. Peter, on the other hand, remembers a moment in a “Cultures of Africa” course in his undergraduate curriculum that sparked his curiosity and longstanding career devoted to understand why some people suffer and die from diseases he had never heard of. These pivotal moments – often followed up with critical discussions with peers, teachers, and mentors – can play a profound role in how people think about the world.

These “Ah Ha” moments early in our lives have influenced our teaching and what we try to do in the classroom. When students engage with a text, film, or audio in a deep way, they leave feeling inspired, as well as full of questions. How students’ passion is sparked and how we respond to that passion plays a significant role in how they use this knowledge immediately as well as throughout their lives.

Together we have initiated two long-term projects dedicated to creating tools to spark these pivotal moments in students’ lives. The first is the Global Health Narratives project, a decade-long effort to design global health curriculum for middle and high school students. This project has resulted in three books, around 100 narratives, and accompanying teaching guides to allow students and educators to engage with the text. The first book, Global Health Narratives: A Reader for Youth (2009, University of New Mexico Press (UNMP)), reflects central themes in global health – from addressing issues of great health and wealth inequality to deconstructing the complexities of affliction among the poor in poor countries. For instance, one narrative contextualizes the onset of malaria and different ways in which people perceive malarial symptoms in rural Mali. The second book, Environmental Health Narratives: A Reader for Youth (2012, UNMP), brings issues of earth, environment, and health into context, incorporating sections on “water”, “air”, “foods and farms”, “climate change”, “urbanization”, and “human impact.” Narratives reach as widely as possible geographically as well as topically in order to foster dialogue of diverse issues from varied settings. The final book has recently appeared. Community Health Narratives: A Reader (2015, UNMP) provides opportunities to discuss some of the trickier hot-button issues in health and health care, such as the role of social relationships, gender and sexuality, mental health, violence, primary prevention, and unequal access to health care in perpetuating health inequities.

The level of sophistication and reading level increases with each book, and the volumes have shown that they can be useful tools in sparking dialogue about complex health inequities among young people – twelve to twenty year-olds. Even more, community health workers, social workers, and nurses in the United States have used the final book on community health to bring complex issues they see in their work to the table for discussion. Therefore, we believe that the potential use of these books of stories – whether alone or together, as well as the accompanying web-based teaching guide – can have great benefits prompting both awareness and in depth discussion.

The second project we co-constructed was a book series for an independent anthropological press (now Routledge) on “Anthropology and Global Public Health: Critical Problems and Constructive Solutions.” The authors we selected for this series of books place narrative at the center of their writing, bringing readers to their scholarship through ethnographically rich writing and global positionality. The books are to be utilized for the growing number of undergraduate programs in global health springing up around the country. With many professors drawing from journalism, including the wonderful books The Spirit Catches You and You Fall Down and Sizwe’s Test, to teach their classes, many professors steer away from the complexities of ethnography for public health students. As anthropologists, we see this as a shame because so many wonderful ethnographies can serve these courses well and provide additional context for the complex political-economic and social circumstances that cultivate global health inequity. And yet, we understand that the theoretical depth to which many scholars are expected to engage with their ethnographic work may turn off an undergraduate reader, particularly one who is not specializing in the humanities or social sciences. The books in our series do not steer clear of theory, but rather deeply engage with a central narrative that raises questions of theory, context, history, and solutions. Situating stories within broader contexts and tying up each book with the question “So what?” makes the texts we publish perfect for an undergraduate course. And the shorter length of these books may make them more attractive than the lengthier journalistic books currently used by many educators.

Why do stories matter? We place narrative at the center of our books because it has “the remarkable power to allow us to ‘perfink’ – perceive, think, and feel at once,” wrote Kate Winskell in the forward to Global Health Narratives. Stories enable us to both deeply connect with the meaning of the problem and reflect on the broader implications of what the story might mean to the reader’s individual experience and the experience of others. The narrative medium holds the power not only to draw in the reader emotionally but also trigger collective critical thinking about the root causes of social injustice. These tools powerfully motivate reflection, engagement, and curiosity to learn more.

What age should educators begin using these texts? We think that they should first be exposed to Global Health at younger ages than they are now. Students come into our undergraduate Global Health courses often with no real idea of the conditions of life and health in low- and middle-income countries. Stories can clearly lay out how social injustice cultivates poor health, but they do so in a way that is not intimidating to the young reader because they avoid too many scientific words. These texts were designed for students in a formative period to set the course for engaged learning and curiosity about cultures, politics, and societies different from their own. Moreover, the stories are written for students at different reading levels. For example, most middle-school curricula include World History and Geography. Many elementary and middle school curricula include engaged learning activities called “Disease Detectives” introducing the logic of Epidemiology. Some of these projects are part of Science Olympiad programs. What the case students neglect, however, is consideration of the human dimension of suffering from diseases.

We have no doubt that students in middle school and high school can engage deeply with issues of social and health inequalities. But how these narratives are used in particular contexts matter. For instance, the engagement students have shown with the text in a public school in rural Iowa differs from a public school in inner city Chicago, Illinois. This is because students’ familiarity with such injustice differs. Those in Iowa showed deep empathy for protagonists whose lives were different from their own — from rural Nepal to urban United States. However, they engaged more deeply with struggles that aligned with their own, from stress associated with agricultural breakdown to bullying and disordered eating. In an inner city school in Chicago, students showed empathy and curiosity for the lives of others. But their ears perked up and their passion was ignited when telling their own stories that resembled those protagonists who confronted gun violence, food deserts, stress, and disordered eating. Indeed, in both cases, students demonstrated empathy for others while connecting to those whose lives seemed most like their own.

The Global Health Narrative project focused on youth protagonists from the beginning in order to provide similarities with the reader, a way for the young reader to connect. While similarities may be as simple as playing soccer or having issues with their siblings, they provide opportunities for people from very different cultures to see that human experience can share values and struggles. And yet, by breaking down the complexities of similarity and difference alike, young readers can see how human experience can be shared in some ways and how systemic inequalities can drastically influence how one person’s experience from the next. Such perspective also enables youth to realize that things that they take-for-granted in their everyday lives (such as access to safe water to drink) are not universal. It provides opportunities for young people to recognize privilege and that they live in a “minority world” of the wealthy. Moreover, such curriculum allows students to begin to understand that vast differences exist and recognize the root of these differences in order to create solutions for them.

While there is a clear market for textbooks on Global Health in the undergraduate and graduate curriculum, figuring out where to place the stories from the Global Health Narratives project has been a real challenge. Initially the books were conceived to serve “Read-Aloud” opportunities in middle school classrooms. We saw multiple opportunities for their use and engagement, and teachers from around the country expressed enthusiasm for the project. And yet, with a slow recognition of the doldrums of the common core, we realized that getting our curriculum into traditional school settings was nearly impossible, even in progressive private schools. Instead, we have focused on after-school learning opportunities from church programs to the Girl Scouts. Some Sunday school classes deal with social justice issues, yet teachers seem hesitant to discuss such topics in terms of disease. These programs can provide time and space for students to engage with the material and discuss their complexities. However, they leave some students out due to each program’s own exclusivities.

Connecting with stories opens doors for students to learn more. By engaging with protagonists in the narrative books, students can begin to look further and discover who are heroes in global health. Students can then become engaged intellectually, financially, and/or emotionally with programs in global health delivery, thereby finding opportunities to make real social change. However, these stories also introduce problems associated with some community-based programs that fail to understand local issues. This can provide classroom opportunities for critical thinking and realizations that “development” programs can be very complicated.

In sum, we have created multiple narrative-based texts that engage with critical global health problems in order to spark curiosity among young readers, from middle school to college graduate. The accompanying teaching guides of the Global Health Narratives Project (www.ghn4c.org) advance the utility of these tools by providing teachers with concrete questions for students to discuss after reading each story. Community Health Narratives also provides exemplar organizations that are making a big impact on the communities they serve. Highlighting who and how people succeed at their quest for improving community health provides students with jump-off points for work in their own communities (such as neighborhoods, church, school, and so on) and futures communities they may serve (such as the global community—through politics, medicine, or public health). Cultivating an understanding of the messiness of global health inequity will undoubtedly serve to promote empathy for others, spark curiosity in youth to learn more, and encourage local engagement on issues of social and health inequity in their own communities. If we want children and young adults to eventually become true global citizens, we have to start earlier.

 

Global Health Narratives Book Series 

Mendenhall, Emily and Kathy Wollner. 2015. Community Health Narratives: A Reader. University of New Mexico Press: Albuquerque.

Mendenhall, Emily and Adam Koon. 2012. Environmental Health Narratives: A Reader for Youth. University of New Mexico Press: Albuquerque.

Mendenhall, Emily. 2009. Global Health Narratives: A Reader for Youth. University of New Mexico Press: Albuquerque.

Global Health Book Series 

Dowdall, Courtney and Ryan Klotz. 2014. Pesticides and Global Health: Understanding Agrochemical Dependence and Investing in Sustainable Solutions. Left Coast Press, Walnut Creek, CA.

Kohrt, Brandon and Emily Mendenhall. 2015. Global Mental Health: Anthropological Perspectives. Left Coast Press, Walnut Creek, CA.

Maes, Kenny, forthcoming. Labor and Lives of Community Health Workers.

 

Emily Mendenhall, PhD, MPH, a medical anthropologist, is an assistant professor of global health in the School of Foreign Service at Georgetown University.  Dr. Mendenhall’s research addresses syndemics of social trauma, poverty, mental illness, and type 2 diabetes among vulnerable populations in the United States, India, South Africa, and Kenya. Her most recent book, Global Mental Health: Anthropological Perspectives, co-edited with Brandon Kohrt, was awarded the Creative Scholarship Award by the Society for the Study of Psychiatry and Culture.

Peter J. Brown, PhD, is a professor of anthropology and global health at Emory University. Dr. Brown’s research has focused on parasitic diseases, particularly malaria, and in one disease of civilization – obesity. He is also interested in gender and health, suicide, Alzheimers, and most recently inequality and health. Dr. Brown was editor-in-chief of Medical Anthropology, editor of Applying Anthropology and the Journal of Medical Anthropology, and a member of the American Anthropological Association Commission on Long-range Planning.

 

In the Journals – August 2016 by Anna Zogas

30 Août 2016 - 4:16pm

Here are some of the articles published in the journals in August 2016. This post includes the abstracts from a special issue of Anthropology & Medicine, “Medical Pluralism and Beyond.” Enjoy!

American Ethnologist

The postneoliberal fabulation of power: On statecraft, precarious infrastructures, and public mobilization in Brazil
João Biehl

In Brazil’s hybrid government of social protection and market expansion, there is under way a fabulation of power, which ultimately serves to “de-poor” people seeking care, working infrastructures, and justice while also shoring up state politics as usual. This process became evident through the failure of a collaborative research project that I coordinated on right-to-health litigation. In rethinking that failure as an experiment in public ethnography, I draw on core disagreements with public officials over the interpretation of our findings from a legal database. Analyzing these disagreements provides an entry point into the mechanisms of veridiction and falsification at work in Brazil, whose government sees itself as providing public goods beyond the minimum neoliberal state. Countering state mythology, public ethnography thus illuminates the improvised quality of postneoliberal democratic institutions and opens up new avenues for theorizing power and the political field.

Royal pharmaceuticals: Bioprospecting, rights, and traditional authority in South Africa
Christopher Morris

The translation of international biogenetic resource rights to a former apartheid homeland is fostering business partnerships between South African traditional leaders and multinational pharmaceutical companies. In the case of one contentious resource, these partnerships are entrenching, and in some instances expanding, apartheid-associated boundaries and configurations of power. The state and corporate task of producing communities amenable to biodiversity commercialization and conservation is entangled with segregationist laws and spatial planning. Rather than exclusion and the closure of ethnic boundaries, resource rights in this context foreground forced enrollment and the expansion of indigenous group-membership as modes of capitalist accumulation in an extractive economy.

