I barely slept the night before my first day of fieldwork in the OR. As a kid I had accompanied my brother to the emergency room and watched a surgeon remove shards of glass from his lower legs. The removal wasn’t bad. But when the suturing began, I got dry mouthed and over-warm and nearly fell out of my plastic chair. I was shuttled out to the waiting room and installed in a different plastic chair, where the blood and bodily matter that I could not handle was replaced by the inane drama of televised small claims court that I could. What if it happened again? I worried throughout that sleepless night. Being forced by my weak constitution to trade surgical scrubs for midday television would be too much humiliation to bear.
Much to my relief, I discovered that I really like the operating room. I like seeing the body’s usually hidden insides, and I have grown used to the sounds and smells of operation. I have observed about 150 hours of sex reassignment surgery by now, mostly facial reconstruction and a little bit of chest and genital work. None of these is performed through the small incisions of laparoscopy: bodies are cut wide open.
When you or I are rolled, drowsy, into the operating room, there is a lot of work that must be done to prepare us for the operation: our bodies are positioned, draped, scrubbed, shaved, and scrubbed again. Anesthetic chemical compounds are slowly pressed into our veins and then into our lungs. Compression sleeves may be wrapped around our lower legs, and catheters dripping with iodine slid into our urethras. All of this prepares our bodies for the surgeon’s first cut, the moment when “the operation” actually begins (its exact time dutifully noted by an ungloved nurse). The first cuts into our skin are made by scalpels, smooth and razor sharp. But once our bodies have been opened, a variety of other instruments might be used to do the cutting: scissors, saws, chisels, electrosurgical devices, and more. These internal dissections are ones that we won’t see when we wake up from surgery and look at its mark. What we’ll see is the cut that opened us, the place where the solid border between inside and outside was sliced in two, transformed from a smooth plane into a port of entry and exit. The wound of incision is a surfaced and well-ordered replacement for the deeper and hidden malady whose existence the incision marked in both time and place: a good injury exchanged for a bad one.
A plastic surgeon recently told me that sex reassignment surgery is the only procedure he performs whose medical indication he himself is not qualified to determine. Instead, he cuts on referral. Because of its somewhat unique therapeutic configuration—as a medically necessary surgery that operates on otherwise healthy body parts in order to alleviate the psychological distress that often comes from gendered misembodiment—surgical sex reassignment also has a somewhat unique process of diagnosis and treatment; surgeons treat a disorder that they are not trained to identify or to understand. With their hands and other instruments, surgeons open bodies in order to alter skin, bone, nerves, arteries, cartilage, muscle, and so on.[i] They do not operate on gender or recognition—the kinds of social and personal things that trans- folks often name as their reasons for undergoing surgery. A psychologist or other “mental health professional” must evaluate these things, and then assure the surgeon that operating is an appropriate course of action, that cutting and reshaping the body will enact a therapeutics located elsewhere.
After all of this and so much more, we are all there in the operating room: the surgeons, the nurses, the patient (absented away by anesthesia), and me. It is a cliché of fieldwork but also a true story that once I stopped trying to figure out the OR, I began to understand how to be there. New procedures, new patients, new surgeons press me uncomfortably into relations with bodies and the techniques by which they are inhabited and intentionally (re)crafted.
The last surgery I observed was a trans- man’s chest reconstruction. His nipples were removed and set aside for grafting, and then the breast tissue was dissected and removed. His ex-breasts, weighing in at just over three pounds apiece, sat in blue plastic tubs on the scrub nurse’s draped table. Once it was verified that the operating team had removed an equivalent volume from each side, the tubs’ contents—gleaming red and bright yellow under the lights—were ignored. But I sat and stared at them, tried to be with them somehow. And I tried to be with the patient, raised to a sitting position, arms spread wide as the surgical team stuck small circles of tissue paper to his chest with petroleum jelly in order to decide where to place his nipples. And I tried to be with the surgical team, teaching and learning a very uncertain and contested form of medicine while enacting the climax of what had been, for the patient, a very long road to the OR. I was there with them all.
As I watched them suture—rows and rows of small insertions, loops, and firm little knots—I knew the patient’s scars would someday look like mine do now: pale pink and six inches across, like a pair of gently shut eyes. They are records of a cut, a line between “before” and “after” that my body keeps for me.
Eric Plemons is Assistant Professor of Anthropology at the University of Michigan and a Postdoctoral Fellow in the Michigan Society of Fellows. He is currently spending time in operating rooms in the United States and Europe and is working on a new project that examines the strange and central place of “patient satisfaction” in trans- genital surgery outcomes research.[i] See Stefan Hirschauer. 1991. The manufacture of bodies in surgery. Social Studies of Science 21(2): 279-319; and Rachel Prentice. 2012. Bodies in Formation: An Ethnography of Anatomy and Surgery Education. Durham: Duke University Press.
Image: “Hydrocephalus Sabuncuoğlu.” Wikimedia Commons.
Afterword by George E. Marcus
Berghahn Books, 2013. 300 pp.
Transcultural Montage contains an abundance of fresh ideas in many sub-disciplines of anthropology such as medical anthropology, cognitive anthropology, cultural and economic anthropology, but also semantics, museology and knowledge production not to mention visual anthropology, the main sub-discipline to which this publication is dedicated. As one flips through the pages of this aesthetically striking edition (300 pages with more than 70 color illustrations) one stumbles upon beautiful, almost poetic accounts, photo images, self-ethnographies and descriptions of religious rituals. While reading the book one has the feeling of having a nice, handpicked collection of anthropological ideas in one’s hands.
But let us take one step at a time: Transcultural Montage is, as its title states, devoted to the theoretical examination of a technique applied in visual anthropology. The most rudimentary definition of ‘montage’ would be an editing of filmic material in order to state something, usually used to suggest the passage of time. However, as the publication shows, montage is also used in many other modes of thought and its presentation — not all of them visual. Elaborating on the ‘disruptive power of montage’ (5) the editors of this volume offer more than a few possible and creative answers to the question of what montage is. Is it a technique? Is it a way of presenting—and therefore of ‘seeing’—a topic?
The editors challenge the reader to think on the basis of Merleau-Ponty’s work about ‘montage’ as a tool for making “present by a certain absence.” (9) Montage can be everything- that is what they claim- it’s a mirror of realities, a means of knowledge production and cinematic representation (11-13). Students of visual anthropology are taught about the meaning and the importance of Rouch’s kilometre- or hour- long footages, an uncut material whose purpose was to report without interfering, to show reality ‘as it is’. The goal being to report objectively as possible while the camera replaced the researcher’s eye. However to avoid montage during editing is also a kind of a montage- its absence is also a statement. This publication is a handbook of how montage can be defined, thought about in its visual, semiotic and verbal-written forms.
Every time when the reader of this book thinks ‘now, this is an original chapter’ or an innovative way to approach theoretically or empirically the notion of ‘montage’, the following chapter or definition of the term in question surpasses the previous one. The book starts with an introduction written by the two editors and places the notion of ‘montage’ into the human endeavour, whether in science, art or cultural practices. The editors invite the reader to feel free to make new connections, to do the ‘montage’ ourselves in our scientific and social expressions. As the editors claim, the publication has set a goal of venturing into the realm of the invisible and to define ‘montage’ by what it doesn’t show, or by its absence (3). This is a wonderful idea to play with, the human sense and the positioning of the camera: a view cannot be present and cannot be presented from all angles. That infinity of viewpoints- an ‘impossibilis’- provides the “invisible ground upon which objects present themselves as visible to us” (3). From that point the editors orient the publication to make present and to “explain by a certain absence the invisible ground of the visible world” (4).
The publication is structured in four major thematic divisions or parts and contains 16 chapters. The major divisions are short introductions to how montage can be used, exploited or explained.
The first part of the book is an introduction to visual anthropology. There are four detailed articles based mainly on the Deleuzian concept of cinema – in which cinema is an ontological practice that creates different ways of organizing movement and time – a creative/constructional human action grounding existential experience (21). Kapferer’s excellent analysis of a ritual (on hat adiya) that relies on montage as an analytical tool also appears in this section. Nielsen’s examination of montage as representation of social identities through the example of house builders in Maputo (Mozambique) pushes us to grasp the notion of time in montage as a means of catching differentiations inherent to social life (p.41).
My personal favourite in this part is Irving’s description of montage as an ethnography of the phenomenology of human senses (76). His description of a descent into the abysses of blindness of a photographer is breathtaking: it’s a mimetic voyage which enables the reader to better grasp what ‘seeing’ can truly mean. This chapter is so well written that one is overwhelmed by the universe of a man which slowly loses his sense of seeing – his basic sense and his main tool and engine of his artistic expression. One feels empathy and profound admiration toward the almost blind photographer who continues to create through ekphrastic dialogue with his assistant. (86)
The second part places montage in the domain of writing anthropology. Dalsgaard takes us into the world of identity constructions, presenting existential conditions as a kind of montage. Antick displays an ethnographic account made of remarks and photographs through a favela tour which makes this chapter a very original contribution to this volume. It contains snapshots, accompanied by just a couple of words which could either be interpreted as ‘explanations’ strictu sensu or simple ‘thoughts’, notes of ideas and feelings.
The third part of the book elaborates the cinematic montage. However, this section is even more original than expected because of the way the five contributors approach the topic. Russel compares, shifting perspectives on gender in Japanese and US movies of the 1930s through archival montage. During the 1930s “institutional authorities mastered the art of montage as a mode of social control” (165). Both countries are struck with an economic depression and cinema, although glittery (168), offers a form of critique of social realities via its female characters in the two analyzed examples. Grossman shows how memory can be analyzed and deconstructed trough the eye of the camera attached to the bike (my personal favourite) while Grimshaw dissects the observational practices of filmmaking.
Finally, the fourth part is a fantastic multidisciplinary approach between museology, visual anthropology, and sociology. The nostalgia for a structural unity of museum collections and exhibitions is tested trough three exhibitions. The selected comments on the Villa Sovietica exhibition which appear as an annex to Chapter 16 – and which are either very positive or very negative – are really worth a read: they are a nice example of how the gaze can be (mis)interpreted.
Overall the editors of the volume deliver on what is promised in the introduction and more. This publication articulates the slipperiness of the idea of ‘montage’ and works as an attempt to introduce the notion of ‘montage’ and all its complexity into anthropology’s glossary of thinking.
One thing is certain: after reading this book, you will never again take for granted the notion of ‘montage’.
Maria Vivod is an Associate researcher and Ethnologist at CNRS (Centre National de Recherches Scientifiques) – UMR 7367 D.E. Dynamiques européennes, Strasbourg, France. She received her PhD in Ethnology in 2005 from the University Marc Bloch in Strasbourg, France. Her research interests include identity, ethnic, and social conflicts; ethnic belonging; world tradition and change; politics of the Balkans; medical anthropology; social mobility and migration; and visual anthropology. She can be reached at vivod AT hotmail DOT com
 ek and phrasis, ‘out’ and ‘speak’ (Greek)
Deep brain stimulation (DBS) involves using a pacemaker-like device to deliver constant, carefully targeted electrical stimulation to areas within the brain. It was first approved in the late 1990s as a therapy for managing the symptoms of Parkinson’s disease. The initial success of DBS led clinicians and device manufacturers to explore other possible applications, and in 2003 it was approved as a therapy for managing dystonia, a neurological disorder characterised by painful and crippling body movements and postures. Other available interventions for dystonia are generally considered to be crude and ineffective. Medications can provide some relief, but for many sufferers they are inadequate or the side-effects are intolerable. Ablative therapy, which involves carefully destroying specific areas of the brain, can provide some therapeutic effect, but this is often short term and the therapy will need to be repeated. There is a great deal of hope among clinicians and sufferers, then, that DBS will prove to be a more effective and safer means of reducing dystonic movements. By 2010 over a thousand individuals, mostly adults, had received DBS for dystonia.
In 2011 I began an ethnographic study of a novel multidisciplinary clinical team in the UK providing DBS to children with dystonia. It is one of few teams worldwide providing DBS to children, and unlike adult DBS services, most of its patients have a complex movement disorder, where dystonia co-exists alongside other manifestations of neurological trauma such as spasticity. Indeed the team (which I refer to as the Paediatric Motor Disorder Service, or PMDS), is considered to be pioneering the delivery of DBS to children with complex movement disorders. For me as a sociologist, it has represented an excellent opportunity to witness the development of a new clinical therapy, and to explore how various social and institutional factors can shape the development of new clinical therapies.
It has also provided me with an opportunity to explore how young patients and their chronic illnesses are rendered intelligible within a clinical context based around a novel neurotechnology. Previous studies have illustrated that new medical technologies tend to reify biomedical-based understandings of health and illness, in which a patient’s experience of illness, and the social aspects of illness, are elided. As Andrew Webster has argued, new medical technologies have tended to facilitate the emergence of health identities based around biomedical criteria (Webster 2002). Neurotechnologies, particularly MRI and other neuro-imaging technologies, have been implicated in this, with some commentators suggesting that they are leading us to an era of neurocentrism in which the essential dimensions of the self are equated with neural circuits and neurochemistry (Vidal 2009). An aim of my project, then, is to determine whether this was the case with the PMDS. I’ve been exploring how children and their illnesses are ‘enacted’ (to borrow a term from Annemarie Mol, (2002)) in various interactions during their time with the PMDS. Here is a team that relies heavily on neuro-imaging technologies and puts electrodes into the brains of children; surely they are, in some way, involved in this ‘neurologisation’ of personhood.