Cultural Anthropology (Open Access)  

The August 2016 issue of Cultural Anthropology features a special section titled “Theorizing Refusal,” edited and introduced by Carole McGranahan. Of particular interest to Somatosphere readers, the section includes:

Theorizing (Vaccine) Refusal: Through the Looking Glass (open access)
Elisa J. Sobo

Here is an excerpt:

What goes on when people say no? How can we theorize refusal? In this essay I hope to show the value of casting refusal not only as an instance of resistance, but also as distinct from the latter in important ways (picture a Venn diagram). In doing so, I seek to open up space for a dynamic and salutary reading of refusal and, by extension, of resistance itself. I therefore highlight refusal’s productivity—not in terms of achieved regime changes or political gains, but of what refusal does for immediate social relations.

My argument starts with the assertion that refusal often begins well before said utterance or act, and extends far beyond the moment of behavioral or verbal proclamation. Moreover, in refusing, resistance—the act of standing against—is not always actually or primarily entailed. Refusal is more about avoidance than active opposition (the characteristic by which most scholars define resistance; see Hollander and Einwohner 2004): in refusal, the overt power contests, class antagonisms, or struggles for liberation or against domination that resistance entails are not necessarily directly implicated. Answering Dimitrios Theodossopoulos’s (2014) call to deprimitivize and depathologize how we think about resistant nonconformity, the refusal concept that I lay out provides an opening for grappling with the fact that even people who are not outsiders or who have not been excluded can be subversive. It also helps correct for a tendency in resistance studies to position resistant nonconformity on society’s (imagined) sidelines because, as I explain, refusal accommodates action taking place directly within the here and now of local social life. Thus, rather than existing as simply a synonym for resistance, the refusal construct can offer, as I hope to show, a complementary albeit partially overlapping (remember Venn) point of view.

Professional Organizers and Thingly Care in Contemporary North America (open access) 
Katie Kilroy-Marac

Within the past decade, material disorder—especially that of the domestic variety—has come to stand alternately as evidence, symptom, and potential cause of mental disorder in the North American popular and psychiatric imagination. Sources ranging from the newly defined Hoarding Disorder diagnosis in the DSM-V, to popular media, to agents of the burgeoning clutter-management industry describe disorder in terms of an irrational attachment, closeness, or overidentification with objects. At the same time, these sources imagine order to result from the cool distance and controlled passion a person is able to maintain toward his or her possessions. Drawing on more than twenty interviews and numerous fieldwork encounters with professional organizers (POs) in Toronto between 2014 and 2015, this article describes how POs aim to reorient their clients materially, morally, and affectively to relieve the disorder they report in their lives. Here, I argue, POs emerge as a species of late capitalist healer whose interventions are animated by a paradoxical double movement. For just as POs act to loosen the object attachments and disrupt the “secret sympathy” their clients share with their possessions, they operate within a realm of magical correspondence where matter and mind are imagined to reflect and affect one another, and where bringing order to a client’s possessions means also bringing order to his or her mind.

Philosophy, Ethics, and Humanities in Medicine (Open Access)

The wizard behind the curtain: programmers as providers (open access)
Mark A. Graber and Olivia Bailey

It is almost universally accepted that traditional provider-patient relationships should be governed, at least in part, by the ethical principles set forth by Beauchamp and Childress (Beauchamp and Childress, Principles of biomedical ethics, 1979). These principles include autonomy, beneficence, non-maleficence and justice (Beauchamp and Childress, Principles of biomedical ethics, 1979). Recently, however, the nature of medial practice has changed. The pervasive presence of computer technology in medicine raises interesting ethical questions. In this paper we argue that some software designers should be considered health care providers and thus be subject the ethical principles incumbent upon “traditional” providers. We argue that these ethical responsibilities should be applied explicitly rather than as a passive, implicit, set of guidelines.

Configurations  

Genetic Romanticism—Constructing the Corpus in Finnish Folklore and Rare Diseases
Aaro Tupasela

The role that national epic poetry has played in romantic nationalism during the nineteenth and twentieth centuries is well documented. The role that the new genetics has played in such processes, however, is less well known and understood as a form of writing national narratives of origin. This article compares and contrasts the work of two doctors in Finland, Elias Lönnrot and Reijo Norio, working over a century and a half apart, to examine the ways in which they have contributed to the formation of national identity and unity. The notion of genetic romanticism is introduced as a term to complement the notion of national romanticism that has been used to describe the ways in which nineteenth-century scholars sought to create and deploy common traditions for national-romantic purposes. Unlike national romanticism, however, strategies of genetic romanticism rely on the study of genetic inheritance as a way to unify populations within politically and geographically bounded areas. Thus, new genetics have contributed to the development of genetic romanticisms, whereby populations (human, plant, and animal) can be delineated and mobilized through scientific and medical practices to represent “natural” historico-political entities in comparison to the use of art and literature during the national romantic period.

Satire of Science in Charles Dickens’s Mudfog Papers: The Institutionalization of Science and the Importance of Rhetorical Diversity to Scientific Literacy
Michael J. Zerbe

This article presents an analysis of the satire of science contained in Dickens’s second and third Mudfog Papers. In these sketches, Dickens satirizes science by targeting the distance that is beginning to materialize between science and culture at large, science enthusiasts’ alleged lack of mental prowess, and the institutionalization of science, especially with regard to the science’s exaggerated sense of self-importance and its craving of governmental funding and legal intervention in support of science. Dickens pillories the institutionalization of science even as he champions the professionalization of literature and the arts; this apparent paradox is explored. Additionally, the incipient interdisciplinary conversation between artists and science enthusiasts that is contained in The Mudfog Papers is considered. Finally, the importance of the satire of science as an example of rhetorical diversity necessary to achieve scientific literacy within the context of science’s nascent institutionalization is discussed, as is the potential of the satire of science to help hold science accountable.

Social History of Medicine

Women Searchers of the Dead in Eighteenth- and Nineteenth-century London
Wanda S. Henry

From plague epidemics in Elizabethan England to cholera outbreaks in the early Victorian era, women determined causes of death for London parishes. Despite criticism about lack of medical training, parishes continued to rely upon women searchers and expanded their responsibilities during the eighteenth century while looking not to midwives and nurses but female relatives of parish workers to fill open positions. Sextonesses and pew keepers became searchers of the dead and served lengthy terms in office. Historians have assumed that Parliament established the General Register Office to supplant searchers with medical men, acting as registrars. However, the transition away from the bills depended more upon the parish’s loss of monopoly on the death business than the medical failings of women searchers. By the mid-nineteenth century, the undertaking industry managed London’s dead, and undertakers, rather than medical men, replaced women searchers as reporters of cause of death.

Medicine and Charity in Eighteenth-century Northumberland: The Early Years of the Bamburgh Castle Dispensary and Surgery, c. 1772–1802 (open access)
Alun Withey

In 1772 in Bamburgh Castle, Northumberland, a charitable institution was established by Dr John Sharp to offer medical provision to the poor of the parish, which was remote from the Newcastle and Edinburgh Infirmaries. Unlike urban institutions, which have dominated hospital historiography, the Bamburgh dispensary was small, occupying only a few rooms in the castle, and situated in a remote, coastal location. And yet, at its height, the Bamburgh dispensary treated thousands of patients per year, often exceeding dispensaries in large towns, and was equipped with the latest medical technologies. Unlike the majority of infirmaries and dispensaries it was not funded by subscription, nor run by governors, but was entirely funded by the Lord Crewe Trust, and administered by Dr Sharp. While Bamburgh is certainly an anomaly, it raises new questions about voluntary institutional medical provision for rural populations, and forms of medical philanthropy.

Infected by the Devil, Cured by Calundu: African Healers in Eighteenth-century Minas Gerais, Brazil
Kalle Kananoja

African slaves played a key role in the colonization of Minas Gerais in the interior of Brazil during the eighteenth century. Popular healers from Africa and of African descent were important providers of health care in the region during the colonial period. Relying on a variety of healing practices, their activities often came under the scrutiny of religious authorities as they were denounced to the commissioners of the Inquisition of Lisbon or to priests in the local parishes. The most commonly denounced healing practice was a spirit possession ritual referred to as calundu. Besides organizing healing rituals, African healers offered herbal remedies to their patients. In some cases, the mixing of African, Amerindian and European practices resulted in hybrid forms of healing, which appealed to a wide array of clients, including blacks as well as whites seeking remedies to their illness.

Immigration, Statecraft and Public Health: The 1920 Aliens Order, Medical Examinations and the Limitations of the State in England (open access)
Becky Taylor

This article considers the medical measures of the 1920 Aliens Order barring aliens from Britain. Building on existing local and port public health inspection, the requirement for aliens to be medically inspected before landing significantly expanded the duties of these state agencies and necessitated the creation of a new level of physical infrastructure and administrative machinery. This article closely examines the workings and limitations of alien medical inspection in two of England’s major ports—Liverpool and London—and sheds light on the everyday working of the Act. In doing so it reflects on the ambitions, actions and limitations of the state and so extends research by historians of the nineteenth and early twentieth century on the disputed histories of public health and the complexities of statecraft. Overall it suggests the importance of developing nuanced understandings of the gaps and failures arising from the translation of legislation into practice.

Medical Eponyms: Patient Advocates, Professional Interests and the Persistence of Honorary Naming
Andrew J. Hogan

Eponyms have been adopted for the naming of disorders since the mid-nineteenth century. Physicians have favoured eponyms for many reasons, including their descriptive neutrality and role in the awards system of medicine. This paper examines the changing interest groups involved in the adoption of eponyms since 1960. As patient advocates have increasingly collaborated in the medical construction of their disorders, they have played a more influential role in the naming of conditions. This has particularly been the case in disorders known by descriptive terms identifying stigmatising features, such as mental, physical and behavioural abnormalities, as well as often-trivialised hardships, like restless legs. Rather than seeking to upend existing medical naming conventions, patient advocates have continued to support the adoption of eponyms, doing so for many of the same reasons as physicians. This has included maintaining the role that eponyms play in honouring the contributions of medical researchers in constructing conditions.

The Strange Case of Hannah West: Skin Colour and the Search for Racial Difference
Rana Hogarth

This article examines the strange case of Hannah West, a ‘very fair female of the white race of mankind’ who had patches of black skin upon her body. A closer glance at William Charles Wells’s 1818 posthumous publication of her case, Account of A female of the white race of mankind, part of whose skin resembles that of a Negro, exposes the process through which Wells crafted an incipient theory of natural selection that was based upon the belief that innate racial differences between blacks and whites were a result of generational adaptations to specific disease environments. Finally, this article demonstrates how Wells maintained Hannah West’s whiteness, despite the potential for her skin to disrupt commonly held associations between skin colour and race. Rather than casting her as a racially transformative figure, Wells used her case to not only reify but also reaffirm the distinctiveness of black and white bodies.

Health Citizenship and Access to Health Services: Finland 1900–2000
Minna Harjula

By analysing access to health services, this paper explores the formation of health citizenship in Finland in the twentieth century. Health citizenship is seen as a part of social citizenship, which emphasises the citizen’s rights to social security. The article constructs four different historical layers of health citizenship, each of which emphasise different dimensions of accessibility and involve different inclusive and exclusive tensions. The article shows the change of focus from promoting the acceptability of medical knowledge and health services, to regional availability of the services in the 1920s–1950s, and to universal affordability in the 1960s–1980s. The reforms of the 1990s respond to a new logic of individual responsibility and result in increasing hierarchies of health citizenship. Elements of the previous historical layers still have a presence in the contemporary health care. Finnish development indicates the interconnectedness of civil, political and health citizenship.

Transnational Nationalism and Idealistic Science: The Alcohol Question between the Wars (open access)
Johan Edman

This article studies the interwar international conferences on the alcohol problem. How did they view the alcohol problem and its causes; what were the consequences for the individual and the society as a whole; and which solutions merited discussion? The first post-war conferences enjoyed an optimistic and internationalistic atmosphere, added to by American prohibition, which had given the temperance movement plenty to be hopeful about. But when the 1920s turned to the 1930s, the conferences were transformed into arenas for national solutions and into outright propaganda pieces. The responses to the alcohol problem debated in the interwar conferences built on a combination of scientifically masked ideological conviction and ideologically inspired passion for science. The apparently neutral ethics of such thinking was manifested in various radical measures to combat alcohol abuse.