During the very first team meeting that I observed it became apparent that this was not the case. A feature of the meeting initially struck me as peculiar (although I soon realised that this was characteristic of all PMDS team meetings). This is the way in which members of the team refer to, and speak about, their young patients. While there is some talk about MRI images, brains, the basal ganglia, electrodes and DBS stimulation parameters, much more time is devoted to talking about a child’s progress at school, their relationship with their siblings and parents, their mood, and their ability to access computers, iPads or assistive technologies. Such considerations seem to have a bearing on the decisions that are made during the team meeting; they are certainly not immaterial to clinical decision making. Indeed, the team subjects their patients to what could be called a ‘broad clinical gaze’; a clinical interest that extends from the shapes and structures of the brain, to the subjective thoughts and emotions of their patients, to the internal dynamics of family life. The patients who were being discussed in team meetings, then, were not the impersonal biomedical entities that have been the subject of so much critical attention from social scientists. Given the various professional backgrounds of those involved in the team (which include occupational therapy, physiotherapy, clinical psychology, speech and language therapy, and neurology), I should not have found this surprising: proponents of multidisciplinarity in healthcare have argued that it leads to a more ‘comprehensive’, ‘patient-centred’ approach.
I have witnessed various manifestations of this broad clinical gaze throughout my fieldwork. Due to the novelty of therapy they are offering, the PMDS team has had to devise new clinical routines for identifying appropriate candidates, for measuring the effectiveness of the therapy, and for managing the expectations of their patients and families. In doing this, the team has employed a wide range of tools and resource from a range of disciplines, particularly occupational therapy. Occupational therapy as a discipline has often been highly critical of the reductive biomedical model of illness, and many occupational therapy tools have been developed in order to support a more ‘social’ and ‘patient-centred’ approach to clinical practice. Several of these tools are routinely used by the PMDS. One is the Assessment of Motor and Process Skills, which the team uses to measure a patient’s disability. During the assessment, the patient must attempt to perform several ‘activities of daily living’ that they feel are important to them. These can include brushing teeth, preparing a bowl of cereal, or dressing oneself. The patient’s performance is video-recorded, and these video-recordings are used by the team’s occupational therapist to grade aspects of the patient’s body movement and body position as they perform each task. The assessment is carried out before and after the DBS system has been implanted, enabling any DBS-induced improvements to be clearly identified. In effect, various aspects of a patient’s domestic life are foregrounded during the assessment, and dystonia is rendered intelligible in terms of its impact on the patient’s ability to use their body as an efficient implement for undertaking culturally-mediated tasks.
A similar tool from occupational therapy is used as a means to manage the expectations of patients and families. Many patients and families who arrive at the PMDS have unrealistic hopes about what DBS can do for them – this is due, in part, to media-generated hype surrounding DBS. In an attempt to ensure that patients and families have realistic expectations before consenting to the procedure, members of the team hold a goal-setting session with each family. This session is based upon the Canadian Occupational Performance Measure, a standardised, ‘semi-structured’ interview in which patients and families are asked to identify the aspects of their day-to-day life that they would like to improve with DBS. The Canadian Occupational Performance Measure encourages patients and families to be explicit about their hopes, and importantly, it prompts team members to convey their predictions in reference to these hopes. In one session I witnessed, for example, a 16-year old patient stated that he hoped that DBS would provide him with sufficient mobility to use the public bus system. A team member replied that this is not a realistic goal for DBS – his inability to use public transport, she told him and his family, was due to muscle weakness around his pelvis and this would not be directly improved with DBS. In this way, by foregrounding specific aspects of the patient’s day-to-day life, family members and patients collectively construct an account of a ‘likely’ future. Patients are again rendered intelligible in terms of their ability to, and desire to, perform culturally-mediated tasks.
The ‘broad clinical gaze’ of the team is a consequence of its multidisciplinary composition, and it is a consequence of the various tools that have been adopted into their routine clinical practices. There is then, an obvious link here between the structure of the clinical team, the type of clinical work they do, and the way in which the patient and illness are enacted during clinical interactions. But this link can be traced further: the team itself is the product of a particular healthcare policy initiative in the United Kingdom. This policy initiative promotes multidisciplinary service provision within the paediatric contexts, as multidisciplinary teams, it is argued, are better suited to assessing the complex needs of a child and will thus ensure better health outcomes (Kennedy 2001; 2010). The policy initiative has had two important consequences. First, it has created a health service funding scheme that makes it financially viable for hospitals to house teams such as the PMDS. The agencies that administer hospitals receive more money from the Department of Health for a service provided to a child than if the same service was provided to an adult. This is on the assumption that a child will need to see a wider range of professionals, and it enables the PMDS team to generate enough revenue so that it is self-sufficient. Second, the policy initiative has influenced the design of clinical spaces, including the newly-built children’s hospital that houses the PMDS. The hospital was specifically designed to encourage multidisciplinary teamwork, and it was specifically designed to support families and encourage patient-centred care. The hospital contains an open-plan office in which clinical teams are expected sit together as a group, and wards have been designed so that a range of health services can be brought to the bedside of the child – rather than the child having to be wheeled to different parts of the hospital. Importantly for the PMDS team, the hospital contains a diversity of spaces that permit a range of activities. Each ward contains a kitchen area for families to prepare food, and a play area with toys, small tables and chairs, and drawing utensils. I watched the occupational therapists convert these into clinical spaces for assessing the child’s ability to perform various domestic chores. The Assessment of Motor and Process Skills, for example, is often carried out in these kitchen areas. The hospital also contains a gymnasium. In here, I watched the physiotherapist carefully construct a space for conducting a gross-motor function examination: A child was encouraged to run, jump, crawl and balance on one foot. The architecture of the hospital, then, permits particular forms of multidisciplinary clinical work. It contains a variety of spaces which enable a variety of profession-specific interactions to be undertaken, all within the one building. In effect, ‘multidisciplinarity’ has been encoded within the material form of the hospital.
Peter Keating and Alberto Cambrosio (2003) argue that during the 20th century there was a great transformation from medicine to biomedicine. In the latter, health and illness are rendered intelligible in terms an array of biological entities such as cellular markers and genes. Keating and Cambrosio describe the transformation as an emergence of biomedical platforms: configurations of healthcare policy, architecture, machines, infrastructure, reagents and ‘ways of thinking’ that reify and perpetuate this biomedical mode of clinical practice. These platforms, they argue, have a structuring effect on clinical research and clinical work. During my fieldwork with the Paediatric Motor Disorder Service I have witnessed the emergence of a different kind of platform; one that exists in addition to those identified by Keating and Cambrosio. This platform is characterised by a configuration of hospital architecture, healthcare policy, assessment tools, a clinical team structure and ‘ways of thinking’ that reify and perpetuate a broad clinical gaze. This gaze has the effect of foregrounding particular social aspects of an illness and aspects of a patient’s experience of illness during clinical interactions – it is according to these aspects that dystonia, for example, is rendered intelligible within the PMDS, and it is according to these aspects that the effectiveness of deep brain stimulation is measured and assessed. Whether or not such platforms exist in other countries or in non-paediatric contexts is matter for further research. But in the setting where I have been doing my fieldwork, this platform has shaped the way in which a new neurotechnology has been integrated into clinical service, and it is structuring the type of patients, bodies and illnesses that are being enacted by within this service. Such platforms may hinder the march towards neurocentrism and the ‘neurologisation’ of personhood that has been envisaged by some commentators. Within the PMDS deep brain stimulation is understood as a tool for ‘unlocking’ the body and enabling patients to engage in the world. Here, then, the neural structures of the brain are implicated in identity and personhood, but only in so far as that they limit an individual’s ability to immerse themselves in culturally-mediated activities. Indeed, it is this immersion that is seen as the ultimate source of ‘the self’.
John Gardner is a PhD candidate at the Centre for Biomedicine and Society at Brunel University, London. His research interests are the dynamics of innovation and social change and the relationship between technology, the body and sociality. In 2010 he was awarded a Wellcome Trust PhD studentship as part of a Wellcome Trust Biomedical Strategic Award (grant number: 086034). John also has an interest in biomedical ethics and is a member of the London and Brighton Translational Ethics Centre (LABTEC).
Keating, P. and Cambrosio, A. (2003). Biomedical Platforms: Realigning the Normal and the Pathological in Late-twentieth-Century Medicine. Cambridge MA: MIT Press.
Kennedy, I (2001). Kennedy, I (2001) Learning from Bristol: The Report of the Public Inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984–1995. London: The Stationery Office.
Kennedy, I (2010). Getting it Right for Children and Young People: Overcoming Cultural Barriers in the NHS so as to Meet Their Needs. London: Department of Health.
Mol, A. (2002). The Body Multiple: Ontology in Medical Practice. Duke University Press.
Vidal, F. (2009) Brainhood, anthropological figure of modernity. History of the Human Sciences, 22: (1): 5–36.
Webster, A. (2002). Innovative health technologies and the social: Redefining health, medicine and the body. Current Sociology 50(3): 443-457.
Image: © Rachael Allen – www.rachaelallen.com
Call for candidates : one year fellowship at the Laboratoire d’anthropologie sociale of the Collège de France (Paris) by Frédéric Keck
The Laboratoire d’anthropologie sociale, based at the Collège de France in Paris, will hire a researcher for a one-year post-doctoral contract starting 1st September 2014 to study the perception of animal diseases in southeast Asia (including China, India and Indonesia).
This position takes part to the project « Social representations of pathogens at the frontiers between species », sponsored by the Axa Research Fund and led by Philippe Descola and Frédéric Keck. The goal of this three-year project is to compare the perception of animal diseases by breeders and health authorities in different parts of the Asia-Pacific area. In the course of this project, three positions will be available : Central Asia (2013), South-East Asia (2014) and Australia (2015).
- Applicants must have been awarded a PhD before the start of the contract.
- Language skills and expertise related to the area of concern
- Experience in ethnographic description and comparative theory
- Ability to engage in a collaborative research with publications and participation to scholarly activity
- Knowledge in human/animal relationships and/or medical anthropology would be appreciated
In the framework of this post-doctoral contract, the applicant will :
- Receive a 2100 euros net salary from 1st September 2014 to 31 August 2015
- Benefit from the environment of the Collège de France : high-quality libraries, research seminars and teaching at the centre of Paris.
- Have the financial means to do fieldwork in the area of concern under the tutorship of renowned experts of this field.
- Acquire knowledge on animal diseases and participate to the activities of the team « Relations hommes/animaux : questions contemporaines » (http://las.ehess.fr/document.php?id=663).
- Organize a workshop to maintain the international network of the project created by the launching workshop : « Zoonoses and emergence of new infectious diseases : when biology meets anthropology » (http://www.college-de-france.fr/site/philippe-sansonetti/symposium-2012-2013.htm)
Candidates must send before April 15 a CV, a sample of writing (article or PhD chapter) and a statement of suitability (less than 3000 words).
Contact : Frédéric Keck – Laboratoire d’anthropologie sociale – 52 rue Cardinal Lemoine – 75005 Paris – frederic.keck@college-de-France.fr
For this installment of “Top of the heap” we spoke to Cheryl Mattingly, Professor of Anthropology at the University of Southern California. Here’s her list of recent – and upcoming – readings:Cheryl Mattingly
Lately my favorite reading topic has been in the “anthropology of morality.” While there are many reasons to object that this is not a new topic for anthropology — when haven’t anthropologists been concerned with societal moralities? — lots of fascinating arguments and claims have recently emerged under this new label. One thing I find intriguing about this still developing conversation is that it has sometimes put anthropologists in sharp debate with one another. I always find that provocative and clarifying. I am also compelled by the way it is prompting new avenues for thinking with philosophy and in some cases promoting on-going conversations between anthropologists and philosophers.
The readings I’m personally recommending are (annoyingly) not all out yet but if they aren’t, they will be appearing soon.
James Laidlaw, The Subject of Virtue: An Anthropology of Ethics and Freedom. (Cambridge University Press, 2013)
Laidlaw’s new book engages the Anglo-American philosophical tradition of virtue ethics (especially the work of Bernard Williams) with a carefully crafted interpretation of Foucault’s ethics of care. I don’t necessarily agree with all of Laidlaw’s arguments — for example his reading of Alasdair MacIntyre — but this is a very rich book, theoretically. Along the way Laidlaw makes sharp and incisive critiques of some dominant anthropological traditions and voices (e.g. Bourdieu-style practice theory and actor network theory). He also offers a reading of Foucault’s ethics that separates it from his earlier works on power and governmentality — and many might find this interesting.
Jason Throop and Jarrett Zigon (Eds), Ethos, Special Issue on Moral Experience, 2014
A number of interesting essays by scholars, including some working between phenomenology and morality. (First 2014 issue, due out momentarily).
Thomas Wentzer, ’I have seen Königsberg burning’: Philosophical anthropology and the responsiveness of historical experience. Anthropological Theory, 2014(1).
Wentzer is a German phenomenological philosopher who is working closely with anthropologists. (He has a chapter coming out in a new book with Michael Jackson, for example). His work is in the tradition of hermeneutic phenomenology, and this paper concerns the relationship of narrative and experience. He represents a new kind of philosopher who is trying to think with thick (rather than thin) examples. This piece is beautifully written. He builds his analysis around a personal example from his own family’s history. (This one is not available to view online yet, but also should be out momentarily).
Jonathan Lear, Radical Hope: Ethics in the face of cultural devastation. (Harvard University Press: 2006).
Another philosopher (American) writing about hope from a virtue ethics perspective and using an ethnographic example. While anthropologists will likely find his picture of culture too simple, this is a fascinating and easily read little book with very big ideas about hope, despair and cultural possibility. I read it after writing my own book about hope and I wish I’d gotten to it beforehand!
Michael Lambek, (Ed.) Ordinary Ethics: Anthropology, Language, Action. (Fordham University Press: 2010).
This is one of my favorite edited collections with essays by many well known anthropologists. My personal favorites are the introductory essay by Lambek, his own chapter and a chapter by Veena Das. (I particularly like their work especially because in their different ways, both are arguing for a complex understanding of ethical life embedded within the ordinary.)
Sune Liisberg, Esther Oluffa Pedersen and Anne Line Dalsgård (Eds.). Anthropology & Philosophy: Dialogues on Trust and Hope. (Berghahn Press: In press).
This won’t be out until January 2015 but I’m including it here because it is a wonderful example of co-writing and thinking between philosophers and anthropologists. It is set up as a series of interdisciplinary dialogues. Most of the essays are directly concerned with moral dilemmas and issues as well.