The Hard School: Physical Treatments for War Neurosis in Britain during the Second World War
Elizabeth Roberts-Pedersen

While accounts of the practice of military psychiatry during the Second World War have tended to emphasise the development of psychodynamic innovations such as therapeutic communities and group therapy in treating patients with war neurosis, this article explores the parallel use of ‘physical treatments’ by British practitioners during the conflict. Focusing on the work of William Sargant and his collaborators at the Sutton Emergency Hospital, it argues for the importance of these treatments not only for understanding the tenor of wartime psychiatry, but for demonstrating the attractions of physical treatments for managing large patient cohorts during wartime and in the post-war decades.

Social Science & Medicine  

The Index of Vulnerability: An anthropological method linking social-ecological systems to mental and physical health outcomes
Paula Skye Tallman

Researchers need measures of vulnerability that are grounded in explicit theoretical and conceptual frameworks, that are sensitive to local contexts, and that are easy to collect. This paper presents the Index of Vulnerability (IoV), a quantitative yet anthropologically-informed method connecting social-ecological systems to mental and physical health outcomes. The IoV combines measures of five life domains; food insecurity, water insecurity, access to healthcare, social support, and social status. Scores on this index increase for each life domain where the individual falls into a “high risk” category. Thus, individuals with the highest IoV scores are those who are at risk across multiple life domains. This approach makes the IoV malleable to local contexts, as scholars can choose which measure of each life domain is most appropriate for their study population. An anthropological study conducted among 225 Awajún adults living in the Peruvian Amazon from March to November of 2013 showed that men with higher IoV scores had significantly lower summary fat skinfolds, lower triglyceride levels, and a greater probability of reporting moderate to severe somatic symptoms and poor perceived health. Awajún women with higher IoV scores had significantly elevated perceived stress levels and a greater probability of reporting poor perceived health and moderate to severe somatic and depressive symptoms. Importantly, comparing the IoV to its constituent parts shows that it predicts a wider range of mental and physical health outcomes than any of the life domains alone. The IoV is presented here in relation to the broader political-economic and cultural context of the Awajún, forwarding a critical biocultural approach within anthropology, and demonstrating the IoV’s utility for other scholars and practitioners.

To tell or not to tell: A qualitative interview study on disclosure decisions among children with inflammatory bowel disease
Claudia Barned, Alain Stinzi, David Mack, Kieran C. O’Doherty

Rationale
Living with a chronic illness poses many challenges, especially during the adolescent stage of development. Few studies have explored young people’s experiences of talking about their illness and how they go about deciding if and when they should tell others about their condition.

Objective
Our study sought the perspectives of Canadian children and adolescents living with inflammatory bowel disease (IBD) to determine how they go about deciding if and when to tell others about their illness.

Methods
Twenty-five participants with IBD, ranging in age from 10 to 17 years old, were interviewed about their experiences.

Results
Our participants highlighted that they generally preferred to conceal their illness. However, when they did disclose, they drew on a diverse range of contextual factors such as their knowledge of the illness as well as the severity of their illness, to make the decision. They also highlighted that one of the main challenges they experience is dealing with negative reactions to the news of their illness. This paper presents a decision-making model describing how children decide whether to disclose or conceal their IBD.

Conclusion
Our study illustrates that for children and adolescents, managing others’ knowledge about their illness has important implications for illness identity management. We argue that knowledge of how children with IBD make disclosure decisions is an important part of understanding the social experience of having IBD, and in creating environments that allow them to adapt to life with IBD. Our study clearly highlights the need for specific programs to be implemented to normalize IBD and to create supportive environments for children and adolescents diagnosed with IBD.

“You get to know the people and whether they’re talking sense or not”: Negotiating trust on health-related forums
Ellen Brady, Julia Segar, Caroline Sanders

The internet is increasingly being used as a source of health advice and information by individuals with long term conditions (LTCs). Specifically, online forums allow people to interact with others with similar conditions. However, it is not clear how online health information is assessed by those with LTCs. This study aims to address this gap by exploring how individuals with contested and uncontested LTCs utilise internet forums. Semi-structured interviews were conducted with 20 participants with ME/CFS and 21 participants with type 1 and 2 diabetes and analysed using thematic analysis. Participants were recruited via online and offline routes, namely forums, email lists, newsletters, and face-to-face support groups. The findings indicate that the use of online forums was a complex and nuanced process and was influenced by a number of individual and illness-specific factors. Participants trusted those with similar experiences and perspectives as themselves, while also valuing conventional biomedical information and advice. By accessing support online, forum users were able to draw on a personalised form of support based on the lived experiences of their peers. However, the role of digital literacy in developing and maintaining online relationships must be acknowledged.

Mothercraft: Birth work and the making of neoliberal mothers
Katharine McCabe

The literature on neoliberal health governance explores how macro-economic neoliberal policies as well as individual attitudes and behaviors reflect an increasingly individualized construction of health and citizens’ responsibility over it. This study contributes to this literature and expands it in important ways. Drawing on qualitative interviews from 22 midwives and birth workers (doulas, childbirth educators, lactation consultants) practicing in the US, this study explores how midwives and birth workers act as “experts of conduct” who promote certain neoliberal values in their logics of care and interactions with clientele. The findings reveal that midwives and birth workers promote a form of maternal neoliberal health governance by: 1) making distinctions between their clientele that signal differences in health competence and resources, 2) encouraging autonomy and responsibility over birth experiences, and 3) promoting an empowerment discourse that hinges implicitly on an exclusionary consumer choice rhetoric. Midwives and birth workers are crucially implicated in shaping maternal subjectivities through pedagogical interactions I refer to as “mothercraft.” This study illustrates how the promotion of certain health identities by experts further stratifies patient populations, exacerbating differences between women based on their socioeconomic status, racial-ethnic, and cultural positions.

“Whenever they cry, I cry with them”: Reciprocal relationships and the role of ethics in a verbal autopsy study in Papua New Guinea
H.N. Gouda, A. Kelly-Hanku, L. Wilson, S. Maraga, I.D. Riley

Verbal autopsy (VA) methods usually involve an interview with a recently bereaved individual to ascertain the most probable cause of death when a person dies outside of a hospital and/or did not receive a reliable death certificate. A number of concerns have arisen around the ethical and social implications of the use of these methods. In this paper we examine these concerns, looking specifically at the cultural factors surrounding death and mourning in Papua New Guinea, and the potential for VA interviews to cause emotional distress in both the bereaved respondent and the VA fieldworker. Thirty one semi-structured interviews with VA respondents, the VA team and community relations officers as well as observations in the field and team discussions were conducted between June 2013 and August 2014. While our findings reveal that VA participants were often moved to cry and feel sad, they also expressed a number of ways they benefited from the process, and indeed welcomed longer transactions with the VA interviewers. Significantly, this paper highlights the ways in which VA interviewers, who have hitherto been largely neglected in the literature, navigate transactions with the participants and make everyday decisions about their relationships with them in order to ensure that they and VA interviews are accepted by the community. The role of the VA fieldworker should be more carefully considered, as should the implications for training and institutional support that follow.

“It’s not if I get cancer, it’s when I get cancer”: BRCA-positive patients’ (un)certain health experiences regarding hereditary breast and ovarian cancer risk
Marleah Dean

Rationale
Women with a harmful mutation in the BReast CAncer (BRCA) gene are at significantly increased risk of developing hereditary breast and ovarian cancer (HBOC) during their lifetime, compared to those without. Such patients—with a genetic predisposition to develop cancer but who have not yet been diagnosed with cancer—live in a constant state of uncertainty and wonder not if they might get cancer but when.

Objective
Framed by uncertainty management theory, the purpose of this study was to explore BRCA-positive patients’ health experiences after testing positive for the BRCA genetic mutation, specifically identifying their sources of uncertainty.

Methods
Thirty-four, qualitative interviews were conducted with female patients. Participants responded to online research postings on the non-profit organization Facing Our Risk of Cancer Empowered’s (FORCE) message board and social media pages as well as HBOC-specific Facebook groups. The interview data were coded using the constant comparison method.

Results
Two major themes representing BRCA-positive patients’ sources of uncertainty regarding their genetic predisposition and health experiences emerged from the data. Medical uncertainty included the following three subthemes: the unknown future, medical appointments, and personal cancer scares. Familial uncertainty encompassed the subthemes traumatic family cancer memories and motherhood.

Conclusions
Overall, the study supports and extends existing research on uncertainty—revealing uncertainty is inherent in BRCA-positive patients’ health experiences—and offers new insight regarding uncertainty management and HBOC risk.

“Halfway towards recovery”: Rehabilitating the relational self in narratives of postnatal depression
Meredith Stone, Renata Kokanovic

This article explores expositions of subjectivity in accounts of postnatal depression (PND). It examines the public narratives of 19 Australian women contributing to a health information website (healthtalkaustralia.org), collected across two Australian qualitative research studies conducted between 2011 and 2014. For the first part of the paper we analysed narrative data using a combination of phenomenological and psychoanalytic techniques. We found that postnatal distress was described in embodied, relational terms and that women depicted their distress as a pre-verbal intrusion into ‘known’ selves. We interpreted this intrusion as a doubly relational phenomenon – informed at once by a woman’s encounter with her infant and her ‘body memory’ of earlier relational experiences. For the second part we examined how and why women classified this relational distress as PND. We drew on illness narrative literature and recent work on narrative identity to explore why women would want to ‘narrate PND’ – an apparently antithetical act in an environment where there is a duty to be a good (healthy) mother. We highlight the dual purpose of the public PND narration – as a means of re-establishing a socially sanctioned known self and as a relational act prompted by the heightened relationality of early maternity. Our focus on the salutary aspects of narrating PND, and its links to relational maternal subjectivities, offers a novel contribution to the current literature and a timely analysis of a largely uninterrogated sociocultural phenomenon.

Social Studies of Science

Neoliberal science, Chinese style: Making and managing the ‘obesity epidemic’
Susan Greenhalgh

Science and Technology Studies has seen a growing interest in the commercialization of science. In this article, I track the role of corporations in the construction of the obesity epidemic, deemed one of the major public health threats of the century. Focusing on China, a rising superpower in the midst of rampant, state-directed neoliberalization, I unravel the process, mechanisms, and broad effects of the corporate invention of an obesity epidemic. Largely hidden from view, Western firms were central actors at every stage in the creation, definition, and governmental management of obesity as a Chinese disease. Two industry-funded global health entities and the exploitation of personal ties enabled actors to nudge the development of obesity science and policy along lines beneficial to large firms, while obscuring the nudging. From Big Pharma to Big Food and Big Soda, transnational companies have been profiting from the ‘epidemic of Chinese obesity’, while doing little to effectively treat or prevent it. The China case suggests how obesity might have been constituted an ‘epidemic threat’ in other parts of the world and underscores the need for global frameworks to guide the study of neoliberal science and policymaking.

Innovation by coercion: Emerging institutionalization of university–industry collaborations in Russia
Olga Bychkova

This article explores the emerging institutionalization of collaborative university–industry networks in Russia. The Russian government has attempted to use a top-down public policy scheme to stimulate and promote network-building in the R&D sector. In order to understand the initial organizational responses that universities and companies select while structuring collaborations, the article utilizes conceptual perspectives from institutional theory, especially drawing on arguments from strategic choice, network-building, and network failure studies.

Social Theory & Health

Psychiatry’s little other: DSM-5 and debates over psychiatric science
Claire Laurier Decoteau and Paige L. Sweet

In 2013, the National Institute of Mental Health (NIMH) broke rank with the American Psychiatric Association (APA) over the release of DSM-5, psychiatry’s ‘bible’ of mental disorders. Announcing that it would use its own biological categorization system in place of DSM-5, NIMH ignited a debate about the nature of psychiatric epistemology. We analyze these DSM-5 debates as a critical moment in psychiatry’s history of epistemological ‘revolutions.’ Psychiatric pioneers, throughout the field’s history, have presumed that biological dysfunction anchored mental disorders, and yet locating biological cause has proved elusive. Each time its failure to secure biological cause is unveiled, psychiatric experts reinvent the field in the image of greater scienticity. Using psychoanalytic theory, we argue that biology operates as Lacan’s objet petit a. The field of psychiatry is propelled forward by a mismatch between its imaginary identification as an objective science and its fragmented actuality as a symbolic system. Despite their attempts to repress the field’s fragmentation, leaders in psychiatry continuously bump into their failure to elucidate the biological foundation of mental disorders, compelling them to reiterate psychiatry’s fantasy identifications, now through imagery of the ‘mysterious’ brain.