Didier Fassin and Samuel Lézé, Moral Anthropology: A Critical Reader. (Routledge, 2014).
This is a huge collection (perhaps too big) but Fassin’s very clearly written introduction — in fact, his introductions in the sections throughout — are extremely helpful. I also appreciated the Kleinman essay on why bioethics needs ethnography.
Joel Robbins, Beyond the Suffering Subject: Toward an Anthropology of the Good. Journal of the Royal Anthropological Institute. 19: 447-462. 2013
I love this essay! It’s very provocative and I don’t necessarily agree with it all, but it is so wonderfully clearly written. It challenges anthropologists to think beyond the “suffering subject” and therefore should be of interest to a broad range of anthropologists.
Upcoming Conference: Moral Engines: Exploring the Moral Drives in Human Life (June 2014)
Just a small announcement, in case anyone wants to attend. It will be held at the Aarhus Institute of Advanced Studies, Aarhus University, Denmark. It is co-organized by several philosophers and anthropologists and will include talks by some prominent philosophers and anthropologists working on issues of morality. For more information, see: http://aias.au.dk/events/show/artikel/aias-conference-1/
Cheryl Mattingly is a medical anthropologist. She is a Professor of Anthropology in the Department of Anthropology and the Division of Occupational Science and Therapy, University of Southern California. She is also currently a Dale T. Mortensen Senior Research Fellow at the Institute of Advanced Studies, Aarhus University, Denmark. She is a frequent Visiting Professor of Anthropology and Philosophy at Aarhus University. She has also been the PI and Co-PI on multiple large-scale, federally funded ethnographic research studies. Her primary research and theoretical interests include narrative, moral reasoning and experience, phenomenology, the culture of biomedicine, chronic illness and disability, the ethics of care, and health disparities in the United States. She has published extensively on these topics, including numerous peer reviewed articles and book chapters. She has also written and co-edited six books (including one currently in press). She received the Victor Turner Prize (Society for Humanistic Anthropology) for Healing Dramas and Clinical Plots (1998) and the Stirling Book Prize (Society for Psychological Anthropology) for The Paradox of Hope: Journey Through a Clinical Borderland (2010). Her forthcoming book is Moral Laboratories: Family Peril and the Struggle for a Good Life (Due out fall 2014).
Image: Matej Krén, “Scanner” (detail)
While training in psychiatry, I frequently heard mental-health practitioners refer to the Diagnostic and Statistical Manual (DSM) as our profession’s “diagnostic bible.” The DSM, of course, is the text produced by a cabal of psychiatric experts that defines the parameters of mental illness and, by extension, mental health. It textually conveys the now commonplace assumption that psychiatry works through systems of classification and codification, a how-to manual through which clinicians observe their patients and then diagnose them as a premise for initiating treatment.
Bible, meanwhile, connotes the assumption that the DSM represents the first and final word about psychiatric conditions, passed from on high, to the diagnostic decisions of doctors, to the supplicant minds and bodies of parishioners.
To be sure, there are ways in which the DSM feels and acts like a bible. At a whopping 947 pages, the current version of the manual, the DSM-5, conveys a King Jamesean heft. And like any good religious text, the DSM demands a certain, structurally reinforced adherence. Mental health practitioners need to use DSM criteria to diagnose their patients, or they will not be reimbursed for their efforts. And patients need to be diagnosed with DSM-defined illnesses or they will not receive financial coverage for their office visits, medications, or hospitalizations. In this sense the DSM produces a congregate of doctors, patients, and insurers all of whom depend, in various ways, on spreading the good word.
There are tremendous benefits to this arrangement, none the least of which is the production of a common economy of suffering and treatment. At the same time, history suggests that blind devotion to DSM diagnostic categories as if by article of faith comes at a cost: diagnosing by-the-book can also mean reproducing a host of era-specific biases, prejudices, and stigmatizations.
For instance, as is well known, the first edition of the DSM—published in 1952 as Mental Disorders: Diagnostic and Statistical Manual—listed homosexuality as a sociopathic personality disturbance.[i] The text conveyed the common “scientific” notion that same-sex attraction represented a pathological hidden fear of the opposite sex caused by traumatic parent–child relationships. The diagnosis of homosexuality also represented a deep conservatism that suffused the profession of psychiatry. Indeed, even in 1973, after the board of trustees of the American Psychiatric Association approved a resolution proclaiming that, “by itself, homosexuality does not meet criteria for being a psychiatric disorder,” the so-called Ad Hoc Committee Against the Deletion of Homosexuality from the DSM forced a vote of the entire APA membership. Only after a 58 percent to 37 percent victory for declassification did the nomenclature committee proceed with removal of homosexuality from the DSM.[ii]
The DSM also emerged at the center of discoveries that psychiatrists overdiagnosed schizophrenia in African American men in the 1960s and 1970s.[iii] Prior to the 1960s, psychiatry defined schizophrenia as a psychological “reaction” to a splitting of the basic functions of personality. The DSM-I described Schizophrenic Reaction as “emotional disharmony, unpredictable disturbances in stream of thought,” and “regressive behavior.”[iv] But in 1968, the second edition of the DSM recast paranoid schizophrenia as a condition of “hostility,” “aggression” and projected anger, and included text explaining that, “the patient’s attitude is frequently hostile and aggressive, and his behavior tends to be consistent with his delusions.”[v] 1968 was a year in U.S. history marked by political protest and racial tension, and the addition of terminology such as aggression and hostility had profound implications. In the aftermath of the DSM-II, clinician overdiagnosis of schizophrenia in African American men rose significantly. Published psychiatric research articles and case studies began to disproportionately describe “schizophrenic” African American men using terminology such as aggressive, hostile, or violent. And advertisements for antipsychotic medications published in leading U.S. journals made similar assumptions.[vi] An advertisement for the antipsychotic medication Haldol that appeared in the May 1974 Archives of General Psychiatry (732-33) shows the troubling, distorted image of an angry African American man below the text, “Assaultive and belligerent? Cooperation often begins with Haldol.”
More recently, the release of the DSM-5 in 2013 led to concerns that the text catered to the pharmaceutical industry by expanding the boundaries of illness beyond psychiatric expertise into ever-more-broad realms of everyday life.[vii]
These and other tensions provide fodder for growing communities of DSM agnostics. For instance, a subcommittee of the Society for Humanistic Psychology recently established a Global Summit on Diagnostic Alternatives intent on producing “alternatives to the current diagnostic paradigm” in mental health.[viii]
Such critiques are well founded, in my opinion. While production of the DSM-5 involved a great deal of thought and effort, current controversies suggest that we psychiatrists still have much to learn from our past mistakes.
At the same time, whatever manual emerged in the aftermath of a total diagnostic cataclysm would still need to address the central lessons that we, as a profession, have learned from progressive versions of the DSM. These are lessons of the need for diagnostic flexibility even in the face of demands for diagnostic orthodoxy. Make no mistake, we psychiatrists want to know what causes mental disease, and science offers promising clues about nosology. But we are not there yet. We do not diagnose schizophrenia, depression, or a host of other illnesses through x-rays, brain scans, or specific laboratory tests. Instead, we query, listen, observe, categorize, and expertly surmise.
Thus, even in an era dominated by an ever-expanding manual, diagnosis remains a projective act, one that combines scientific understanding with a complex set of ideological and political, assumptions. Seemingly straightforward attempts to help people, by naming their anguish and then addressing it, always and already become intertwined with a host of complex cultural, commercial, or political agendas.
In this sense, much like the actual bible[ix], psychiatry’s DSM is to my mind best understood, not as a reflection of timeless truth, but as an ever-changing reflection of the ways we make sense of an ever-changing world and its aberrations.
Jonathan Metzl is the Frederick B. Rentschler II Professor of Sociology and Psychiatry, and the Director of the Center for Medicine, Health, and Society, at Vanderbilt University in Nashville, Tennessee. He received his MD from the University of Missouri, MA in humanities/poetics and Psychiatric internship/residency from Stanford University, and PhD in American Culture from University of Michigan. A 2008 Guggenheim fellow, Professor Metzl has written extensively for medical, psychiatric, and popular publications. His books include The Protest Psychosis, Prozac on the Couch, and Against Health.
[i] Mental Disorders: Diagnostic And Statistical Manual. Washington: APA Press, 1952.
[ii] Even then, although homosexuality per se was expunged from the third edition of the DSM (1980), the manual still contained the diagnosis of “ego-dystonic homosexuality,” an ill-defined condition in which a person’s same-sex desire caused psychic distress.
[iii] Jonathan M. Metzl, The Protest Psychosis: How Schizophrenia Became a Black Disease (Boston: Beacon Press, 2010).
[iv] Mental Disorders: Diagnostic and Statistical Manual. Washington: APA Press, 1952, pp. 26-27.
[v] Diagnostic and Statistical Manual of Mental Disorders, 2nd Edition (Washington: APA Press, 1968), vii, viii.
The University of Washington Department of Anthropology is seeking an anthropologist to fill a temporary, one-year (9 month), full-time (100% FTE) lecturer position in medical anthropology to begin September 2014. The position is not renewable at this time. The lecturer will be responsible for teaching six undergraduate courses per year that serve a vibrant undergraduate program in Medical Anthropology and Global Health. Teaching responsibilities will include two offerings of Introduction to Medical Anthropology and Global Health (a large lecture class with 4-5 TAs each quarter). The remaining courses will include 300- and 400-level courses approved for the Medical Anthropology and Global Health track (see http://depts.washington.edu/anthweb/undergrad/tracks-options/med). The department is especially interested in individuals who can offer engaging courses that offer fresh perspectives to the discipline and underscore the relevance of medical anthropology and global health in today’s world. Ability to incorporate some biocultural perspectives and materials is welcome, though not required. Successful candidates must be committed to working with diverse student and community populations, and should contribute to an inclusive environment and to the diversity and excellence of the academic community through their teaching. Applicants should have a PhD by the time of appointment and be able to demonstrate a high level of proficiency in teaching. The University of Washington is an affirmative action, equal opportunity employer and is committed to building a culturally diverse educational environment. It strongly encourages applications from women, minorities, individuals with disabilities, and covered veterans. University of Washington faculty engage in teaching, research, and service.
To apply, submit a single PDF file including the following items in the specified order: 1) a cover letter that describes the applicants teaching experience and philosophy, list of courses to potentially offer at University of Washington, and a brief description of your research experience as it relates to teaching; 2) a curriculum vitae; 3) up to three syllabi; 4) teaching evaluations; 5) contact information for three professional references; and 6) a diversity statement that addresses how your experience and understanding of diversity influences your teaching and your vision of how to encourage inclusion of individuals and groups from underrepresented backgrounds in the classroom and larger university community. Priority will be given to applications received prior to March 21, 2014. Applications should be sent electronically to: Professor Bettina Shell-Duncan, Chair, Lecturer Search Committee, maghlect AT uw DOT edu
Cornell University Press, 2012. 240pp.
Finley’s portrayal of the difficulties of soldiers returning from Afghanistan and Iraq elegantly interweaves narratives and analysis. Drawing on 20 months of ethnographic fieldwork in San Antonio, Texas, involving 133 study participants (62 of which were veterans), Finley conveys her message through the construction of six narratives that “represent composites of several individuals who participated in the research” (xiii). The use of composites is a methodological technique to protect the privacy of research participants. This proves particularly important in Finley’s study given the sensitive nature of these individual’s service in the military and/or in their anxiety over receiving a diagnosis of psychological injury. Adam, Brian, Chris, Derek, Jesse, and Tony all have unique stories to tell about what compelled them to join the military (honor, respect, bravery, hardship, aspirations for a better future), the traumas they experienced as soldiers on the front lines (constant hyper vigilance, temporary paralysis and incontinence from sheer terror, loss of friends, loss of a limb, the murder of a child), and the hardships they experienced in returning home to negotiate their new identities as war veterans. It is through these individual narratives that Finley deconstructs some of the preconceptions of PTSD symptoms and sufferers – the extreme and unanticipated violence associated with PTSD, the social isolation as a consequence, the link to specific ethnic groups, the shame experienced by PTSD sufferers and the related idea that the machismo of military culture contributes to delayed treatment and increased suffering – revealing that PTSD sufferers and symptoms are varied, diverse and intimately influenced by our culture(s). The book clearly distills various historical and contemporary views of combat-related PTSD, and examines how these perspectives and definitions are internalized and responded to. Finley notes that veterans’ personal experiences of PTSD and the cultural politics that surround and shape those experiences are interrelated: “Combat trauma (the personal) may occur during war (the political) but is unavoidably shaped by the meaning of the event to the individual (the personal), a meaning that is partly the product of a shared vocabulary for the describing experience (the cultural)” (158).
Finley’s portraits of war offer a perspective of an evolving American warrior – a civilian, turned soldier, and then veteran. It is this progression of time in service and the changing perspectives of self and illness that structures the book. The first half focuses primarily on narratives. The second half offers an analysis of the cultural, political, and historical influences shaping the experiences of PTSD in three particular cultural contexts: families, the US military, and the VA’s mental-health-care system. Rather than switching to a more removed and analytical register in this section, Finley offers a rendering of how each of her composite veterans uniquely experiences the devastating impacts of PTSD, including substance abuse, insomnia, domestic violence, distancing of friends and family, divorce, and unemployment. By drawing on their narratives, Finley not only challenges popular ideas of PTSD as incurable and permanently debilitating, but offers a hopeful outlook on how significant advancements have and continue to be made in acknowledging, understanding, and treating PTSD. True to her applied anthropology perspective, Finley closes her book with a substantial offering of recommendations. Informed by her intimate relationships with veterans, their families and health care providers, the recommendations are positioned at the levels of policy, family and community and cover both prevention and impact minimization.
Rich in descriptive detail, Finley’s text is careful, sensitive, and thoughtful. Finley transports us from picnic tables at a local Veterans of Foreign Wars post on the Fourth of July, to an army Humvee being ravaged by an IED, to the bedside of a soldier whose leg has been amputated as a result, to a college campus too overwhelming with potential hidden dangers for a PSTD sufferer to traverse, and to a Chuck E. Cheese entertainment center where a recovering veteran plays untroubled with his family.