Capitalising on cultural dichotomies: Making the ‘right choice’ regarding cochlear implants
Tracey Edelist

In this article, I examine how health professionals in Ontario, Canada, frame disability, deafness, language and culture within the dichotomy between Deaf culture/sign language and Hearing culture/oral language, and the relation such framing has to parental decision making regarding hearing technologies and mode of communication for their children. I address how the Deaf/Hearing dichotomy has influenced the medicalisation of deafness and its version of integration via rehabilitation, explored through Michalko’s (1999, 2002) concept of ‘estranged familiarity,’ complicated further by the representation of Hearing people within Deaf culture. After first summarizing the historical processes that resulted in the creation of Deaf (and Hearing) culture, I use Bhabha’s concept of hybridity (1994) to deconstruct the notion of essentialist Deaf and Hearing identities. Through consideration of how d/Deaf people and hearing children of Deaf adults inhabit various in-between spaces, the fluidity of cultural identity is acknowledged. I conclude by proposing that through exploring the myriad ways to be in-between, the artificiality of the essentialised Deaf/Hearing dichotomy is revealed, allowing for a re- examination of the exclusive cultural and communication ‘choices’ presented to many parents of deaf children.

Translational biomedicine in action: Constructing biomarkers across laboratory and benchside
Stefano Crabu

This article, based on ethnographic research conducted in a major Italian institution specialising in cancer care and research, provides insight into the clinical and basic research laboratory practices articulated around an experimental protocol designed to develop a biomarker. The article adopts an ‘ecological’ perspective matured in the field of science and technology studies of the translational process and suggests that biomedical activities are multi-directional, and cannot be understood in reductionist terms, that is, as a two-way linear transfer of bio-knowledge from the bench to bedside and back. I propose the notion of technomimicry, in its dual acceptation in the clinical and experimental sense, to understand the cognitive, social and material strategies involved in the circuit of migration of heterogeneous materials and information across scientific laboratories and clinics. Clinical and experimental technomimicry theoretically capture the multi-directional and multi-modal process of the re-location of materials and bio-knowledge from one site to another. These concepts also highlight how the epistemological boundaries of the clinic and laboratory are required to be mutually adjusted and continuously realigned in order to translate laboratory facts into clinical activities, and clinical evidence into researchable issues.

Rethinking therapeutic strategies in cancer: Wars, fields, anomalies and monsters
Simon Stewart and Cyril Rauch

This article argues that the excessive focus on cancer as an insidious living defect that needs to be destroyed has obscured the fact that cancer develops inside human beings. Therefore, in order to contribute to debates about new cancer therapies, we argue that it is important to gain a broader understanding of what cancer is and how it might be otherwise. First, in order to reframe the debate, we utilize Pierre Bourdieu’s field analysis in order to gain a stronger understanding of the structure of the (sub)field of cancer research. In doing so, we are able to see that those in a dominant position in the field, with high levels of scientific capital at their disposal, are in the strongest position to determine the type of research that is carried out and, more significantly, how cancer is perceived. Field analysis enables us to gain a greater understanding of the complex interplay between the field of science (and, more specifically, the subfield of cancer research) and broader sources of power. Second, we draw attention to new possible ways of understanding cancer in its evolutionary context. One of the problems facing cancer research is the narrow time frame within which cancer is perceived: the lives of cancer cells are considered from the moment the cells initially change. In contrast, the approach put forward here requires a different way of thinking: we take a longer view and consider cancer as a living entity, with cancer perceived as anomalous rather than abnormal. Third, we theorize the possibility of therapeutic strategies that might involve the redirection (rather than the eradication) of cancer cells. This approach also necessitates new ways of perceiving cancer.

City & Society

A Crouching Village: Ebola and the Empty Gestures of Quarantine in Monrovia
Danny Hoffman

In its scale, its virulence, and, most significantly, its urbanity, the 2014-2015 outbreak of Ebola Virus Disease (EVD or simply Ebola) in the Mano River region of West Africa seemed to challenge the basic tools of modern public health. As a result, the government of Liberia took the extraordinary step of implementing a cordon sanitaire around one of the poorest neighborhoods in the capital city, Monrovia. Observers labeled both the quarantine and the ensuing riots as barbaric acts not seen since the plagues of the Middle Ages. This characterization masked the real history of racial separation that defines many African cities, and cast Monrovia’s poorest residents as morally bankrupt, primitive savages. In this article I instead explore the quarantine as an instance of the repetition of a familiar urban form, and read the ensuing violence in Monrovia’s West Point neighborhood not as an ethical problem but as an “empty” political gesture.

Anthropology & Medicine – Special Issue: Medical Pluralism and Beyond

Introduction to the special issue ‘medical pluralism and beyond’ (open access)
Danuta Penkala-Gawęcka & Małgorzata Rajtar

Risky encounters with doctors? Medical diversity and health-related strategies of the inhabitants of Bishkek, Kyrgyzstan
Danuta Penkala-Gawęcka

This paper introduces the notion of ‘risky encounters’, referring to the way in which contacts with doctors are commonly perceived by the inhabitants of Bishkek, the capital city of Kyrgyzstan. The author’s research conducted between 2011 and 2013 revealed that most people were extremely critical of biomedical personnel, despite positive assessments of healthcare reforms expressed by experts. Owing to the prevailing distrust of doctors, their interventions are often considered risky to one’s health, which strongly influences people’s health-related strategies in the context of medical diversity. This perception of risk is deeply embedded in feelings of uncertainty and anxiety, which should be viewed from the more general perspective of the political, economic and social uncertainties resulting from the difficulties of the period of post-Soviet transformation. It is evident that medical diversity in Bishkek provides people in need with many non-biomedical treatment options, and a distrust of doctors significantly contributes to the popularity of complementary medicine. Economic constraints and local concepts of health, illness and efficacy are among the many other factors that play a role in therapeutic choices. However, the current paper focuses on risk, uncertainty and trust, as emotions that are central to an understanding of the health-related strategies and tactics used by the inhabitants of present-day Bishkek.

Patients’ webs of relations in the medical landscapes of Central Ukraine
Iwona Kołodziejska-Degórska

Village dwellers in Central Ukraine have access to various types of therapy that comprise diverse medical landscapes. Patients’ movements within these landscapes are possible thanks to each person’s web of relations. Medical landscapes are not fixed, but vary and dynamically change for each person, depending on their fluid and interchanging, hierarchical webs of mutual relations with other people, personal bodies, institutions, discourses, political powers, other non-human organisms, or objects such as medicines. This paper was inspired by the medicoscape concept (Hörbst and Krause 2004) as well as Ingold’s idea of meshwork analyses of relations between various actors: in this case, patients, healers, a weak state, official healthcare providers, pharmacists and medicinal plants, in the context of patients’ therapeutic choices. Self-medication based on herbal remedies is a very important feature of people’s medical landscapes in Central Ukraine and usually the first therapy choice for most interlocutors. That is why this paper is focused on the presentation of the means through which people acquire knowledge about medicinal plants, and the ways they interact with plants and plants interact with them. In this way, showing the complexity of villagers’ webs of relations is possible. The analysis is based on ethnographic research conducted between 2009 and 2013 in the Vinnytsia region (Central Ukraine).

Jehovah’s Witness patients within the German medical landscape
Małgorzata Rajtar

Blood transfusions belong to standard and commonly utilised biomedical procedures. Jehovah’s Witnesses’ transfusion refusals are often referred to in bioethical and medical textbooks. Members of this globally active religious organisation do not, however, challenge biomedical diagnosis and treatment as such. A result of both their trust in and their interpretation of the Bible, they question only this medical treatment. In spite of the global presence of this religious community and its uniformly practised teachings, including those pertaining to blood, experiences and choices of Jehovah’s Witness patients have been understudied. Drawing on a nine-month fieldwork with Jehovah’s Witnesses and physicians in Germany (mainly in Berlin) between 2010 and 2012, the paper addresses treatment choices made by Witness patients and their relationship with physicians. In light of the long tradition of ‘medical heterodoxy’ established in German culture and society, Germany constitutes an ideal point of departure for such a study. By utilising the concept of ‘medical landscape’ it is argued that Jehovah’s Witnesses in my field site find themselves at the intersection of different medical landscapes: in the ‘immediate’ surroundings of the German healthcare system that is open to different ‘treatment modalities’, and that of the United States, which favours biomedicine. The paper also argues that Jehovah’s Witnesses’ position towards blood transfusions can further be used as a lens to shed light on the German (bio)medical landscape itself.

Biomedical practices from a patient perspective. Experiences of Polish female migrants in Barcelona, Berlin and London
Izabella Main

This paper focuses on the diversity in patients’ experience of bio-medicine and contrasts it with the normative view characteristic of health professionals. Ethnographic fieldwork among Polish migrant women in London, Barcelona and Berlin included interviews about their experiences with local healthcare and health professionals. Themes drawn from the narratives are differences between the cities in terms of communication between patients and health professionals, respect for patients’ choices and dignity, attitudes to pregnancy and birth (different levels of medicalization), and paediatric care. It is argued that patients continuously negotiate among their own views and expectations based on previous experiences and knowledge from personal communication; internet forums and publications; and the offer of medical services in the countries of their settlement. Patients experience pluralism of therapeutic traditions within and outside bio-medicine. In turn, representatives of bio-medicine are rarely aware of other medical practices and beliefs and this leads to various misunderstandings. By highlighting the pluralism of medical practices in European countries and the increasing mobility of patients, this case study has useful implications for medical anthropologists and health professionals in a broader Western context, such as raising sensitivity to different communication strategies and a diversity of curing traditions and expectations.

Forms of medical pluralism among the Polish Community in Misiones, Argentina
Monika Kujawska

The paper addresses forms of medical pluralism, studied from the microsocial perspective, among the Polish community in Misiones, Argentina. It shows different attitudes to health treatment within the field of home medicine, local non-biomedical specialists and biomedicine. It points out the relationship between the diversity of offers of medical assistance and community members’ negotiations between various medical approaches. It also identifies the factors influencing these choices. While prior research examines Indigenous and Mestizo medical ethnobotany in this region, there has not been research on medical pluralism and very little study of complementary and alternative medicine among the inhabitants of Misiones. The study group comprises Polish peasants who settled in northern Misiones between 1936 and 1938 and their descendants born in Argentina. Field research was based on semi-structured, in-depth and free-listing interviews. The analysis was carried out using both qualitative and quantitative approaches. The results show that Polish settlers tried to reconstruct bits and pieces of their familiar and traditional healing practices in the new environment. Phytotherapy plays the most important role among home therapies. It is at home that most treatments start. Members of the Polish community also treat folk illnesses at home and report them to local healers. The growing influence of biomedicine does not contribute to the elimination of home medicine or non-biomedical specialists in the study area. There has been a medicalization of childbirth and fractures, but folk experts such as curanderos, hueseros and naturistas are still very popular in the region.

Everyday violence, mobility and access to antenatal care by Nicole Ferreira

29 Août 2016 - 12:00pm

I met Libby on a cold winter morning at the clinic. She was a short woman with a strong voice and slow walk. Libby was 35 years old and taken by surprise at being pregnant again. She had one child, a son who was already 17 and whose presence filled the two hour conversation as Libby returned to stories of him. I walked with her to my car to get my flask of tea for us to share. I got the flask and we decided to stay outside to talk in the fresh air despite my concern for the quality of the audio recording. We sipped tea while she described how she had prepared to come to the clinic for her appointment on August 6th 2015. The sun only rose after 7:30 that winter day. She had left her house at 5:30am to get to the clinic, and had walked nearly two kilometres from her home in Lavender Hill (an area notorious in Cape Town for gang violence) to Retreat MOU in the dark. It took about twenty minutes.

The time I woke up it was half past four so I told myself ‘just another few minutes’ and then the alarm went off quarter to five, put on the kettle, wash my face, wash my private parts, finish breakfast cornflakes on the stoep[1], see what people is walking around, brush my hair, brush my teeth, then I came here twenty past five, half past went out of the house and came here… When I looked up it was quarter to six… my sister actually asked if she can walk me, and I said no it’s fine, I will just pray. And when I came here by the corner, I said ‘jirra dankie, god thank you’ … because I was walking alone, there were two ladies coming, and one guy he was still looking at me and the other one was there by the shop, and there was the other dirrrty one, jirra[2] man, my heart is pump for him because he must grab you, very scared of him… and when I came here I said god thank you for bringing me safe here and as I entered I threw my card in and went to sit and I see I’m number two, I always want to be number one or two that is my aim when I come to this clinic because I want to be out early because I have stuff to do…

Libby also explained that she had to remind herself not to walk fast or do anything too strenuous because “when I walked from Lavender hill till here, if I walk fast I get pains here (pointing at her belly), then I must walk slowly…”

Libby’s aim to be first in the queue for the day is common among people dealing with public services in South Africa. To be in the first 100 in the queue, people need to arrive at the buildings between 6am and 8am. Later than that and one would be likely to spend the whole day waiting. Libby walked rather than spending money on taxi fare as she was recently unemployed. Walking was free, but caused bodily fear and stress as her heart ‘pumped’ in fear for her safety. Her experience offers insight into the relationship between bodies, space, violence and structural inequality. Pregnant women felt afraid of being targeted in armed muggings and sexual assaults, as women, pregnant women, and women with children are perceived by the women and clinic staff I spoke to as “weaker targets”. Navigating gendered spaces shaped by violence in turn shapes access and timing to antenatal care.

This is the fifth instalment of the series from The University of Cape Town’s First Thousand Days of Life Research Group, led by Prof. Fiona Ross. My research explores the intersection of public health and state recommendations and regulations for “early” antenatal booking and attendance in public health facilities in South Africa. Research indicates 40.2% of pregnant women arrive at the clinic after the recommended gestational age of 12 weeks for their first ante-natal care booking (Day and Gray, 2012/2013: 241; Masuku, et al., 2012). My research seeks to explore the ways that violence and precarity shape when, how and whether women adhere to state guidelines for maternal care.

For the state, “early” booking is a critical intervention in reducing maternal and infant morbidity and mortality. The importance of the “early” check-up is emphasized in South African health care guidelines, policies and strategies such as in the Department of Health’s Basic Guidelines for Antenatal Care (2007), as well as in international policies and public health strategies and initiatives. The female body and experience in the political framework of state governance and biomedicalisation is centred within modes of self-surveillance of their sexual and reproductive lives. The political recommendations are premised on the assumption that women have modes of access to resources and clinics; assumptions that neglect the everyday experiences of women navigating South Africa’s tense public spaces and complex public transport systems. Lack of access and lack of transportation have been cited as “reasons” for lateness (Abrahams and Jewkes, 1998). The details of everyday life where violence and precarity are shaping factors in forms of life, and in turn shaping factors to antenatal care access, go unexplored within the above findings. My ethnographic fieldwork was situated in a state Midwife Obstetrics Unit and Antenatal Care Unit that serves the Southern Peninsula of Cape Town. It includes working class areas such as Lavender Hill, Lotus River, Parkwood, Sea Winds, Vrgrond, Ottery, Pelican Park, Grassy Park, Capricorn Park and Pollsmoor Prison, some of which are overwhelmed by gang and other violence. In examining women’s narratives about when they have come to book for ante-natal care, I draw on Elizabeth Povinelli’s (2011) ideas of “quasi-events” to consider the details of everyday life in spaces of violence and precarity that shape mobility, access, and timing to antenatal care.

The historical geography of Cape Town, being radically segregated along “racial” divisions, is still a part of the city’s segregated make-up (Group Areas Act, 1950; Pinnock, 1989; Ross, 2010). Areas such as those in the Southern Peninsula, within it the locally termed “Cape Flats”, had been separated from the mountain suburbs by empty land and a freeway (Pinnock, 1989). Isolation is quite literally built into the “township” and “Cape Flats” with buffer zones of segregation (Pinnock, 1989). The spatial histories of inequality and forced removals of complex communities afforded opportunities for the rise of gangs and drug trade within the Cape Flats, and the massive incarceration of working class men (Pinnock, 2016). The historical, spatial and ideological isolation form the backdrop of the experiences of my pregnant participants, as they continually spoke of the “hopelessness” of “escaping” such areas… “Everywhere you go it’s the same thing, no escape…” Their everyday world is made and unmade by spatial, temporal, and affective dimensions of the constant threat or fear of violence: “You can’t walk anywhere because too many gangsterism going on …no matter where you go you’ll find it”.  “WHEREVER you walk, you walk into a gang”.

Mersell, one of the young women whom I met in the long clinic queue, had followed it with a tired “I want to move – but everywhere is the same “it works on me… on my stomach and head… especially when they shoot children…” Her description of the violence working on her stomach and head, is a reference to the common Afrikaans term senuweeagtig (“working on one’s nerves”) (Ross, 2010:6).

Capturing the dimensions of life, Jemima described her experience of the areas:

I don’t really feel safe. They shoot here, especially drug dealers. I had a friend drug dealer, 18 years old, got shot in a shop buying cigarettes… I saw the body after… in the shop…even in Lavender Hill, they shoot a small boy there, I just had to cry… for the mother… shooting is death here…”

There were episodes of revenge attacks between rival gangs (the Mongrels and the Euro cats) over the course of 2015. The attacks were a part of the long-standing battle for territory in the suburb of Ottery. Despite the gang violence being episodic, the effect was such that people were constantly afraid and alert. They perceived an environment that was constantly threatening. The pregnant women I met recounted stories of daily shootings in their neighbourhoods. They explained that they feared walking around because they did not know when there would be shooting. The fear and threat of a continual presence of shooting (despite it actually being episodic) placed my participants’ experiences and affective responses (fear, loss of hope) within a present continuous, where violence and its affective responses had a durative aspect. For Veena Das (1997; 2007), the idea of duration focuses attention to the everyday slow rhythms of death in the wake of aftermaths of eventful violence. I find her idea useful to consider how suffering in certain instance moves beyond linear chronology, to that of duration. Povinelli (2011) suggests that endurance might be one way to conceptualise the experience of such duratives. In taking these women’s experiences of time and subjectivity as enclosed in a durative present, because of violence, drug trade, and poverty, the actual (present) and eventual (future) included forms of life where the potential of violence was constantly imagined. Women’s tiredness was captured in the expressions of wanting to move but knowing that “everywhere is the same”, where the gang violence continually “works on” bodies and lives.

Their fears were not only for themselves, but also their children. Good parenting meant restricting children from leaving the boundaries of their homes for fear of gang violence. Nevertheless, children still walked to and from schools. Spaces are marked by the boundaries of gangs and their territories; mobility within neighbourhoods is restricted to specific spaces and to daylight hours. Sometimes spaces are renamed by community members. One such is “The Battlefield” in Ottery, a space between blocks of flats: once a part of childhood play, it is now a no-go zone for ordinary residents. Playgrounds, open areas, rivers, and bridges mark the landscape and embodied experiences of navigating space for those I spoke with in the course of research. Veena Das (2007) claims that violence as it descends into the ordinary not only interrupts it, but also changes it. Events of violence are woven into the fabric of everyday life, where space, bodily experiences, naming, orientating, insulating/isolating, and parenting constellate around expectations of everyday violence. Along with gang violence, there were peaks of (commuter) taxi violence that halted all movement in the areas as taxis competing for routes and passengers fired guns and blocked off roads. As a consequence, many pregnant women were unable to come into the clinic for the scheduled appointments.

The vignettes reflect the experiences of many pregnant women. Access to ante-natal care and indeed even to the space of the clinic is implicated in the wider political economy and the historical production of a geography of violence. As policy, strategy, biomedical and clinical protocols and clinic interactions shape the making of a biomedical subject (Clarke et al., 2003; Davis-Floyd and Sargent, 1997; Jordan, 1997; Inhorn, 2007), what goes uncounted in the statistical capturing of “lateness” in spaces of violence are the ways that local worlds are shaped, including by violence. For pregnant women, arriving “on time” and maintaining clinic schedules are implicated in subjective experiences of layers of violence, in the production of space and in the relation between violence and sociality. What does carrying life and the unfolding of life mean in a space where the everyday is infused with a constant presence of life-threatening violence? Povinelli’s offers the frames of ‘endurance’ and ‘eventfulness’ (2011), as modes through which to think about the layering of violence in everyday lives. She suggests that everyday ‘quasi-events’, by which she means events that “never quite achieve the status of having occurred or taken place”, do not rise to the surface of what can be seen and accounted for in political evaluations of Aboriginal life. Quasi-events are not aggregated, and thus apprehended, and evaluated – they do not reach a status of eventfulness that is to be grasped as an ethical and political demand in the same way that crises and catastrophes receive response (Povinelli, 2011: 13). I use her ideas to think about how the statistical capturing of “lateness” – those 40.2% of pregnant women who arrive late for antenatal care – misrecognises the composition of the subject who reports for care, as it anticipates that individuals are autonomous and independent of their contexts. For Povinelli, endurance is not a homogenous space, or a singularity: “endurance encloses itself around the durative—the temporality of continuance” (Povinelli, 2011:32). To call attention to the everyday, especially in spaces of violence and inequality, is to call attention to the “quasi-events” that shape life and responses to care, and here antenatal care. The everyday experiences and quasi-events, that are seen as the attenuated background conditions of life that do not enter typical accounts of causality and life-making, can be brought forward by focusing on the present durative (Povinelli, 2011: 153; Das, 1997; 2007). The benefit of critically viewing these events and affects as everyday, enclosed around the durative, allows one to ask as Das (1997:68) asks, what this does to the self, community, and nation.

 

Nicole Ferreira is a Master’s by Research student in Social Anthropology at the University of Cape Town. Her work is situated within Professor Fiona Ross’ First 1000 Days of Life research project. Her research focuses on experiences of pregnant women accessing antenatal care at a state clinic in the Southern Peninsula of Cape Town. Her research specifically seeks to understand the experiences that contribute to what the state categorises and castigates as “late” presentation at antenatal clinics. Nicole is interested in how life and access to care are shaped by different ways of knowing, social experiences, and temporal and spatial experiences in spaces of violence and precarity. The research explores the organisation of state management of pregnancy, organisations of power, and questions of ethical conduct.

 

Notes

[1] Stoep is a small veranda or set of stairs outside of a house.

[2] A colloquial Afrikaans term used as an expletive, and commonly understood as an expression of frustration, and annoyance.

 

References

Abrahams, N and Jewkes, R. 1998. “Study Of Health Care Seeking Practices Of Pregnant Women In Cape Town Report Three: Women’s Use and Perceptions of Retreat Midwife Obstetric Unit and T. C. Newman (Paarl) Hospital”. CERSA-Women’s Health Medical Research Council.

Abrahams, A, Jewkes, R and Mvo, Z. 1998. “Study Of Health Care Seeking Practices Of Pregnant Women In Cape Town Report Four: Summary Of Findings, Conclusions And Policy Action”. CERSA-Women’s Health Medical Research Council.

Clarke, A, Fisherman, J, Fosket, J, Mamo, L, and Shim, J. 2003. Biomedicalization: Technoscientific Transformations of Health, Illness, and U.S. Biomedicine. American Sociological Review, 68(2)

Das, V. 1997. “Language and Body: Transactions in the Construction of Pain”. In Kleinman, A, Das, V and Lock, M (eds) Social Suffering. Berkeley: University of California Press. 67-89

—. 2007. Life and Words: Violence and the Descent into the Ordinary. Berkeley: University of California Press.

Davis-Floyd, R and Sargent, C (Eds). 1997. Child Birth and Authoritative Knowledge: Cross-Cultural Perspectives. California: University of California Press.

Day, C and Gray, A. 2012/2013 “Health and Related Indicators Chapter 17”. South African Health Report.

Inhorn, Marcia C. (2007). Reproductive Disruptions: Gender, Technology, and Biopolitics in the New Millennium (Fertility, Reproduction and Sexuality). New York: Berghahn Books. 