Yet, in keeping the text narrowly focused on the experiences of her participants in San Antonio Finley omits some of the wider anthropological discussions about war, trauma and PTSD. Finley briefly mentions debates about understanding PTSD as a universal phenomenon or as a Western-derived cultural construct to explain certain types of suffering. More attention to this question as well as to the issue of the “medicalization” of trauma would be welcome. A deeper examination would have contributed nicely to the discussion of new treatment strategies: Why are these accepted by the ‘new’ breed of psychologists but rejected by older generations? Is this division in the discipline of psychology unique to San Antonio, the VA system, or is can it be generalized to psychologists treating PTSD patients elsewhere in the US and the world? Similarly, Finley’s account could have been extended to include findings on PTSD in non-US, non-military, non-contemporary contexts, perhaps broadening the relevance of her research beyond its immediate contexts: the cultures of southern Texas, the military, and men.
It is only in the conclusion that Finley shifts some attention to female veterans. More attention to women would have have been a welcome addition to this ethnography. In Iraq and Afghanistan female service members were often exposed to the same risks of mortar, rocket, and improvised explosive device attacks as their male colleagues. Women in the military are also at greater risk for what is termed ‘military sexual assault’ than their male counterparts. Another issue regarding women is the potentially more dramatic identify shift they experience in social reintegration at times resulting in greater difficulty in adjusting to the roles and social expectations of the macho-soldier and the feminine-civilian.
Finally, Finley poses the question, “Who is responsible for [the] suffering [of veterans]?” (169), but limits her answer to saying only that it is a question that will be answered differently across cultural worlds. Explaining her limited offering of discussions of the politics of the wars in Iraq and Afghanistan, Finley says that the political debates of the wars had no influence on the experiences of PTSD of her study participants. She offers little indication of how she came to this conclusion, and whether this may be unique to the San Antonio setting. I am left wondering then about the intended audience for Fields of Combat and about Finley’s decision to limit the critical potential of her analysis. A more thorough theoretical discussion, drawing upon concepts of biopolitical subject-making, for instance, would help shed light on veterans’ relationship to the state and the political positioning of their suffering.
In defense of Finley, many other scholarly anthropological works on PTSD tend to portray the individual, in part, as a victim, desperately trying to survive and make sense of what is often viewed as incomprehensible and overwhelming. Theirs is an effort to maintain or create subjectivity in the face of dehumanizing experiences. However, Finley demonstrates that for the veteran, despite the fact that elements of structural violence may have directed their life trajectory in the direction of joining the military, they embrace their choice and are dedicated to what they do. Their agency is an important element in the equation. And, that the road to PTSD involves the whole of their life experience and does not simply begin with the experience of trauma. It is the fact that they have accepted this calling in their minds that is being betrayed by their acknowledging suffering. However, the intimate interplay between the personal and the political could have been explored to a more satisfying depth.
Nicola Bulled holds a PhD in Anthropology from the University of Connecticut as well as a Masters degree in Public Health from Boston University. She is currently a Fogarty Foundation funded Water and Health Initiative in Limpopo (WHIL) Post-doctoral Fellow with the University of Virginia’s Center for Global Health.
The shortest month, February often seems to be shorter on new journal content, as well, falling as it does between months where biannually-, triannually-, or quarterly-publishing journal’s issues are released. However, this month saw the publication of, in addition to the work below, three (!) special issues, written up in other Somatosphere posts:
The journal Health, Risk & Society has a special issue, entitled “Risk, Pregnancy and Childbirth.” You can find more about it here.
Social Science & Medicine published a special issue, entitled “Structural Stigma and Population Health,” the write-up of which can be found here.
And, Sociology of Health & Illness (the ampersand journals represent this month) also has a special issue: “From Health Behaviours to Health Practices: Critical Perspectives.” The specifics on it can be found here.
In American Ethnologist has an article by Kristin Peterson on pharmaceutical markets and access to medications in Nigeria that might be of interest to readers.
The drug patent monopoly has been described as a key deterrent to Africans’ access to brand-name, life-saving drugs. Research in Nigeria, however, shows that another factor restricts access in that country: Brand-name pharmaceutical companies’ pricing and marketing strategies keep patented drugs off the market. In this article, I retheorize the question of monopoly in the pharmaceuticals industry. I first track the historical precedents of this particular iteration of the drug monopoly. I then situate the monopoly in the context of ethnographic research I conducted on pharmaceutical markets and drug marketing (2005–10) as well as on Nigeria’s compliance struggles with the WTO’s Trade Related Aspects of Intellectual Property (TRIPs) Agreement (1999–2003). TRIPs enforces patent holders’ rights and mandates intellectual property harmonization across nation-states. In analyzing these two ethnographic sites together, I argue that rather than its purported short-term legal existence, the current drug monopoly operates as though it has an indefinite life.
Philosophy, Ethics, and Humanities in Medicine has two new articles online for the month of February:
Performance enhancement, elite athletes and anti doping governance: comparing human guinea pigs in pharmaceutical research and professional sports
Silvia Camporesi and Michael J. McNamee
In light of the World Anti Doping Agency’s 2013 Code Revision process, we critically explore the applicability of two of three criteria used to determine whether a method or substance should be considered for their Prohibited List, namely its (potential) performance enhancing effects and its (potential) risk to the health of the athlete. To do so, we compare two communities of human guinea pigs: (i) individuals who make a living out of serial participation in Phase 1 pharmacology trials; and (ii) elite athletes who engage in what is effectively ‘unregulated clinical research’ by using untested prohibited or non-prohibited performance enhancing substances and methods, alone or in combination. Our comparison sheds light on norms of research ethics that these practices exacerbate with respect to the concepts of multiplicity, visibility, and consistency. We argue for the need to establish a proper governance framework to increase the accountability of these unregulated research practices in order to protect the human guinea pigs in elite sports contexts, and to establish reasonable grounds for the performance enhancing effects, and the risks to the health of the athlete, of the methods and substances that might justify their inclusion on the Prohibited List.
Has the sanctity of life law ‘gone too far’?: analysis of the sanctity of life doctrine and English case law shows that the sanctity of life law has not ‘gone too far’
Abdul-Rasheed Rabiu and Kapil Sugand
The medical profession consistently strives to uphold patient empowerment, equality and safety. It is ironic that now, at a time where advances in technology and knowledge have given us an increased capacity to preserve and prolong life, we find ourselves increasingly asking questions about the value of the lives we are saving. A recent editorial by Professor Raanan Gillon questions the emphasis that English law places on the sanctity of life doctrine. In what was described by Reverend Nick Donnelly as a “manifesto for killing patients”, Professor Gillon argues that the sanctity of life law has gone too far because of its disregard for distributive justice and an incompetent person’s previously declared autonomy. This review begins by outlining the stance of the sanctity of life doctrine on decisions about administering, withholding and withdrawing life-prolonging treatment. Using this as a foundation for a rebuttal, a proposal is made that Professor Gillon’s assertions do not take the following into account:
1) A sanctity of life law does not exist since English Common Law infringes the sanctity doctrine by tolerating quality of life judgements and a doctor’s intention to hasten death when withdrawing life-prolonging treatment.
2) Even if a true sanctity of life law did exist:
a) The sanctity of life doctrine allows for resource considerations in the wider analysis of benefits and burdens.
b) The sanctity of life doctrine yields to a competent person’s autonomous decision.
This review attempts to demonstrate that at present, and with the legal precedent that restricts it, a sanctity of life law cannot go too far.
In the journal Social Studies of Science, Adam Hedgecoe has an article about the ethics of clinical research:
Focusing on the high-profile drug disaster at London’s Northwick Park Hospital in 2006, this article explores how such an event can be seen as an example of organizational deviance co-constructed between the company running the research and the research ethics committee which approved the trial. This deviance was the result of the normalization of a specific dosing practice in the broader regulatory field, allowing the researchers and regulators to take a risky dosing strategy for granted as best practice. Drawing on the work of Diane Vaughan, this article uses interview data with researchers and members of the research ethics committee concerned as well as documentary material, to show how work group cultures between regulators and those they are intended to oversee are maintained, and how the culturally embedded assumptions of such work groups can result in organizational and regulatory deviance.
In addition to these, while Cultural Anthropology did not have articles directly related to Somatosphere’s primary areas of interest, it did release its first Open Access issue in February, a noteworthy accomplishment! You should definitely go see Brad Weiss’s comments on the work it took to move to Open Access — and the work to come — as well as a bevy of interesting articles, if you haven’t already.
And, as always, happy reading!
From Health Behaviours to Health Practices: Critical Perspectives — A Special Issue of Sociology of Health & Illness by Aaron Seaman
The journal Sociology of Health & Illness has just published a special issue, entitled “From Health Behaviours to Health Practices: Critical Perspectives.” The articles and their abstracts are listed below:
The concept of health behaviour has become ubiquitous in health-related research and intervention studies, as well as among policymakers. Developed from psychology, it is based on a number of key underlying assumptions that enable it to be integrated in an existing health research paradigm. However, by conceiving individual health behaviour as discrete, stable, homogeneous and measurable, many other aspects of health-related activities, in particular those relating to power and sociality, are excluded. As a consequence, any genuine contribution from medical sociology or related disciplines is, at best, limited. To counter this, it is proposed that reconceptualising what people do in terms of health practices, rather than health behaviour, captures the emergent and contingent properties of people’s activities in particular situations. Rather than serving as a direct replacement term, and thus reproducing the same epistemological assumptions, it is argued that its very flexibility and capacity to articulate different theoretical orientations is likely to be its major strength.
Actors, patients and agency: A recent history
This article examines the history of patients’ behaviour since the middle of the 20th century. It describes a number of strategies that have served to encourage patients to exercise increasingly autonomous behaviour. The effect has been to instil a sense of agency in previously passive patients.
A socially situated approach to inform ways to improve health and wellbeing
Christine Horrocks and Sally Johnson
Mainstream health psychology supports neoliberal notions of health promotion in which self-management is central. The emphasis is on models that explain behaviour as individually driven and cognitively motivated, with health beliefs framed as the favoured mechanisms to target in order to bring about change to improve health. Utilising understandings exemplified in critical health psychology, we take a more socially situated approach, focusing on practicing health, the rhetoric of modernisation in UK health care and moves toward democratisation. While recognising that within these new ways of working there are opportunities for empowerment and user-led health care, there are other implications. How these changes link to simplistic cognitive behavioural ideologies of health promotion and rational decision-making is explored. Utilising two different empirical studies, this article highlights how self-management and expected compliance with governmental authority in relation to health practices position not only communities that experience multiple disadvantage but also more seemingly privileged social actors. The article presents a challenge to self-management and informed choice, in which the importance of navigational networks is evident. Because health care can become remote and inaccessible to certain sections of the community, yet pervasive and deterministic for others, we need multiple levels of analysis and different forms of action.
A relational approach to health practices: Towards transcending the agency-structure divide
Gerry Veenstra and Patrick John Burnett
Many health scholars find that Pierre Bourdieu’s theory of practice leaves too little room for individual agency. We contend that, by virtue of its relational, field-theoretic underpinnings, the idea of leaving room for agency in Bourdieu’s theory of practice is misguided. With agency manifested in interactions and social structures consisting of relations built upon relations, the stark distinction between agency and structure inherent to substantialist thinking is undermined, even dissolved, in a relational field-theoretic context. We also contend that, when treated as relationally bound phenomena, Bourdieu’s notions of habitus, doxa, capital and field illuminate creative, adaptive and future-looking practices. We conclude by discussing difficulties inherent to implementing a relational theory of practice in health promotion and public health.
Environmental justice and health practices: Understanding how health inequities arise at the local level
Katherine L. Frohlich and Thomas Abel
While empirical evidence continues to show that people living in low socio-economic status neighbourhoods are less likely to engage in health-enhancing behaviour, our understanding of why this is so remains less than clear. We suggest that two changes could take place to move from description to understanding in this field; (i) a move away from the established concept of individual health behaviour to a contextualised understanding of health practices; and (ii) a switch from focusing on health inequalities in outcomes to health inequities in conditions. We apply Pierre Bourdieu’s theory on capital interaction but find it insufficient with regard to the role of agency for structural change. We therefore introduce Amartya Sen’s capability approach as a useful link between capital interaction theory and action to reduce social inequities in health-related practices. Sen’s capability theory also elucidates the importance of discussing unequal chances in terms of inequity, rather than inequality, in order to underscore the moral nature of inequalities. We draw on the discussion in social geography on environmental injustice, which also underscores the moral nature of the spatial distribution of opportunities. The article ends by applying this approach to the ‘Interdisciplinary study of inequalities in smoking’ framework.
Why behavioural health promotion endures despite its failure to reduce health inequities
Fran Baum and Matthew Fisher
Increasing rates of chronic conditions have resulted in governments targeting health behaviour such as smoking, eating high-fat diets, or physical inactivity known to increase risk for these conditions. In the process, many have become preoccupied with disease prevention policies focused excessively and narrowly on behavioural health-promotion strategies. These aim to improve health status by persuading individuals to change their health behaviour. At the same time, health promotion policy often fails to incorporate an understanding of the social determinants of health, which recognises that health behaviour itself is greatly influenced by peoples’ environmental, socioeconomic and cultural settings, and that chronic diseases and health behaviour such as smoking are more prevalent among the socially or economically disadvantaged. We identify several reasons why behavioural forms of health promotion are inadequate for addressing social inequities in health and point to a dilemma that, despite these inadequacies and increasing evidence of the social determinants of health, behavioural approaches and policies have strong appeal to governments. In conclusion, the article promotes strategies addressing social determinants that are likely to reduce health inequities. The article also concludes that evidence alone will not result in health policies aimed at equity and that political values and will, and the pressure of civil society are also crucial.