Jordan, B. 1997(1978). Birth in Four Cultures; “Authoritative Knowledge and its construction”. In Davis-Floyd and Sargent (eds) Child Birth and Authoritative Knowledge: Cross-Cultural Perspectives. University of California Press: California.

Masuku, M, Mampe, T, Matse, M and Jassat, W. 2012. “Community Dialogues: North West Province”. Health Systems Trust, KZN.

National Department of Health. 2007. Guidelines for Maternity Care in South Africa: A Manual for clinics, community health centres and district hospitals.

Pattinson, R. 2005. “Basic Antenatal Care Handbook”. MRC Maternal and Infant Health Care Strategies Research Unit Obstetrics and Gynaecology Department, University of Pretoria.

Pinnock, D. 2016. Gang Town. South Africa: Tafelberg Publishers Ltd.

Povinelli, E. 2011. Economies of Abandonment: Social Belonging and Endurance in Late Liberalism. Durham: Duke University Press.

Ross, F. 2010. Raw Life, New Hope. Decency, housing and everyday life in a post-apartheid community. Cape Town: UCT Press.

The “Good-Enough Anthropologist” by Elizabeth Durham

26 Août 2016 - 8:26pm

“Where are all the anthropologists?” The question came from public health worker Douglas Hamilton on the first day of the Princeton-Fung Global Forum on Ebola, held in November 2015 in Dublin, Ireland. There, the place of anthropology in the recent outbreak was touched on by the first speaker, and swiftly become one of, if not the, recurring themes of the conference. The question was addressed not to me, but to the panelists on stage — not an anthropologist among them, not that day — but as a graduate student working on issues of health in West and Central Africa, I could not help but take the question for my own. So in response, I suggest that anthropology was simultaneously everywhere and nowhere in this context, a state of affairs that goes beyond this outbreak in calling for anthropologists to conduct both research and better public relations, and in calling into question the forms public anthropology can and should take.

From the moment Peter Piot, the co-discoverer of Ebola, gave his opening remarks, the question of anthropology-in-Ebola took hold of the Forum and its diverse attendees. “We have to listen far better,” Piot argued, “to what people think before we start putting in place measures… [involving social scientists in Ebola] helped a lot. Although I had some big discussions! Some anthropologists said, ‘Okay, I need to spend two years in that village to understand what people think’ [a statement that drew laughs from the audience].” He continued: “We don’t have the time for that… we needed more kind of social marketing people, people who can do a snapshot and understand it rapidly, what’s going on.” While I doubt that Piot’s setting of the stage in this way was truly mocking or malicious — I may have snickered too, and it is certainly not lost on me that it’s taken in sum several months for me to submit this piece, revise it and usher it to publication — the stage was nevertheless set, and so the questioning continued. In response to Hamilton’s query, the panelists hastened to engage anthropology, almost in a defensive manner. The CDC’s Rebecca Levine emphasized that “anthropologists were not completely lacking” or absent in Ebola, but rather “were tremendously useful” during her stints in the field. On a similar if slyer note, MSF Ireland’s Gabriel Fitzpatrick stated that “anthropology is one of the key answers… but I would say, one of the few times I have worked with an anthropologist, it takes a while to get a report back [cue audience laughter].” On the next panel, NPR’s Brooke Gladstone asked “Why do we even need one [an anthropologist]?”, arguing that West Africans were perfectly capable of speaking for themselves across cultures, especially since “these people aren’t in some hidden enclave in the Kalahari or in the North Pole.” For her part, Margaret Chan, the Director-General of the WHO, indirectly tipped her hat to anthropology, noting that “when technical interventions go against culture, culture will always win.” Such themes carried over to the second day of the Forum as well: “I apologize: I’m not an anthropologist,” noted the Wellcome Trust’s Jeremy Farrar in his opening remarks, “so I’m not starting the day well [more laughter!]… [but] anthropologists have got more engaged. [Pause] Thank you [said wryly; even more laughter!].” Who knew a conference on Ebola could be so humorous? By the time the three anthropologist-panelists (Princeton’s João Biehl and Carolyn Rouse, and Berkeley’s Raphael Frankfurter) took the stage on the second day — along with their comrade-in-arms, Princeton’s Angus Deaton, who declared that “I’ve been sort of anointed as an economist, [so] then I can do what economists don’t want me to do, which is behave like an anthropologist” — anthropology-in-Ebola felt both underdone and overdone.

And this, I think, is an important point. Thus, rather than straightforwardly recounting the remarks of these anthropologist-panelists or the overall contributions of anthropologists regarding Ebola (important as such recounting is), I want to outline the existence of a particular second version of anthropology at play here. At the risk of reading too much into the numerous anthropology jokes that circulated throughout the Forum — though reading too much into phenomena is evidently anthropologists’ forte! — I suggest that they speak to a more profound, if subtle, discomfort on the part of non-anthropologists as to what they perceived as the mismatch between anthropological knowledge and anthropology as a form of practice. In other words, few of the non-anthropologists at this Forum denied that knowledge about the various sociocultural landscapes in and across Sierra Leone, Guinea, and Liberia was or would have been pertinent in the context of Ebola, but they did question the temporality and methodology associated with anthropological ways of “collecting” this knowledge. What struck them as funny and odd was thus not what they viewed as the self-evident utility of sociocultural knowledge, but rather, the notion that it could take anthropologists years to grapple with something that is, after all, so self-evidently useful. They appreciated our skills, but rolled their eyes at how we (whoever “we” are; the “real” anthropologists? The “academic” anthropologists? Not exactly a homogenous group) chose and choose to employ them.

What I suspect these non-anthropological actors at the Forum would have preferred to see from anthropology during the recent outbreak amounts to what Didier Fassin (2010) terms “‘cultural keys’”: quick and concise ethnographic soundbites that enable the architects and executioners of medical interventions to “interpre[t] ‘resistance in the population’” (40). The ideology underlying such keys Fassin (2001) dubs “culturalism”: the supposition that “the pertinent explanation [of an issue] can be found among those who are the object of the action, not those who instigate it… by overdetermining the role of cultural factors, it sweeps aside any socioeconomic or sociopolitical explanations of the phenomena examined” (306). This “tendency to attribute health problems to cultural practices,” elaborates Dominque Behague (2014), is “politically convenient as it relieves governments, institutions, and politicians of their responsibilities, while it also identifies a clear target… the local population.” Anthropologists, particularly those working within the academy, have tended to shun the spread of cultural keys and culturalism, often rightly so: my own previous fieldwork on HIV/AIDS in Cameroon reinforced for me that shallow understandings of complex phenomena serve no one well. Nevertheless, our deliberate restraint in this regard has inadvertently led to the rise of this particular second version of anthropology: what I call the “good-enough anthropologist.”

This concept of the “good-enough” comes from psychoanalysis, in particular from the work of Erik Erikson (1950) on “good-enough holding” and of Donald Winnicott (1960) on “good-enough mothering.” Stripped to their conceptual bones, such terms refer to the ways in which the basic, ordinary, competent nurturance of an infant is generally sufficient to ensure that the child develops “normally” as this is defined along psychoanalytic lines. In anthropology, the “good-enough” manifests most prominently in the work of Nancy Scheper-Hughes (1992) on motherhood in Brazil, in which she acknowledges its psychoanalytic roots but finds them somewhat too optimistic (360). More useful for my purposes, however, is her application of this concept to anthropology itself. “Weary [of] postmodernist critiques [and mindful that] the anthropologist is an instrument of cultural translation that is necessarily flawed and biased,” Scheper-Hughes calls for “good-enough ethnography [in which] we struggle to do the best we can with the limited resources we have at hand — our ability to listen and observe carefully, empathetically, and compassionately” (1992: 28). In all of these contexts, the “good-enough” is itself good.

My use of the “good-enough” is not so positive. By the “good-enough anthropologist,” I here refer to the subtle assumption of many of the non-anthropological actors at the Forum that as long as they acknowledged at least some of the sociocultural aspects of Ebola in some form, they were, if not necessarily “real” anthropologists, then good-enough anthropologists for the purposes of confronting this outbreak. In other words, “real” anthropologists would not or could not give cultural keys for unlocking Ebola, so non-anthropological actors transformed themselves into good-enough anthropologists in the process of seeking those keys on their own. And so cultural keys and culturalism were present at the Forum, despite anthropologists’ refusal to engage them. Among the more glaring examples: Chan labeled one of the main drivers of this disease as “centuries-old cultural beliefs and traditions… cultural beliefs and practices of the community proved to be one of the most difficult barriers to address.” Farrar lamented that “the risk is not in the technology, not in the data; the risk is that the population don’t see the benefits” of medical interventions, an issue that was important in this epidemic and would be even more so in future ones. Moreover, I simply lost track of the number of times handwashing and the color of body bags were brought up in a generic West African context. Ultimately, IRC’s Emmanuel d’Harcourt unwittingly said it best: Ebola has shown a need, he argued, for “people who get it. It’s anthropologists, but it’s also people who think like anthropologists.”

In this light, my answer to Hamilton would be that anthropology was, and continues to be, simultaneously everywhere and nowhere in this context — everywhere in the form of the good-enough anthropologist, and nowhere in the form of the “real” anthropologist’s rejection of cultural keys and culturalism. One might argue that this emergence of the good-enough anthropologist is, to a certain extent, progress — that it at least suggests an increasing acknowledgment of, and increasing seriousness concerning, the validity of the sociocultural in the realm of the biomedical (as if the two can be separated). There may be some truth to this. Yet while the good-enough anthropologist may be a form of public anthropology, it is not a public anthropology of anthropology’s making. This makes it both disconcerting and intriguing, a “public afterlife of [an] ethnography” (Fassin 2015) that calls into question just who, precisely, can be an ethnographer. As such, it suggests that anthropologists ought to expand our academic practice to encompass both research and better public relations: non-anthropological actors become good-enough anthropologists when we ourselves are not good enough at self-promotion, at clearly defining and communicating what it is we do, how we do it, and why we do it this way.

The issue of what constitutes “good anthropology” is, of course, controversial within anthropology: this is part of the issue, albeit an inevitable one. Moreover, while good-enough anthropology easily veers into culturalism, I can also admittedly see where it has the potential to foster a more democratic anthropology (though this is not the direction it has largely taken thus far), raising and/or reopening key questions similar to the one above. Who controls public anthropology, if anyone? What can or should “real” anthropologists do when faced with a public anthropology they may find dismaying? Is public anthropology an anthropology with a public presence, an anthropology practiced by publics, or both? Do attempts to trace such public afterlives aid the democratization of anthropology, or do they border on a way for scholars to reassert authority over the works they write? These are questions whose value lies more in discussion than in simple answers. Nevertheless, I know at least some core tenets of “good anthropology” when I see them. A willingness to take seriously the voices, views, and criticisms of our interlocutors, and to acknowledge that research — all research, not just anthropology — is constructed on and by deeply entrenched relations of power. An acknowledgement that “cross-cultural translation” (another Forum buzzword) amounts to far more than the simple substitution of a phrase in one language for a phrase in another. An ability to be comfortable (and comfort is not laziness) with partial conclusions, epistemological uncertainty, and the terrifying-yet-liberating idea that “everything is more complicated than you thought” (Appiah 2008: 198). More than this — an ability to dissect “the illusory sense that there is firmness and stability in the intrinsically messy social world of people, health, and disease” (Adams 2013: 84), even as we strive to respect and depict the ways in which those with whom we work often seek this very firmness and stability in their lives and on their own terms.

So: if the Fung Forum suggests that anthropology is everywhere-nowhere, where to go from here? The notion of an extended fieldwork stint in the midst of a swift-moving outbreak may seem laughable — and in situations like these, anthropology ought to accordingly adjust the temporal structure of its work as much as professionally possible — but it is no cause for overthrowing anthropology in favor of culturalism and its keys. At the risk of sounding too opportunistic, Ebola’s wake could and should be a period not merely for anthropological scholarship in this regard, but for better communication of the value of this work to diverse audiences, and for better making a virtue out of epistemological complexity. It is also worth pursuing further the above intersections and implications of academic democratization, good-enough anthropology, and public anthropology. I realize, of course, that such communication is only as interesting as its listeners want it to be; that this task itself is undeniably complex; and that I myself am only beginning to undertake it in my current research on mental health in Cameroon and Senegal. Nevertheless, this task is also increasingly necessary — because the good-enough anthropologist is on the rise, and for the time being, that is not good enough at all.