Behaviour change and social blinkers? The role of sociology in trials of self-management behaviour in chronic conditions
Bie Nio Ong, Anne Rogers, Anne Kennedy, Peter Bower, Tom Sanders, Andrew Morden, Sudeh Cheraghi-Sohi, Jane C. Richardson, and Fiona Stevenson
Individual-focused self-management interventions are one response to both an ageing society and the purported increase in chronic conditions. They tend to draw on psychological theories in self-management interventions, but over-reliance on these theories can reinforce a narrow focus on specified attitudinal and behavioural processes, omitting aspects of living with a chronic condition. While advances have been made in health behaviour change theory and practice, scant attention has been paid to the social, with the question of social context remaining under-theorised and under-explored empirically. This is particularly noticeable in trials of behaviour change interventions for self-management. The common sociological critique is that these ignore context and thus no explanation can be given as to why, for whom and under what circumstances a treatment works. Conversely, sociologists are criticised for offering no positive suggestions as to how context can be taken into account and for over-emphasising context with the risk of inhibiting innovation. This article provides an overview of these issues and provides examples of how context can be incorporated into the rigid method of trials of self-management for chronic conditions. We discuss modifications to both trial interventions and design that make constructive use of the concept of context.
Thinking about changing mobility practices: How a social practice approach can help
Sarah Nettleton and Judith Green
Policy efforts directed at encouraging physical activity have had minimal success to date. Drawing on Bourdieu’s theory of practice, we suggest that a social practice framing might provide useful ways of thinking about why and how some practices do and could change. This article takes three case studies of transformations in mobility practices to explore conditions of possibility for change, using a secondary analysis of qualitative data from studies on cycling in London and fell running in the English Lake District. Three modes of transformation: unthinkable, thwarted and resisted, are rooted in differential interrelationships of field, habitus and doxa in these contrasting cases. We suggest that the notion of tacit, practical knowledge is more useful to understanding why change is thinkable or unthinkable than participants’ reasoned accounts of their practice; that where new social fields are available that are congruent with habitus, change is possible and that where field and habitus are tightly aligned, the conditions of possibility for change are reduced. Efforts directed at changing practice might usefully focus not on behaviour or environments but on identifying the social fields in which mobility practices are likely to be malleable. The sociology of public health needs to focus less on health behaviour and more on social practice.
Providers’ constructions of pregnant and early parenting women who use substances
Cecilia Benoit, Camille Stengel, Lenora Marcellus, Helga Hallgrimsdottir, John Anderson, Karen MacKinnon, Rachel Phillips, Pilar Zazueta, and Sinead Charbonneau
The research literature indicates that problematic substance use as a form of health behaviour is poorly understood, being sometimes viewed as deviance, at other times as a disease, and most often as a combination of these states. The use of substances by women who are pregnant or new parents is often conceptualised within an individualised framework. Yet drinking alcohol and using other drugs during pregnancy and early parenthood cuts across social divisions and is shaped by socio-structural contexts including health care. There is a growing body of literature that critically examines public health interventions that are aimed at implementing harm reduction and health promotion techniques in service delivery to help pregnant and early parenting women who are identified as problem substance users. We examine qualitative data from representatives of a recent harm reduction intervention, focusing, in particular, on providers’ individual conceptualisations of the problematic behaviour. Our results show that most study participants regard any substance use during pregnancy, birth and the postpartum period as fundamentally unacceptable. This framing of problematic substance use is accomplished via gendered responsibilisation of women as foetal incubators and primary caregivers of infants. We discuss our results in light of the current literature and suggest policy implications.
Staying ‘in the zone’ but not passing the ‘point of no return’: Embodiment, gender and drinking in mid-life
Antonia C. Lyons, Carol Emslie, and Kate Hunt
Public health approaches have frequently conceptualised alcohol consumption as an individual behaviour resulting from rational choice. We argue that drinking alcohol needs to be understood as an embodied social practice embedded in gendered social relationships and environments. We draw on data from 14 focus groups with pre-existing groups of friends and work colleagues in which men and women in mid-life discussed their drinking behaviour. Analysis demonstrated that drinking alcohol marked a transitory time and space that altered both women’s and men’s subjective embodied experience of everyday gendered roles and responsibilities. The participants positioned themselves as experienced drinkers who, through accumulated knowledge of their own physical bodies, could achieve enjoyable bodily sensations by reaching a desired level of intoxication (being in the zone). These mid-life adults, particularly women, discussed knowing when they were approaching their limit and needed to stop drinking. Experiential and gendered embodied knowledge was more important in regulating consumption than health promotion advice. These findings foreground the relational and gendered nature of drinking and reinforce the need to critically interrogate the concept of alcohol consumption as a simple health behaviour. Broader theorising around notions of gendered embodiment may be helpful for more sophisticated conceptualisations of health practices.
Current international attention to reproductive health behaviour is inspired by a western celebration of individual rights, autonomous action and rational choice. A predominant idea is that individuals should be free to act in accordance with their reproductive intentions and that, in doing so, they will attain their desired (and quantifiable) fertility outcomes. Yet such a framework leads to a misrepresentation of the reproductive dynamics on the ground, because individual fertility intentions are often not a priori defined, decisions are often not the result of rational calculation and reproductive happenings do not exist in a social vacuum. This article provides sociocultural evidence for a different conceptualisation of reproductive health behaviour. On the basis of long-term anthropological fieldwork in the East Province of Cameroon, I will analyse the complexities of fertility-related decision-making. Two case studies from the field will show that reproductive happenings are often characterised by indeterminacy and contingency. In order to understand the complex ways in which women give direction to these uncertainties, I propose an encompassing framework of reproductive navigation that explicitly acknowledges the influence of sociality and corporeality on fertility aspirations and actions.
Sustained multiplicity in everyday cholesterol reduction: Repertoires and practices in talk about ‘healthy living’
Catherine M. Will and Kate Weiner
This article is concerned with talk about and the practices of healthy living in relation to cholesterol reduction. It draws on qualitative interviews with 89 people who are current or former users of either cholesterol-lowering functional foods or statins for cardiovascular risk reduction. Focusing on data about everyday activities including food preparation, shopping and exercise, we illustrate four repertoires that feature in talk about cholesterol reduction (health, pleasure, sociality and pragmatism). Using Gilbert and Mulkay’s notion of a ‘reconciliation device’, we suggest ways in which apparently contradictory repertoires are combined (for example, through talk about moderation) or kept apart. We suggest that, in contrast to the interactiveness of the repertoires of health and pleasure, a pragmatic repertoire concerning food provisioning, storage and cooking as well as the realities of exercise, appears distinct from talk about health and is relatively inert. Finally we consider the implications of these discursive patterns for daily practices. Our data suggest there is little emphasis on coherence in people’s practices and illustrate the significance of temporal, spatial and social distribution in allowing people to pursue different priorities in their everyday lives. Rather than the calculated trade-offs of earlier medical sociology we draw on Mol to foreground the possibility of sustained multiplicity in daily practices.
Enjoy your food: On losing weight and taking pleasure
Else Vogel and Annemarie Mol
Does healthy eating require people to control themselves and abstain from pleasure? This idea is dominant, but in our studies of dieting in The Netherlands we encountered professionals who work in other ways. They encourage their clients to enjoy their food, as only such joy provides satisfaction and the sense that one has eaten enough. Enjoying one’s food is not easy. It depends on being sensitive. This does not come naturally but needs training. And while one kind of hunger may be difficult to distinguish from another, feeling pleasure may open the doors to feeling pain. What is more, sensitivity is not enough: enjoying one’s food also depends on the food being enjoyable. A lot of care is required for that. But while engaging in such care is hard work, along the way clients are encouraged to no longer ask ‘Am I being good?’ but to wonder instead ‘Is this good for me?’ Both these questions are normative and focus on the person rather than on her socio-material context. However, in the situations related here the difference is worth making. For it entails a shift from externally controlling your behaviour to self-caringly enjoying your food.
The current issue of Health, Risk & Society is a special issue, entitled “Risk, Pregnancy and Childbirth.” Along with an introduction by Barbara Katz Rothman, the issue contains seven articles organized around four thematic areas. The abstracts are listed below.
Pregnancy, birth and risk: An introduction
Barbara Katz Rothman
In this introduction, I use my nearly 40 years of work in the area to reflect on the total medicalisation of pregnancy and childbirth that informs even the critical sociology that purports to examine the issue. The risks that are faced in pregnancy and birth are not only the inherent dangers that midwives have worked with across time and space but also those particular risks introduced by medicalisation itself. Medicalisation blinds us to those risks on the one hand, while it blinds us to the skills and knowledge that midwives and birthing women themselves have on the other. The women and midwives researched in these articles show us that in pregnancy and birth, as in most of life, it is not just a matter of ‘real risk’ versus ‘perceived risk’ as risk theorists (too) often describe it. There is rather an intelligent balancing of risks, weighing of risks and contextualising of risks. What we see in this issue is a glimpse into the ways in which people intelligently, creatively and determinedly balance risks.
The Emergence of Risk Discourses in Pregnancy and Childbirth: Medicalisation, Feminism and Eugenics
‘Knowledge is power’: Risk and the moral responsibilities of the expectant mother at the turn of the twentieth century
Helga Kristin Hallgrimsdottir and Bryan Eric Benner
The notion that ‘older’ mothers experience elevated risks during pregnancy and childbirth has proliferated since the mid-twentieth century. In this article, we take the contemporary concern with age as a starting point from which to historicise and contextualise the concept of maternity risk. To this end, we examine maternal hygiene manuals (self-help guidebooks on motherhood and pregnancy) published between 1880 and 1920 in Canada, the United States and the United Kingdom. Our analysis of these manuals indicated that pregnancy during this period was presented as a potentially dangerous affair that required constant surveillance by the self (and others) to ensure favourable pregnancy outcomes. A dominant theme that emerged from the manuals was that the expectant mother was morally responsible for mitigating a range of risk factors, including adequate exercise, sleep, fresh air, as well as for choosing an appropriate father and ensuring his health. At the same time, the manuals indicated that the failure to seek out expert advice and take up responsible practices was linked to adverse consequences for the expectant mother’s health, and her newborn’s health and moral character later in life. We conclude this article by discussing how findings from our historical data can provide an important context for understanding risk discourses around pregnancy as historically specific and culturally contingent, especially with respect to risks associated with maternal advanced age.
Risky Pregnancy Behaviour: Policing Women
‘I don’t think it’s risky, but…’: Pregnant women’s risk perceptions of maternal drinking and smoking
Raphaël Hammer and Sophie Inglin
In Switzerland, official recommendations relating to alcohol and tobacco use during pregnancy are based on a zero-tolerance policy. However, epidemiological research indicates that some pregnant women do not adhere to the abstinence principle, and this raises the issue of how pregnant women identify and respond to health risks. This article draws on a sociocultural study of 50 mainly white, partnered and educated pregnant women carried out in Switzerland between May 2008 and June 2009. The study used semi-structured interviews that examined how and in what ways pregnancy had changed women’s consumption of alcohol and tobacco and their perceptions of their riskiness. In this article we draw on these data to examine participants’ perceptions of the risks of smoking and drinking during pregnancy. We examine three main issues: women’s understandings of official recommendations, their contextualisation of risk in daily life and the moral issues which they saw surrounding smoking and drinking during pregnancy. We found that the women in our study perceived drinking and smoking during pregnancy as different types of risks with different meanings. The participants contextualised official recommendations about drinking during pregnancy and had their own views about its riskiness. In contrast all participants saw smoking as harmful and risky irrespective of the level of consumption. The pregnant women in our study saw smoking during pregnancy as a risk-taking behaviour and a failure to act in the best interest of the foetus. In contrast, under certain conditions, they saw moderate drinking of alcohol during pregnancy as acceptable and responsible behaviour.
The risk of being ‘too honest’: Drug use, stigma and pregnancy
In this article, I examine the ways in which risk is constructed and managed by those involved in the pregnancy and childbirth of women who use drugs, including the women themselves. I discuss how constructions of risk influence maternal care outcomes and the understanding of choice, often in the form of stigmatisation. In this article, I draw on data from a qualitative research study that I conducted in 2011 in a western Canada city in which I interviewed 13 pregnant and parenting women who had used drugs during their pregnancy. In this article, I show how the everyday risk construction of pregnancy, labour and delivery is compounded significantly by drug use and the stigmatisation associated with this perceived risk-taking behaviour. The participants in the study often internalised this understanding of risk and this manifested itself in delays in accessing maternal health and social care services. The women in the study had different understandings of risk and these were structured by the women’s own understanding of general risk factors during their pregnancy, as well as their experiences of the constructions of risk and risk management by health and social care professionals. While structural life chances can constrain women’s feelings of self-efficacy, services that promote clients’ ability to make choices can facilitate reduced stigmatisation and facilitate the development of more compassionate and autonomous approaches to risk management.
Birth and Risk Management: Managing the Risks of the Birthplace
To what extent are women free to choose where to give birth? How discourses of risk, blame and responsibility influence birth place decisions
Kirstie Coxon, Jane Sandall, and Naomi J. Fulop
Over the past 50 years, two things have changed for women giving birth in high-income nations; birth has become much safer, and now takes place in hospital rather than at home. The extent to which these phenomena are related is a source of ongoing debate, but concern about high intervention rates in hospitals, and financial pressures on health care systems, have led governments, clinicians and groups representing women to support a return to birth in ‘alternative’ settings such as midwife-led birth centres or at home, particularly for well women with healthy pregnancies. Despite this, most women still plan to give birth in high-technology hospital labour wards. In this article, we draw on a longitudinal narrative study of pregnant women at three maternity services in England between October 2009 and November 2010. Our findings indicate that for many women, hospital birth with access to medical care remained the default option. When women planned hospital birth, they often conceptualised birth as medically risky, and did not raise concerns about overuse of birth interventions; instead, these were considered an essential form of rescue from the uncertainties of birth. Those who planned birth in alternative settings also emphasised their intention, and obligation, to seek medical care if necessary. Using sociocultural theories of risk to focus our analysis, we argue that planning place of birth is mediated by cultural and historical associations between birth and safety, and further influenced by prominent contemporary narratives of risk, blame and the responsibility. We conclude that even with high-level support for ‘alternative’ settings for birth, these discourses constrain women’s decisions, and effectively limit opportunities for planning birth in settings other than hospital labour wards. Our contention is that a combination of cultural and social factors helps explain the continued high uptake of hospital obstetric unit birth, and that for this to change, birth in alternative settings would need to be positioned as a culturally normative and acceptable practice.