 

Elizabeth Durham is an incoming second-year PhD student in anthropology at Princeton University. She works on the localizations of “global mental health” in Cameroon and Senegal, and has researched HIV/AIDS in the former country as a 2012-2013 Fulbright Student Research Grantee.

 

Works Cited

Adams, Vincanne. 2013. Evidence-Based Global Public Health: Subjects, Profits, Erasures. In: When People Come First: Critical Studies in Global Health. João Biehl and Adriana Petryna, eds. Princeton: Princeton University Press, pp. 54-90.

Appiah, Kwame. 2008. Experiments in Ethics. Cambridge: Harvard University Press.

Behague, Dominque. 2014. Thoughts on Ebola. The Center for Medicine, Health, and Society, Vanderbilt University. Available from: http://www.vanderbilt.edu/mhs/2014/12/thoughts-on-ebola/.

Erikson, Erik. 1950. Childhood and Society. New York: Norton.

Fassin, Didier. 2001. Culturalism as Ideology. In: Cultural Perspectives on Reproductive Health. Carla Obermeyer, ed. Oxford: Oxford University Press, 300-317.

Fassin, Didier. 2010. Noli Me Tangere: the Moral Untouchability of Humanitarianism. In: Forces of Compassion: Humanitarianism between Ethics and Politics. Erica Bornstein and Peter Redfield, eds. Santa Fe: School for Advanced Research Press, 35-52.

Fassin, Didier. 2015. The Public Afterlife of Ethnography. American Ethnologist 42(4): 592-609.

Scheper-Hughes, Nancy. 1992. Death without Weeping: the Violence of Everyday Life in Brazil. Berkeley: University of California Press.

Winnicott, Donald. 1960. Ego Distortion in Terms of True and False Self. In: The Maturational Processes and the Facilitating Environment: Studies in the Theory of Emotional Development. Donald Winnicott, 1965. New York: International Universities Press, 140-152.

Conference Report: The Humanization of Health Sciences through Innovation in Health Professions Education by Thomas Cousins

23 Août 2016 - 12:00pm

Brocher Foundation, May 2016

Introduction

This three-day event took place at the Brocher Foundation Institute, Geneva, from May 17-20 2016, and was generously funded by a Brocher Foundation award. The organising team included Berna Gerber, Thomas Cousins, and Lizahn Cloete (Stellenbosch University), Megan Wainwright (University of Cape Town), Michelle Pentecost (University of Oxford), Ferdinand Mukumbang (University of the Western Cape) and Guddi Singh (Medact, UK).

Just down the road from the Villa Diodati where 200 years of Shelley’s Frankenstein was being commemorated (“a mythic expression of the anxieties of a world confronted with the growing power of science and technology”), a group of 25 scholars gathered at the Fondation Brocher. We had reason to consider anew the ways in which humanities and medicine might be reconciled, learned, and applied in ex-centric contexts between the global south and north, where distinctions between war and everyday life are constantly blurred. Our aim in bringing together a range of scholars from around the world and across many disciplinary — and transdisciplinary! — homes, was to consider new ways of bringing together humanities and social science knowledges with the training of health professionals.

The conversation emerged out of a network of practitioners and researchers interested in health professions education, starting at a workshop on “Building the Critical Health Social Sciences in Malmesbury, South Africa in 2015 organized by Chris Colvin (UCT) and Hayley MacGregor (Sussex), and taken forward at a second meeting with colleagues from around South Africa in March 2016 at the University of Stellenbosch. The Geneva conference covered three broad themes: (1) Health Sciences Curricula in Practice: Experiences of Teaching and Learning; (2) Critical theory and new pedagogies and (3) Praxis and theory: towards integration.

For an overview, links to the program, and speakers’ abstracts and biographies, see the report by our colleagues Megan Wainwright, Lizahn Cloete and Ferdinand Mukumbang.

In this conference report, we want to draw out some key reflections from the event that we consider to have application for medical anthropology, science and technology studies, cultural psychiatry, psychology and bioethics, beyond the remit of the conference focus.

‘Humanising the health sciences’: old wine in new bottles?

While this conference built on an established scholarship in health sciences education, medical humanities and critical pedagogies, it nevertheless made some important departures. The organisers’ deliberately provocative title about “humanizing” thrust the group into early debates on the notion of “humanisation” and the various social and political logics it brings with it, not to mention the wide divergence between meanings of “humanisation” across various national and local contexts, and the possible objects of “humanisation”: care, physicians, their training, or critical thinkers.

A critical humanisation?

A strong theme of many contributions concerned what we might call a critical orientation towards our own normativities. In the ‘chasm between theory and practice’, as Iona Heath put it, what is taken for granted? As Rolf Ahlzen eloquently reminded us, there is an ethic inherent to clinical practice: that the health professional must of necessity objectify the physical body, but that he must ultimately return from this ‘ontological excursion’ to situate the patient back in his or her person and societal context. As such the biomedical encounter is inherently paradoxical: the clinician must grapple with ‘biology and biography.’ Further, practitioners’ own biographies and biologies impact on their pedagogy. For example, Lizahn Cloete discussed how training occupational therapy students about disability without experiential knowledge presents a limit to teaching.

Simon Forrest, describing his experiences with teaching sociology in undergraduate medical education at Durham, suggested that in place of an evangelical passion for “humanisation”, we should be making a stronger moral and political case in our training of health professionals, by exploring the social dimensions of health through situated examples (see also the UK network of Behavioural and Social Scientists Teaching in medicine BeSST, which is creating a core curriculum in Medical Sociology). Jill Gordon‘s take, drawing on her work at the University of Newcastle (Australia) in supporting Aboriginal and Torres Strait islanders’ physician training, was founded on an appreciation of the “client and extra-therapeutic factors” that so crucially shape health outcomes (instead of an assumption about the efficacy of medical techniques or specific therapies). Berna Gerber, chair of speech therapy at Stellenbosch University, described using her education in philosophy to open up communication and clinical judgement as vital dimensions of “humanisation” in working with health professionals. “Philosophy” as a clinical practice, then, might be a way to think of medicine less as a science (its own self-image) and more as a science-using practice of caring for the sick.

Caroline Hodge, a medical student at UCSF with a background in medical anthropology, described the marginal status of social science in the medical curriculum in California, but spoke up the positive possibilities that come from such marginality, such as student-led electives which can offer potent spaces for alternative narratives in the context of institutional investments in outcomes- and evidence-based approaches. Lizahn Cloete spoke powerfully about using Paolo Freire’s ideas in occupational therapy in support of prevention-oriented approaches to more integrated interventions for Foetal Alcohol Syndrome in South Africa. Megan Wainwright’s careful thinking through of the problem of addition versus integration of humanities and social sciences into health sciences education provided strong material that brought together many of the participants’ concerns from other contexts. One succinct intervention was to ask whether students should not be taught to read more, but to read better. Jane Macnaughton questioned the rationale that health professions education should be “humanised” in terms of the content that is taught, and made a case for a more experimental approach to education that allows for non-quantifiable processes and outcomes in the “processes of becoming” that unfold between patients and healers. Rather than devising new content for curricula, she suggested, we should be thinking about new kinds of research and modeling new orientations and relations in the practice of healing.

If these conversations sound to some readers like reinventing the wheel, it might indicate the necessary (re)turning and re-thinking that the politics of ill-being presents to established modes of thinking, teaching, and writing. Some suggested we take forward alternative conceptions of care, evidence, and the specificity of “context”; how this might translate into institutional practices of training across disciplines animated our debate.

By the end, the ‘humanisation’ of health sciences appeared less obvious as an endeavour than when we had started, producing more questions and challenges than solutions or answers.

Humanising health sciences in the North and the South

Experiences and material from South Africa, Iraq, Lebanon, Australia, Brazil, the UK, USA, and Canada, were exchanged and digested, prompting a set of debates about the circulations of biomedicine and its pedagogies between the global South and North. Margaret Lock’s assertion that ‘all medical knowledge and practice is historically and culturally constructed and embedded in political economies, and further, [is] subject to continual transformation both locally and globally’ (2008: 480) offers a useful starting point. What do the various health professions look like in each of these particular social and clinical conditions? How does the education of health professionals in these regions diverge in their clinical ambition or social or political grounding? Do these particularities affect biomedicine’s epistemologies across these contexts? It’s one thing to recognise that many Northern contexts increasingly resemble the Third World (see Meyers and Rose Hunt [2014] on “the other Global South”), or that privileged elites the world over enjoy first class health care; it’s another to think how those inversions might shape health professions training in Nigeria, Iraq, South Africa, or the USA. How does pedagogy navigate those transformations, or traverse these locales? For example, Seth Holmes spoke about American students who do not feel that learning about health issues elsewhere is relevant to those who will only practice in the US, while Michelle Pentecost and Thomas Cousins described how for South African medical students, the humanitarian crisis is often thought of as ‘out there’ in Africa. Do such political geographies matter for how we think of social sciences and humanities in relation to health professions and their pedagogies? Given that the global workforce in health care is highly mobile, how might new generations of students frame ethics of care and local responsiveness? Producing knowledge and the path to healing are not merely the preserve of labs, clinics, or classrooms in the North, but are redistributed through actually existing techniques and practices in many ex-centric locations.

Notions of humanity: conflict medicine and decolonisation

Omar Dewachi and Vinh-Kim Nguyen, in their presentations and discussions, focused attention on the need to redefine our framings of medical practice in a time when there is increasing ambiguity on what constitutes war or peace (Dewachi 2015, Dewachi et al 2014; see also Benton and Atshan 2016). While the impossibilities and devastations that war in the Middle East presents to health and wellbeing might appear radically opposed to medical practice in peaceful contexts, whether Southern or Northern, it emerged that there are many points of convergence in health professionals’ experience between, for example, informal settlements in South Africa, and war-time Iraq: violent trauma, stock-outs, and the effort to reconstitute norms and lives, bring easy notions of ‘conflict’ into question. These tensions offer new ways of thinking about the ordinary and the everyday in the context(s) of conflict medicine. Nurses, doctors, and other health professionals must bear the contradictions of the contexts in which they work. The 2016 junior doctors’ strike in the UK raised the question of conscience/conscientization: when does the practice of health care necessitate or eventuate an activist politics that exceeds the clinic? In South Africa, the question of ‘activism’ and ‘politics’ are never far from the surface in debates over health systems, resource allocation, and staff retention. Related to this is the question of how increasingly privatised models of care impact on different regions, and how this comes to bear on the way that health-care professionals ‘self-make’ in their vocations, and how this contrasts with the humanist concern that traditionally animates the subjectivities and techniques of the self called for by medical training. Similarly, the difficulty of publishing qualitative research in medical journals, and the frequent exclusion of qualitative questions and evidence in guideline development, means that patients’ voices and experience are lost to science and thus to improving clinical practice (Wainwright & Macnaughton 2013). If hierarchies of knowledge are to include patients’ experiences and other ways of knowing, is this shift to be effected through education or a broader culture change?

Pedagogically, we need to consider how concerns with inequality and social justice in health professions training articulate with students’ expectations of their responsibilities as health care workers. What might “politics” and “conscientisation” mean in engagements with “the curriculum”? How should we think, speak, and act across and between the various locales of our experience/expertise, both South and North, in the classroom or clinic or beyond it? What would it mean to “decolonise” medical curricula, amidst calls for “humanisation”? One response to these questions was the strong call to continually historicise biomedicine and medical practice, which can in turn reveal what present global circumstances mean for health, health care and healing.

Conclusion

Far from simply returning to an established conversation about the place of the humanities and social sciences in health science education, this conference brought old questions to bear on the contemporary moment in which we find ourselves trying to educate young health professionals. What was remarkable about the workshop was the way in which practice and experience were reflected on carefully, and how the philosophical and political implications of the concepts at stake could be explored. In addition, the combination of scholars from the South and North, emerging and more established scholars, humanities, social sciences, and clinical work, made for an energising and rewarding set of conversations.