Negotiating risky bodies: Childbirth and constructions of risk
Rachelle Joy Chadwick and Don Foster
Policy makers, practitioners and researchers have identified risk as a key concept in relation to maternity care and childbirth. There is however a lack of research exploring women’s discursive constructions of risk and childbirth in relation to sociological risk theories. In this article we explore pregnant women’s everyday negotiations of risk in relation to the self-chosen plan to birth either at home or via an elective Caesarean section. We use sociocultural risk theories to contextualise our findings. This article draws on data from a study conducted in 2005–2006 in which we interviewed 24 pregnant middle-class South African women who were planning a home birth or elective Caesarean section and used social constructionist discourse analysis to analyse the data. We found that women’s risk constructions were related to three different conceptions of birthing embodiment: technocratic bodies, vulnerable bodies and knowing bodies. Women who planned Caesarean sections were committed to biomedical constructions of risk and birth. Woman who planned home births shifted between endorsing and subverting biomedical models of risk. They also resisted definitions of birthing bodies as inherently abject (unclean, polluting, unruly) and constructed the process of giving birth as risky in medicalised settings. In such settings, the birthing body was constructed as vulnerable to objectification, loss of dignity and shaming. Women who planned to give birth at home constructed an alternative approach to birth which emphasised embodied ways of knowing, relational connection and empowerment over normative and medicalised risk constructions. In the process, biomedical risk definitions were destabilised.
Managing the Risks of Medicalisation
Time, risk and midwife practice: The vaginal examination
Mandie Scamell and Mary Stewart
In this article, we examine the impact on midwifery practice of clinical governance in the UK with its shift from individual autonomous practice based on personal experience and intuition (embodied knowledge) to the collective control of work based on guidelines and protocols (encoded knowledge) associated with the scientific–bureaucratic approach to care. We focus on the ways in which midwives use partograms and associated vaginal examinations to monitor and manage the progress of labour. The partogram represents (among other things) a timetable for dilation of the cervix during labour. Women who fail to keep up with this timetable are shifted from a low-to-high risk category and subjected to additional surveillance and intervention. In this article, we draw on empirical evidence taken from two independent ethnographic studies of midwifery talk and practice in England undertaken in 2005–2007 and 2008–2010, to describe the ways in which midwives practice of vaginal examinations during labour both complies with, while at the same time creatively subverts, the scientific–bureaucratic approach to maternity care. We argue that although divergent in nature, each way of practicing is mutually dependent upon the other: the space afforded by midwifery creativity not only co-exists with the scientific–bureaucratic approach to care, but also sustains it.
Pregnancy, risk perception and use of complementary and alternative medicine
Mary Mitchell and Stuart McClean
Pregnancy and childbirth are events of major significance in women’s lives. In western countries women are increasingly using complementary and alternative medicine during this time. However, there is little research exploring the factors that are influential in women’s motivations to use complementary and alternative medicine during pregnancy and childbirth. This article draws on data from a narrative-based study designed to explore women’s experiences of complementary and alternative medicine use during pregnancy and childbirth. The study involved 14 women living in the South-west of England, who had used complementary and alternative medicine during pregnancy and childbirth. We elicited narratives by interviewing women two to three times. The women in our study used complementary and alternative medicine both as a response to the uncertainty of pregnancy and childbirth and as a defence against manufactured risk, and in doing so indicated their desire to transform an unpredictable and unmanageable future into one which is more predictable and manageable. It was a means of dealing with the stress and anxiety associated with uncertainty which has to be dealt with. Their consciousness of the risks of biomedicine developed though the practice of complementary and alternative medicine, and their high educational status and relative affluence facilitated their choices. There was a tension evident in their narratives between a need to ‘be in control’ versus a desire for a natural childbirth without medical intervention. Women in the study showed their autonomy by actively pursuing complementary and alternative medicine while at the same time selectively using expert medical knowledge.
This week Martyn Pickersgill of the University of Edinburgh speaks to “Top of the heap” about some recent books on humanitarianism, pharmaceuticals, dementia and expertise.
Amongst other bits and pieces, I currently have two large projects on the go: one, on access to therapy in mental health, and the other, on neuroscience and family life. With regards to the former, I’m thinking a lot about what each of those key terms (‘access’, ‘therapy’, and ‘mental health’) actually mean in practice, and who are the people imagined to require therapy and why. The scholarship of the wonderful Didier Fassin has been central to my work in this area, and I’m finding myself returning again and again to Humanitarian Reason: A Moral History of the Present (UC Press, 2011) – not least because of Fassin’s attention to how ‘needs’ and ‘the needy’ are constituted through a range of affective, epistemic and bureaucratic tools. It’s a beautiful example of a how a carefully descriptive text can also be analytically insightful and carry normative weight.
Relating to access, one of my collaborators, Emilie Cloatre, has a new book out: Pills for the Poorest: An Exploration of TRIPS and Access to Medication in Sub-Saharan Africa (Palgrave, 2013). In it, Emilie interweaves insights from socio-legal studies and STS, exploring the ways in which these traditions might speak to each other (and the limits to this), especially regarding her case studies: the circulation of pharmaceuticals around Djibouti and Ghana. For me, this is really helpful for thinking about the governance of other kinds of care, much closer to home (especially in terms of the social lives of therapeutics, and role of law in shaping these). Pills for the Poorest has just been shortlisted for the 2014 Hart Socio-Legal Book Prize so get your copies whilst Amazon still has them in stock!
As for books that quite literally are at the ‘top of the pile’, I’ve just bought Margaret Lock’s The Alzheimer Conundrum: Entanglements of Dementia and Ageing (Princeton UP, 2013). This should be directly relevant to my ongoing work on neuroscience, and a new project on epigenetics, but I would have bought it anyway: Lock gave the Monroe Lecture at Edinburgh back in 2011, and whetted my appetite for the full text even then. I’m looking forward to having a chance to sit down and really read it properly. There’ve been some great monographs and edited collections out recently around the brain sciences and this will surely be a major contribution to those.
Finally, I’m planning on getting a bit more into the political science literature. I’m part of a new group at Edinburgh – the Centre for Science, Knowledge and Policy (SKAPE), aimed at bringing STS and politics into closer alignment – and I recently bought one of my Centre colleague’s books – Christina Boswell’s The Political Uses of Expert Knowledge: Immigration Policy and Social Research (Cambridge UP, 2009). Christina’s work explores in detail the ways in which expertise is leveraged to facilitate and legitimate political action – themes which have considerable relevance for the research I’m doing around access to care, but also in respect to my interests in the ‘use’ of neurobiological knowledge in a range of contexts.
Martyn Pickersgill is an STS scholar at the University of Edinburgh. He currently holds awards from the Wellcome Trust, Leverhulme Trust and AHRC concerned with the social and legal dimensions of biomedicine and the health professions. Martyn sits on the Editorial Board of Sociology of Health & Illness, is Book Reviews Editor for New Genetics and Society, and is co-editor of Sociological Reflections on the Neurosciences.
Image: Beverly Fishman, “Pill Spill,” Toledo Museum of Art, Glass Pavilion, Blown glass, 2011
In February 2011, Paul Rabinow, Gaymon Bennett and I began to reflect on the impasses we had experienced in our collaborative work with groups of bioscientists and other social scientists, which had begun in 2006 (Rabinow and Bennett 2012). The core concerns in our interconnected projects in collaboration were how ethical practice and human and bioscientific knowledge practices could best be brought into an integral and mutually enriching relationship. After five years of work, a series of turning points produced both the need to reflect on blockages in the field, but also to shift position and practice: we needed to leave the field.
Our book Demands of the Day: On the Logic of Anthropological Inquiry (Rabinow and Stavrianakis 2013) conceptualizes and narrates “leaving the field” and opens up a series of problems for anthropological practice which, to our surprise, had received insufficient attention, among them: (1) the objects of knowledge produced by participant-observation, (2) the subject positions of the former participant-observer(s), once they have left the field (3) the affective dynamics of the field and the exit from it, which must be carried out reflectively, and (4) the narrative modality given to this process.
Anthropologists Todd Meyers and Kevin Karpiak have responded to Demands of the Day with two engaging discussions which we hope will open up and further discussion of contemporary anthropological practice, forms of participant-observation and the price to be paid for different forms of engagement. You can find their texts here:
Todd Meyers, “Other voices, other rooms.”
Anthony Stavrianakis is currently a Fernand Braudel postdoctoral fellow at the Maison des Sciences de l’Homme.
Over the next few weeks, we will be putting into place a new editorial arrangement at Somatosphere, as part of which our longtime Book Reviews Editor, Todd Meyers, will be taking on the role of Associate Editor for the site. Book reviews have been a central part of Somatosphere for the past five years – mainly thanks to the phenomenal job that Todd has done.
I’m very pleased to announce that Seth Messinger will be assuming the role of Book Reviews Editor. Seth is an Associate Professor in the Department of Sociology and Anthropology at the University of Maryland, Baltimore County and a researcher with the Center for Rehabilitation Sciences Research at the Uniformed Services University of Health Sciences. He received his PhD in anthropology from Columbia University in 2003, and from 2002 – 2004 held an NIMH funded postdoctoral fellowship at the Institute for Health, Health Care Policy and Aging Research at Rutgers University. His research interests include the anthropology of biomedicine and psychiatry, trauma, memory, and history. Back in 2011 he wrote a piece for the site about his research at Walter Reed Army Medical Center.
Welcome Seth! And if you are a book author, publisher or publicist interested in suggesting a book to be reviewed on the site, or if you are interested in reviewing a book, please feel free to contact Seth Messinger directly at sethm AT umbc DOT edu
One almost feels sorry for the human these days. After a heady flight toward near divinity, the figure has tumbled, Icarus-like, down from the intellectual firmament to a posthuman sea of forms, forces and flows large and small. Even anthropology (the very citadel of anthropos!) is now awash with multispecies mashups, circulating microbes and wandering genes, not to mention zombie attacks and planetary talk of global warming. Foucault’s modest erasure on the beach in The Order of Things seems positively quaint by comparison. Alternately reduced to a vessel for other entities or stretched into an anthropocene, the human has been on one wild relational ride.
Of course, there are other stories. Having spent recent years following humanitarians — people for whom the human remains a live and morally charged concept — I cannot escape a degree of bemusement about recent talk of the human’s deflation to a microbial host, or expansion to a geological epoch. My bemusement is not due to any loss of reverence for humanity, or the thinness of claiming it in practice; the aid world offers scathing testimony on that account. Rather, it is a more humble sense of the term I wonder about, the casual assumption of practical commensurability during encounters, of common accord of shared capacity and standing, if not specific values or agreement. Or put another way: how did species recognition become such a commonplace in the first place?
Historically, after all, not all languages named such an inclusive grouping, preferring to differentiate between categories of selves and others. Part of the early struggle of anthropology lay precisely over questions of common standing, the degree to which former primitives, heathens and barbarians might join a common circle with those seen as civilized. This thin equality rarely counts for much, absent the courtesies of host relations or the provisions of state citizenship. But it does play an active role in moral imagination, where questions of inclusion and exclusion loom large. Tensions over these questions occasionally bubble to the surface, in modest as well as dramatic ways.
Indulge me in an anecdote. About a decade ago I was interviewing an aid worker on the porch of his residence in Kampala. We had almost finished when a representative of the electrical utility and his assistants showed up to fix the power line running to the house. Wearing blue overalls and equipped only with large rubber gloves, they slowly went to work. Given the lack of equipment the performance inspired more anxiety than confidence, particularly as they did not disconnect anything beforehand. After watching a few half-hearted attempts to reestablish his connection, the aid worker lost patience, telling the technician and his men to leave and return when they were able to do a proper job. The technician, however, seemed reluctant to go. He launched into a lengthy explanation about why things were at an impasse, a complicated story involving not only an absence of material parts but also the neighbor who drew power from the same line. In the background, I began to gather, lay some larger dispute about responsibility and ultimately payment. The aid worker stood firm: it was no use, and they should leave. This negotiation all took place in English, a language not native to either party, and both resorted to a good deal of exaggerated gesticulation. Finally the technician drew himself up and tried a new appeal. “You’re a human being,” the man said. “I’m a human being. As we are human beings it’s a physical matter. I’m trying to explain to you in a humanitarian way.” My host hardly missed a beat. “I am a humanitarian worker!” he cried, proceeding to list a set of countries that he had visited in his professional capacity. Then he repeated that they should see the neighbor, whom he implied would pay them cash. The exchange continued, but some of its tension appeared to have ebbed. In the end the two shook hands, and the electrician left to try his luck next door. Two hands, one shake: a human connection asserted and acknowledged even amid disagreement.
I was startled enough by this odd encounter to record it in my notebook, but never quite knew what to make of it afterward. The overtones of colonial and class distinction remained muted, the conclusion inconclusive. It appeared a non-event, really, distinguished only by the inflated appeals that appeared midway through an otherwise banal encounter. I recall this non-event now, however, in relation to the human as a commonplace. Its very oddity underscores how rarely people announce themselves as humans, or seek to establish standing so baldly on that basis. Doing so takes seriously the possibility that such recognition might not be given, or part of the realm of comfortable assumption.
Moments that openly violate species recognition, of course, stand as a stark exception, providing the most memorable ground for claiming humanity, as well as defining crimes against it. As numerous astute commentators have noted, the human takes sharpest form in moments of such violation. In classes I sometimes show a clip from an old PBS Frontline documentary about the Rwandan genocide, The Triumph of Evil (1999). It shows a chilling moment of selection in the early days of terror, when soldiers from powerful states arrive to evacuate their citizens, and their citizens alone. Embassy pets make the cut; Rwandan staff do not.
The contrast between the dog saved and the human sacrificed reveals not only the full depth of political inequality, but also that liminal zone where inhumanity defines the less than human. In the face of an actual event, appeals to common humanity do little to stem a tide of political violence. As Hannah Arendt noted long ago in The Origins of Totalitarianism, the “abstract nakedness” of being human rarely proves sacred or inviolable in practice. The overall shallowness of such claims, however, should not obscure the finer gradations observed in practice, the categories of humans who do not count, and nonhumans who sometimes do. When push comes to shove, even those recognizing common standing might give preference to a familiar animal over a human with the wrong appearance, lineage or passport.
Students tend to find the scene discomforting. It disturbs the larger moral drama of genocide with an additional thread of connection and disconnection, that airlift that extends citizenship beyond humanity. It widens the chasm of potential guilt and bad feeling in an unexpected direction. No one, however, blames the dog.
The last point is not entirely facetious; earlier in European history some animals stood trial for perceived crimes. The question of human recognition or non-recognition implies a different degree of culpability than murder, let alone political manipulation and wanton mass slaughter. But all these moments of evaluation and definition suggest moral agency, and with it a capacity to be accused or held accountable before normative judgment. In this sense the “posthuman” world still seems relatively firm about one species boundary, one preserve, perhaps, for a power of reason. When it comes to guilt, blame and the potential for inhumanity, we (the we who spend our time reading and writing academic blogs at least) rarely denounce microbes, rocks or dogs. In such cases the human may still claim a place of pride.
Peter Redfield teaches anthropology at the University of North Carolina at Chapel Hill. The author of Life in Crisis: The Ethical Journey of Doctors Without Borders (California 2013), he is currently exploring the wilds of humanitarian design.
The so-called moral economy of the poor has been defined as the coming together of “a consistent traditional view of the social norms and obligations, of the proper economic functions of several parties within the community” (Thompson 1971: 79).
This particular angle on the construct of the moral economy, deriving primarily from historical, sociological, and anthropological research among “pre-industrialized” and “non-industrialized” societies, has in recent years been used to elucidate the complex systems of reciprocity that operate as a key to daily survival for many impoverished, homeless and housing-insecure folks who also happen to heavily use or be addicted to drugs. Drawing on this take on the moral economy, Bourgois and Schonberg’s photo-ethnography, Righteous Dopefiend, poignantly and explicitly illustrated the problematic intersection of mutual obligation, rational generosity, and generalized reciprocity with a neoliberal harm reduction ethos (which promotes “empowerment,” autonomy, and individual responsibility) and injection-related risk practices. For example, as they demonstrate, “the best protection from withdrawal symptoms is to maintain a generous reputation, because everyone is eager to help someone who will reciprocate in the future” (Bourgois and Schonberg 2009: 83). That is, an individual’s engagement in high-risk practices such as needle sharing ought not be framed as irrational, but as driven by a pragmatic drive to participate in an established moral economy, one that will secure survival or even well-being down the line. Such networks are akin to Fafchamps’ solidarity networks, arising in a context of scarcity and making it survivable through systems of shared expectation and trust (1992). This particular application of the moral economy has been influential in re-evaluating the unintended harms that may result from interventions as well-intentioned as syringe exchanges and other public health outreach and education programs. And, it has provided a powerful lens through which to view and make sense of the multiple ways diverse and multi-level risk environments (Rhodes 2002) may render those who use drugs structurally vulnerable (Quesada, et al. 2011).
This perspective on the moral economy is the one to which I originally turned when seeking to understand “getting by” and everyday life among active methamphetamine users in Northern Colorado. But, as always seems to be the case with anthropological data, there are pieces that don’t quite fit the assumption of rationality as it stands. I want to use this post as an opportunity to consider an extension of the moral economy from one that privileges the physical and material to one that is inclusive of the emotional as part of what is considered rational in the navigation of the everyday.
* * *
I first met Dorothy* in 2011, while conducting ethnographic interviews with women who use methamphetamine. I was at the local harm reduction organization, and she was in to get a routine HIV test and pick up supplies (condoms, food, etc.). Seeing my flyer, she wanted more information and, possibly, to set up an appointment for an interview. Dorothy was the fourth person I met in the course of conducting my dissertation research and today, three years later, she remains one of my closest and most “reliable” research participants. When she came in for that first interview, only a day or two after we first met, Dorothy was dressed as if for church, wearing jewelry and make-up (the only time I’ve ever seen her in the latter). Before I could even begin the consent process, she began telling me about her work with the homeless, how, on a regular basis, she uses her food stamps to buy groceries which she then preps and brings to a group of about twenty (mostly) men who spend their days drinking in a central city park. When I asked her, What got you interested in (it), why is that your passion right now? Dorothy responded with no hesitation:
Umm, because I lost my kids and my home and somebody I thought I was in love with in 24 hours . . . and I was homeless for 12 years . . . I got a place now.
Although she was only recently off the streets herself and depended upon a variety of government subsidies and whatever cash she could hustle up cleaning houses or selling burritos to local businesses at lunchtime to make ends meet, I learned over the years that Dorothy routinely spent her food stamps on other people. Sometimes this was her on-again off-again boyfriend, sometimes it was for buddies passing through town, but most often it was on food that she prepared and served to this group of chronically homeless men who would likely never be able to reciprocate. If we look at this as Dorothy does, though, she has two motivations. The first is the one evidenced by her quote, above: She is “giving back.” This action fits very neatly with a central component of her identity; she is a caretaker at heart. It is not just something she does, it is who she is.
In this sense, Dorothy’s generosity can be viewed as fitting into an established societal system of generalized reciprocity, one that conceptualizes ethics as something internalized, as a manifestation of “discipline” in the Foucauldian sense (Fassin 2012). To give back is something ethical, something good, and as such, something she wanted me (and others in her network) to know about. This perspective abates the assumption of the rational actor, but arguably reduces the individual to her subjectivity, something formed, in this instance, without her knowing. It also continues to privilege the practicality and tangibility of the action, positing that Dorothy benefits from disciplining herself, from “fitting in,” rather than acknowledging that Dorothy also benefits emotionally: she derives pleasure from the act of giving itself. And that is the second motivation that is clear in talking with Dorothy. Giving back is not just who she is. It is what makes her happy.
And the thing is, she’s not the only one.
I finished my dissertation research in 2012 and immediately moved on to a study of methamphetamine acquisition and survival strategies. This means I have now been working in a research capacity with active meth users in Northern Colorado for three years and Dorothy’s story, her generosity in the face of scarcity, is far from novel, though for her, giving may be a more deeply significant aspect of her identity than for others. Participants in my research can often be found cooking meals for those who are less fortunate and offering to share what little they have, often to their own detriment.
Meghan is another example. She and I were sitting on the lawn outside the library, playing with her grandson, when she looked at me sadly. I relapsed, she said. A few weeks ago. I had a whole year and I blew it. I haven’t used again, but it’s so hard. When I first met Meghan, she was approaching a year of post-treatment sobriety. She had acquired housing, was volunteering, and attending AA and NA meetings several times each week. Despite insisting that she prioritized her own sobriety, she remained embedded in the relationships that had dominated her days as a homeless methamphetamine user. She routinely offered a helping hand to members of her former drug using and survival network, many of whom were homeless, most of whom still used, and some of whom continued to offered her meth even though she turned them down and asked them to stop. Meghan knew these continued relationships were potentially harmful to her sobriety, but she repeatedly told me with pride how the “kids” still referred to her as “mama.” Not long after she told me about her relapse, two teens approached us, Hey, mama and updated her on their latest struggles, their latest drama. She offered comforting words, a hug, some advice, and when they left, she turned to me and smiled. The risk was worth it.
And while the concept of emotion has perhaps been gendered, such that the privileging of the physical over the emotional has been credited to a persistent patriarchal hierarchy, men are not removed from these struggles. I saw Charles at least once a month for five or six months. Like Meghan, he was struggling to quit using meth. He was living on the streets, couch-surfing occasionally, generally avoiding the shelters. His girlfriend had recently gone to jail when we first met and our interviews and meetings were regularly interrupted by very brief phone calls from jail. Though Charles had a very meager monthly income, most days he put whatever money he earned on his girlfriend’s books. This kept him from getting a room and, perhaps, excluded him from participating in the broader solidarity networks. According to Fafchamps’ interpretation, this action could almost be seen as a means of accumulating wealth, something that is generally frowned upon in these moral economies of the poor (1992). From Charles’ perspective, he was taking care of Deb. He knew she might leave him immediately upon her release, and he recognized that she might just be spending the money he was putting on her books, not planning for their future. But he was adamant that his role was to take care of her, and his compassion was key to his choice. Like Dorothy and Meghan, when Charles told me of his acts of giving, he lit up, not just with pride, but with joy.
I am by no means the first person to argue that the emotions of drug users can be of importance (see, for example (Simmons and Singer 2006)), but I assert that the recognition of emotion as playing a role in rational decision making is underdeveloped. In focusing our conversations around the concrete, tangible, physical aspects of survival, we once again privilege a particular conceptualization of “the rational,” one that positions it in opposition to the emotional, which becomes, thus, irrational. My early analysis of this ongoing research suggests, however, that, for many, the emotional gains associated with generosity may be just as important as the practical ones, in some cases more so, and as such, the choosing of emotional benefit, of subjective well-being need not be framed in terms of economics or even support. Even where discipline may be at play, this needn’t undermine or overshadow the significance of the emotion itself. If the internalization of social norms as a means of promoting or enforcing self-control were the only explanation for the prideful adoption of a caretaker or provider role, all would derive considerable, sacrifice-worthy joy from it, or all would feel martyred.
This attention to emotion is not an attempt to discount the rational as we have previously conceptualized it, or to gloss over the significance of the pragmatics of physical and material elements of survival. Rather, it is an attempt to begin the process of considering an integration of the emotional in relation to rational decision making, to highlight the importance of attending to emotion, even in the context of ration, even in the context of the political and the economic.
After all, there is something decidedly humane in an effort not to rationalize how someone is feeling, but to recognize that perhaps that feeling itself is sufficient drive to act. By attempting to situate our understanding and explanations of behavior in a context that frames only the physical or material as rational, are we in fact simply reflecting and as such perpetuating the construction of the “selfish addict”? Perhaps more troubling, I wonder if by excluding the role of emotion from discourse on the rational we risk obfuscating the humanity of it all, forgetting that suffering, too, can be/often is emotional, and perhaps the most rational choice in all of this is to choose a moment of joy, even at the expense of survival.
Stacey A. McKenna is a Research Assistant Professor in the Department of Health & Behavioral Sciences at the University of Colorado Denver and an Instructor of Anthropology at Metropolitan State University of Denver. She holds a PhD in Health & Behavioral Sciences and an MA in Medical Anthropology. Her research interests include the construction of social problems; ethnography of drug use; the role of personal networks in survival, addiction and recovery; gendered constructions of risk; and the anthropology of human-animal interactions/relationships. She is currently a co-investigator on a NIDA-funded ethnographic study of the drug acquisition and survival strategies of active methamphetamine users in Northern Colorado.
*All names used in this article are pseudonyms.
Funding: The ongoing research referenced in this piece is funded by the National Institute on Drug Abuse.
Bourgois, Philippe, and J Schonberg. 2009. Righteous Dopefiend. University of California Press.
Fafchamps, Marcel. 1992. Solidarity networks in preindustrial societies: Rational peasants with a moral economy. Economic Development and Cultural Change 41(1):147-174.
Fassin, Didier. 2012. Introduction: Toward a Critical Moral Anthropology. In A Companion to Moral Anthropology. D. Fassin, ed. Malden, MA: John Wiley & Sons, Inc.
Quesada, James, Laurie Kain Hart, and Philippe Bourgois. 2011. Structural vulnerability and health: Latino migrant laborers in the United States. Medical Anthropology 30(4):339-362.
Rhodes, Tim. 2002. The ‘risk environment’: a framework for understanding and reducing drug-related harm. International Journal of Drug Policy 13:85-94.
Simmons, Janie, and Merrill Singer. 2006. I love you … and heroin: care and collusion among drug-using couples. Substance Abuse Treatment, Prevention, and Policy 1(7).
Thompson, EP. 1971. The moral economy of the English crowd in the eighteenth century. Past & Present 50:76-136.
Imagine a world where you can walk into a hospital, submit a urine and blood sample, and be told 20 minutes later that you not only have a particular type of ear infection, but also a 50% chance of developing diabetes in the next ten years. Such is the promise of “personalized medicine,” in which the development of molecular diagnostics and therapies enables medical care to be tailored to individual bodies.
This vision of personalized medicine is predicated upon the collection and analysis of “big data”: the use of computerized tools and databases to find hidden patterns within large data sets to find hidden patterns. Data, proponents of personalized medicine say, will lead to more precise and objective ways of diagnosing and treating disease, and will help to redefine heterogeneous categories like cancer and obesity.
But to some extent, medical care has always been personalized. Throughout the 20th century, physicians practiced patient-centered care and used the “art” of clinical judgment in order to avoid one-size-fits-all approaches to medicine (see Richard Tutton’s paper in Social Science & Medicine). What then, is new about modern forms of personalized medicine, and why should we pay attention to them?
In the quest for personalized medicine, the post-genomic or “omics” fields such as genomics, proteomics, and metabolomics take center stage. Researchers work with gigabyte upon gigabyte of data, sitting in front of computers to analyze the patterns and statistical relationships contained within molecular information.
But alongside this focus on data, alternative narratives and ways of engaging with biology are emerging. Life, for the post-genomic sciences, is made up of systems and networks (see, for example, an article on network medicine). Linear notions of disease causation, as well as the reductionist metaphors of the informational code of life, are out. Notions of complexity, probability, variability, and dynamic systems are in.