References

Benton, A and Atshan, S. 2016. “Even War has Rules”: On Medical Neutrality and Legitimate Non-violence. Special Issue: The Clinic in Crisis: Medicine and Politics in the Context of Social Upheaval.  Culture, Medicine, and Psychiatry 40 (2): 151–158.

Dewachi, O. 2015. Blurred lines: Warfare and health care. Medicine Anthropology Theory. 8 July 2015.

Dewachi, O, Mac Skelton, Vinh-Kim Nguyen, Fouad M Fouad, Ghassan Abu Sitta, Zeina Maasri, Rita Giacaman. 2014. Changing therapeutic geographies of the Iraqi and Syrian wars. The Lancet 383 (9915): 449–457.

Meyers, T and Rose Hunt, N. 2014. The other global South. The Lancet 384 (9958): 1921–1922.

Lock, M. 2001. The tempering of medical anthropology: troubling natural categories. Medical Anthropology Quarterly, 15(4): 478-92.

Wainwright, M & Macnaughton, J. (2013). Is a qualitative perspective missing from COPD guidelines? The Lancet Respiratory Medicine, 1(6), 441-442.

After the End of Ebola by Patricia Kingori

19 Août 2016 - 12:00pm

When the international teams began closing the Ebola Treatment Centres (ETCs) in Sierra Leone, Liberia and Guinea this signalled the end of Ebola for many people. As researchers, NGO employees, and an array of personnel from across the globe said their good-byes to local staff, packed their bags, checked out of their hotel rooms and flew home, reflections on their experiences began filling the pages of academic journals and news outlets. Their discussion of Ebola in the past tense, as something that happened and that was, was underscored by international agencies declaring that affected countries were ‘Ebola free’, and Ebola was at an ‘end’.

There are however, exceptions in the narratives of Ebola as something that was. These are found in the accounts of those who lost loved ones and who continue to grieve, as well as those who form part of national infrastructures still struggling from disruption and massive loss of lives. These accounts, visible throughout the outbreak, are still being captured across a range of disciplines. In contrast, the accounts of local staff and volunteers who worked tirelessly at ETCs to help fight their country’s battle with Ebola are barely visible. Yet, it is precisely their stories that provide some of the most valuable insights into how the social, economic, and psychological effects of Ebola continue despite the political and humanitarian rhetoric pronouncing its end.

One of the most dominant images of the most recent Ebola outbreak has been of a figure, disguised by a white contamination suit, carrying a dead body. At the beginning of the outbreak bodies were committed to burial grounds but soon the number of deaths, coupled with the increased risk of contagion, necessitated a different approach, and the number of cremations began to rise.

The many volunteers, with no previous experience of working in health care, found themselves doing the most high-risk jobs of cleaning and disposing of the blood, vomit, and bodily waste of Ebola victims. They were also working around the clock in crematoriums in the incredibly high temperatures needed to burn the bodies of thousands of men, women and children. They worked tirelessly to cremate bodies in their own communities; knowing fully that in these communities cremation is a longstanding taboo.

Some of these local staff gave up paid employment to help in the humanitarian crisis. For the unemployed, the outbreak held the possibility of assisting in the humanitarian effort and also a proved relatively lucrative opportunity, albeit a dangerous one, to secure paid employment. In the context of high rates of unemployment and scarce opportunities to be involved in meaningful work, the opening of the ETCs with promises of compensation, training, professional recognition and certificates coupled with the possibility of securing long-term employment after the outbreak, proved a powerful motivation. For instance, in Liberia contracts were negotiated and then written promising local staff an ‘incentive package’ in the region of $250 USD per month. After the outbreak, if they survived, they would receive $2,500. If they died their families would be given $5,000. To put these figures in context, the average civil servant in Liberia earns approximately $125 per month. Others without formal employment live on less than a dollar per day.

Ultimately, very few local staff received anything close to the amount they were promised, and some have gained no compensation at all. The families of the deceased staff members, with their depleted emotional and economic resources are forced to try and dig further into their reserves as they continue to seek compensation for their loved ones who gave up their lives helping others.

For those who survived, the struggle continues to try and gain something of what they have been promised through ongoing court cases and sporadic protests. In Sierra Leone, during the outbreak, many local ETC staff went on strike for not being paid the risk compensation promised to them by the government. The presence of international staff and foreign organisations provided local staff with some leverage in gaining international media attention in their negotiations with their own government. But now, for many of these international staff, the battle with Ebola is over. They have received recognition in the form of promotions, accolades, and publications for their efforts. Moreover, many take pride in the work that they have done.

Yet what remains and continues of Ebola among the local staff is much more than a list of financial grievances. Many of the ‘cremation boys’ as they have come to be known, stigmatised and often traumatised by their work, have gone into hiding and rarely disclose their experience to others. Other local staff having witnessed scores of deaths including those of family, friends and colleagues, continue to try and make a life, gain recognition, employment, and subsistence.

Acknowledgements

This blog is part of ongoing research funded by the Wellcome Trust Society and Ethics funding stream (Grant number 108769/Z/15/).  We would like to thank all those who have contributed to the account presented here.

 

Patricia Kingori, PhD, is a Wellcome Trust Biomedical Society and Ethics Fellow at the Ethox Centre, University of Oxford. Her disciplinary background is in Medical Sociology and her current interests research interests lie at the intersect of sociology of science and medicine and a critical examination of ethics with a particular interest in the frontline practitioners of medical research, the politics of health and what research and guidelines come to mean in practice.

Catherine McGowan is research fellow at the London School of Hygiene and Tropical Medicine, in the department of Social and Environmental Health Research. 

 

 

Humanitarianism in the Anthropocene by Sverre Molland

13 Août 2016 - 12:00pm

The decade has been conceptually rich for anthropologists. From multi-species ethnography to the practice of care, the past several years have seen a flourish of analytical concepts and theoretical preoccupations. Two key developments among these emergent and often-interlinked topics are anthropology’s focus on international humanitarianism and the Anthropocene. To date these two important research streams have not been linked. This seems destined to change, since the questions that underlie the anthropological study of humanitarianism—fundamental questions about our moral and political stance towards human life—overlap considerably with the central preoccupations of the Anthropocene debate—which asks what future forms life and politics will take on this planet. This short reflection hopes to encourage the discussion.

In its most defuse form humanitarianism is an ethos: the insistence that all people are fundamentally alike and thus deserve a certain equity of consideration. The concept of humanity implies a certain biological sameness, but also moral equality (Fassin 2012:1-17). Thus humanitarian discourse simultaneously universalizes and essentializes. It insists that—in our biological needs, our ability to feel pain, to suffer and to hope—we are all alike. Because we are all subject to the same vagaries of time and trauma the very fact of being human merits dignity and respect. Since we are all united in our weaknesses, certain elementary levels of substance—freedom from starvation, or arbitrary dislocation or death—should be guaranteed to all humans. People should not be instrumentalized, made tools of others’ selfish pursuits. Humans have a basic duty of care to other humans, especially in times of extremity. These are moral prescriptions, but they have the character of fact; in the present day the humanitarian argument is so pervasive that it seems axiomatic.

Humanitarianism is a noble sentiment, but makes for a difficult practice. When put into action, humanitarian ideals become a form of operationalized compassion. In more contemporary, professionalized form, humanitarian action constitutes an industrialized response to suffering. The same tools and techniques that power global capitalism also enable humanitarian action: transnational supply chains, administration, media and communications mobilize personnel and materials to far away places. While the international aid industry is small by comparison to other large-scale industrial complexes, it is a multi-billion dollar industry nevertheless. From charitable beginnings, global humanitarian action has undergone a process of professionalization. In the face of institutionalization, the welter of need and the surge of so many bodies, the original motivation—to care for people united in their ability to suffer—is obscured; a numerical or biopolitical definition of life takes over. Much of the anthropological literature on humanitarianism highlights how the philosophy and practice are simultaneously products of, responses to, and exacerbated by the globalized, post-colonial condition.

Where the anthropology of humanitarianism shows how the concept of compassion for “humanity” is enacted in different spaces and times, the Anthropocene forces us to view humanity in relation to space and time itself. Just as our individual actions influence the lives of others and our local environment, our collective and historical human activity affects the life course of the planet as a whole. Humanity is a force of nature. In making this explicit, the Anthropocene has been characterized as a destruction of dualisms, a concept that renders long-standing theoretical divides—such as nature/culture, modern/non-modern, human/non-human—if not demonstrably false, then at least not fit for analytical purpose (Sanders & Hall 2015). The Anthropocene highlights the fallacy of society as an imagined world apart from nature, and the natural, geological world as a force outside social and cultural influence. It spells the end of Natural History, as culture itself is recognized as a geological force.

At this point, commonalities and differences become apparent. In some ways, humanitarianism and the Anthropocene are natural partners. Both place humans at the centre of the action. They are firmly anthropocentric. The two concepts also draw attention to the interconnectedness of people, to notions that care and stewardship are essential duties of individuals and humanity as a whole. In this way they are entirely deterritorialized projects: everywhere and nowhere at once; there is no part of the planet where humans are not humans, or where the effects of the Anthropocene do not reach.

In other ways, humanitarianism and the Anthropocene may seem opposed. Contemporary humanitarian action puts human welfare—a circumscribed, biological version of welfare—as its foremost goal. By contrast the Anthropocene is about planetary welfare, or (if “welfare” is too anthropocentric a concept) at least about understanding humanity as a force that impacts planetary equilibrium.

In the most brutal formulation, humanitarianism is bad for the planet. Its stubborn insistence on prolonging marginal lives produces surplus population. It achieves this through consumption of resource-intensive products of global industrial capitalism. No one has estimated the net carbon footprint of the humanitarian aid industry, but it likely rivals that of similar multi-billion dollar globalist enterprises. The aid industry accounts annually for hundreds of thousands of flights of hundreds of millions of kilometres, as managers, medics, consultants and media jet to all corners of the map. The industry’s iconic white LandCruisers—which daily ply disaster zones by the thousands—get around 12km to the litre. This is to say nothing of the diesel generators, the air-conditioned offices, transnational shipping, mounds of medical waste, and the home comforts, such as tinned food and drink, airlifted to expats in remote postings.

To phrase a critique in such blunt terms is not to argue against the humanitarian enterprise. Nor is it to argue that some lives are not worth saving. It is to call attention to the manner in which practices intended to foster welfare are themselves entwined in practices that exacerbate existing perils. It is also to illustrate how, (after a short period of unfashionablity), a certain dualistic moral calculus is resurgent: one that frames human wellbeing as subordinate to political exigency and public finance. This is a calculus that pits individual life and liberty against collective interest—when that interest is framed in terms of the nation state or, increasingly, the planet. It is a calculus highly visible today in discourses over migration and asylum. It will only become more prominent as the Anthropocene advances.

Thus anthropologists of humanitarianism have much to exchange with scholars of the Anthropocene. The humanitarian ethos calls for us to address people in crisis. It is a call that resonates deeply in our own lives, in part because, as Latour has noted (2014), to live on planet earth at the time of the Anthropocene is to live life in crisis.

 

Darryl Stellmach is a Postdoctoral Researcher in Medical Anthropology, Food and Nutrition Security at the University of Sydney. In 2014, for his doctoral research at the University of Oxford, he undertook an ethnography of aid agency response to the South Sudan conflict. Prior to his studies Darryl spent ten years as a humanitarian aid worker.

Dr. Sverre Molland is a lecturer in Anthropology and Development Studies at the Australian National University. His research explores the intersection of development, security and migration in Southeast Asia.

 

Works Cited

Fassin, D., 2012. Humanitarian Reason: A Moral History of the Present. University of California Press.

Latour, B., 2014. Anthropology at the time of the Anthropocene—A personal view of what is to be studied, in: Distinguished Lecture Delivered at the American Anthropological Association Annual Meeting, Washington.

Sanders, T., Hall, E.F., 2015. Anthropologies #21: Is There Hope for an Anthropocene Anthropology? [WWW Document]. Savage Minds. http://savageminds.org/2015/09/05/anthropologies-21-is-there-hope-for-an-anthropocene-anthropology/ (accessed 7.27.16).

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