Here metabolomics, the post-genomic study of the molecules and processes that make up metabolism, appears as a potentially radical new way of examining biology and disease. By analyzing the molecular composition of urine, blood, and tissue samples, metabolomics explores how metabolism changes in response to disease, diet, and environment.
To study metabolism, researchers use a variety of biochemical and statistical technologies to develop “biomarkers,” quantifiable biological entities which can be used to understand biological processes or diagnose diseases like cancer or diabetes. Metabolomics, they claim, provides a compelling alternative to genomics, in that it shows the dynamic outcome of the interactions between genes, metabolic pathways, and the environment.
My research for the past four years has centered on this emerging field of metabolomics, and on how it signals the changing practices and objects of biomedicine. Consequently, this post is concerned with how metabolomics—as a case study for the dynamics of big data—is being used to develop “personalized medicine.” Moreover, it explores what this means for the kinds of persons and populations that are implicated in or “made up” (see Ian Hacking’s essay “Making Up People”) in personalized medicine research.
Finding persons in metabolomics research
For now, let’s leave these questions and turn to a recent meeting I had with Professor Jeremy Nicholson, the head of the Department of Surgery and Cancer at Imperial College London, and also the founding father of one of the leading metabolomics[i] laboratories in the world. We are meeting in the sixth-floor space of the Computational and Systems Medicine laboratory, a sprawling set of offices and experimental facilities housed primarily within Imperial’s South Kensington campus.
It’s been a while since I’ve been back here, and I’m blown away by the changes that have occurred since the laboratory began developing the “Phenome Centre,” a multi-million pound private-public partnership to carry out broad-scale metabolic phenotyping and epidemiological studies. The Centre, which opened at Hammersmith hospital in mid-2013, is a “legacy” of the London 2012 Olympic Games.
As the story goes, Jeremy Nicholson helped to transform the biochemical machinery used to test for illegal performance-enhancing drugs into a cutting edge laboratory. The resulting Centre—a collaboration between a number of UK universities, the analytical technology companies Waters Corporation and Bruker Biospin, and the government-run Medical Research Council (MRC) and National Institute for Health Research (NIHR)—is a testament to the increasing size and strength of the field of metabolomics in the UK and beyond[ii]. Following from these developments, the sixth-floor space has been transformed from a slightly haphazard arrangement of desks and machines, to a modern facility neatly partitioned by glass walls and digital displays.
Professor Nicholson warmly welcomes me into his office, and when I complement him on the new space, he jokingly says, “It’s because of all of this darn publicity, we had to make it look good. I miss the old lab. It felt more like a place where you could actually do science.” Exuding energy and excitement, he begins to tell me about the range of developments occurring across his laboratory.
There are efforts to improve histology with the “iKnife,” a surgical knife that can analyse the biochemical signature of the smoke generated during electrocautery. There are clinical trials on diagnostic methods for breast and colon cancer. There are pilot projects to develop biomarkers for Alzheimer’s disease, and even to improve intensive care treatments for hypoxia by sending teams of intensive care practitioners up Mount Everest, where they conduct experiments on themselves and other volunteers at high altitude.
In the back of my mind, I am aware that such developments are enveloped in the hype and promise of post-genomic technologies. Even so, I can’t help but become caught up in this vision of the technological future of biomedicine. These projects are all housed under the theoretical umbrella of personalized medicine, in which metabolomics will provide more accurate, specific, and cost-effective biomedical solutions. Professor Nicholson has managed to unite a diverse array of medical professionals and research specialties around one cutting-edge, post-genomic vision.
Central to this vision of personalized medicine is the notion of the “patient journey,” where metabolomics technologies are integrated into hospital settings to model and monitor patients as they move through various parts of medical care. Also central is the notion of “molecular epidemiology,” where metabolomics technologies enable longitudinal studies to molecularly characterize states of health and disease within populations. Together, metabolomics researchers claim, the combined notions of the patient journey and molecular phenotyping are “two sides of the same coin” that will revolutionize biomedicine.
However, as I listen to Professor Nicholson, I ask myself: What are the end goals of this research? How are researchers using new practices and forms of knowledge to investigate personalized and population medicine? Moreover, what types of persons are we dealing with here, in this search for personalized medicine?
The person in anthropology
Since the 1930s, anthropology—spurred by the work of Marcel Mauss—has been interested in notions of the person and personhood, as well as related notions such as the individual, the self, and the body. Early in this history, as British social anthropology investigated the cultures of colonized tribes and peoples, it defined the person as a nexus of social positions or relationships, rather than as an amalgamation of individual characteristics. But when anthropologists began to look at different cultural contexts, the notion of the person as occupying a social position began to break down. In more recent anthropological thought—espoused, for example, in Marilyn Strathern’s work in Papua New Guinea or Viveiros de Castro’s work in the Amazon—persons emerged as constantly contested, negotiated, and changing entities.
But persons, as such work also teaches us, are shaped by the shifting dynamics of knowledge and power. As Michel Foucault’s foundational work on techniques of power demonstrates, the rise of modern institutions and technologies for data collection promote the exercise of power and control at the level of populations (through processes of “governmentality”) and individuals (through “technologies of the self”). Such techniques of power have the fundamental ability to alter subjectivities—as scholars have noted with the concept of “biological citizenship”—and to influence how individuals and collectives live and experience their lives.
This brief digression into anthropological notions of persons provides an important starting point for thinking through the efforts—as embodied by the Phenome Centre—to develop personalized medicine with metabolomics. Biomedicine and data-intensive research are establishing new kinds and quantities of relationships between persons and things. Increasingly, for example, nature and culture are intertwined: notions like kinship, life and death, and time are redefined through technologies like assisted reproduction, organ transplantation, and cell culture, respectively. Perhaps, then, with changes in the practices and technologies of biology, notions of persons are also being conceived of and “made up” differently.
Persons as multiple, molecular, and…relational?
With this in mind, I want to turn back briefly to some of the happenings within the metabolomics laboratory. During my fieldwork several years prior to the aforementioned meeting with Professor Nicholson, I observed a PhD student carrying out a metabolomics experiment to determine more “personalized” ways of diagnosing pancreatitis. Pancreatitis, which often manifests as a sudden and serious inflammation of the pancreas, is easily confused with other conditions that give rise to abdominal pain. This student’s work sought to determine metabolic markers that could detect whether a given patient had pancreatitis upon hospital admission.
One day, I observed a meeting between the student and her supervisor, in which she discussed the difficulties she was having analyzing her data. The data had come from the urine and blood of patients hospitalized for pancreatitis. The student explained, with frustration, that her experiments did not show a clear difference between patients diagnosed with pancreatitis and patients diagnosed with other conditions. Instead, her results showed three separate clusters of patients, each of which contained a mixture of pancreatitis and non-pancreatitis patients.
As the student discussed the perplexing result with her supervisor, it became clear that each of the three clusters corresponded to the location within the hospital in which each patient had been treated. One cluster was from patients in the intensive care unit (ITU). Another was from patients in the accident and emergency (A&E). And the last was from patients admitted into the gastroenterology ward.
Seeing these results, the student and her supervisor acknowledged that the experiment had been impacted by differences in sampling and experimental conditions. But the results also inspired the supervisor to begin to rethink the category of pancreatitis, and what it meant for the health of the patients in the experiment. He said, “[The data] reinforces the fact that…diseases are not homogenous or easy to separate…And it shows that people behave differently when they get really sick. And actually, we can see that, we can measure it.”
Together, the student and the supervisor used this moment of uncertainty to rethink diseases as molecularly diverse entities. According to their reasoning, the similarities and differences between patients were not due to clinical symptoms, but rather to a series of complex molecular characteristics reflecting the severity of the patients’ disease, the hospital environment in which they were being treated, the drugs they were taking or receiving, the composition of their gut bacteria, and their overall state of well-being.
Observing two metabolomics researchers reasoning through their work, it became clear to me that the persons (patients) in this experiment were multiple and molecular entities. They were defined according to groups of biochemicals or sets of statistical relationships, which reflected the body’s response to the environment in space and time.
Ultimately, though metabolomics researchers draw on the standard demographic categories like sex, gender, ethnicity, and age in their research, their subsequent understandings and definitions of persons do not necessary correspond to these same categories. As metabolomics research looks for more personalized approaches to disease diagnosis and treatment, it makes up persons as metabolic patterns and relationships. This is reminiscent, as a colleague described, to the modern possibility of tracking down internet users not by their IP addresses, but by their “personalized footprint” generated by website visits and Google searches. Persons, then, are not only constituted by information that they contain, but also by the emergent patterns of relationships that they embody. What, then, does this mean for how persons are understood and treated with personalized medicine?
As metabolomics researchers seek to collect information and maximize their knowledge of disease, they recognize that it is impossible to measure and model everything about the world. Despite this, they try to capture the interactions between many things—genes, gut bacteria, environment—in order to provide the best possible approximation. There is a seductive element of complexity and holism here, one that captivated me during my meeting with Professor Nicholson. With the ability to measure life—with precision, at the molecular level, as the outcome of the organism in its environment—the possibilities for metabolomics seem limitless.
In conclusion, I want to return to the original premise for this post: what it means to deliver personalized medicine with metabolomics research, and what types of persons emerge in the process. Perhaps, as metabolomics research shows, persons are defined relationally, but according to statistical relationships rather than social relationships. Perhaps personalized medicine is as much about making up new persons, as it is about attributing ever finer metabolic resolution to individuals. Perhaps in the quest to define persons, new elements of personhood are foregrounded, while others retreat from view.
What is at stake, I want to suggest, is the very nature of measurement in metabolomics research. What types of information or relationships is metabolomics capable of capturing? Or, put otherwise, what types of information or relationships is metabolomics not capable of measuring?
Here, I am reminded of a conversation I had once with a clinician doing a short research project in the metabolomics laboratory, while still working shifts in the intensive care unit. The clinician described a challenging case, where a woman suffering from a drug overdose was in need of a liver transplant. In such cases, clinicians relied on a statistical test called Model of End-Stage Liver Disease (MELD)[iii], which calculated a patient’s probability of dying over a certain period of time without a liver transplant. Though the clinician and his team had suspected that the woman’s prognosis was poor, her MELD score was not high enough to qualify her for a liver transplant. Contrary to the results of the test, the clinician drew on what he referred to as “gut feeling”–tacit knowledge of the woman’s skin color, pallor, quality of respiration, and general change over time—to sense that the woman was more sick than her MELD score indicated.
A few weeks later, as the clinician and his team predicted, the woman’s health took a turn for the worse. Subsequently, she scored high enough on the statistical test (MELD) to qualify for and receive a life-saving liver transplant. This case, said the clinician, typified how medical practitioners often knew that patients were in need of a transplant before the statistical models indicated so. They carried out “their own pattern recognition” based on their judgments and impressions of patients, and by applying statistical models repeatedly to patients until they displayed a result that would qualify them for a liver transplant. What struck me about this case was not only that the patient’s care was inherently individualized, but also that her treatment relied on a series of factors that were beyond quantification with standard clinical methods. This type of care, though not based on data or post-genomic technologies, was highly “personalized.” It entailed interpretive care attuned to the individual status and needs of the patient. For me, this raised key questions about whether metabolomics’ experiments, as they configured patients into a series of measurable and seemingly objective variables, were able to capture those elements of health—or personhood—that facilitated the best medical care for the individual.
As this and the other cases I have discussed show, metabolomics entails shifts not only in the practices for carrying out personalized medicine, but also in the definitions and categories of persons being treated. What is still unclear—and what I am grappling with in my own work—is what such persons might be, and what consequences they might have for the provision of medical care in the 21st century.
Ultimately, is the type of personalized heralded by metabolomics addressing the type of person we tend to think of anthropologically, as existing relationally within society? Can this type of medicine, with its basis in data and statistics, ever be personalized in the way we want it to be, or in a way that leads to more attentive and higher quality care for patients?
Nadine Levin is a Research Fellow at the University of Exeter, where she is exploring how Open Access and Open Data policies affect the practice of post-genomic research. She completed her DPhil in 2013 in Anthropology at Oxford University, with a dissertation that explored how researchers in the field of metabolomics create, analyze, and use data to make claims about metabolism and health. Her current research explores how metabolism is being configured in relation to big data, and what consequences this has for biomedicine.Works cited Goodacre, Royston, ‘Metabolomics – the Way Forward’, Metabolomics, 1 (2005), 1–2 <doi:10.1007/s11306-005-1111-7> Kinross, James M., et al. “Metabolic phenotyping for monitoring surgical patients.” The Lancet 377.9780 (2011): 1817-1819.
[i] The terms “metabolomics” and “metabonomics” are used interchangeably to describe the field, though both terms have a slightly different history. While metabolomics is said to focus on the characterization of metabolism at the cellular or organ level, and metabonomics is said to focus on the combined effects of the environment, disease processes, and gut bacteria at the organismal level, both terms entail overlapping sets of practices and ideas. The term metabolomics is attributed to researchers working on model plants and organisms at the University of Manchester, while the term metabonomics is attributed to researchers working on nuclear magnetic resonance (NMR) and bodily fluids at Imperial College London.
[ii] The past decade has seen a surge of developments in metabolomics research. Though the field was formally inaugurated into the scientific literature in the late 1990s, it has grown significantly in the last five years with the establishment of several major funding initiatives and industrial partnerships worldwide. In the United States, the National Institutes of Health (NIH) recently initiated an investment of more than $50 million USD in metabolomics research through an NIH Common Fund. In parallel, a number of research groups with expertise in metabolomics have emerged throughout the United Kingdom, resulting in the development not only of the MRC-NIHR Phenome Centre, but also of the comprehensive MetaboLights database for metabolomics experiments and associated information at the European Bioinformatics Institute (EBI). In Canada, developments in metabolomics have been supported through investments in the Metabolomics Innovation Centre, a nationally funded core facility supporting metabolomics activities across a range of Canadian universities, as well as the Human Metabolome Project, an attempt to catalogue the range of metabolites present in human beings.
[iii] Model of End-Stage Liver Disease (MELD) is a linear regression on a combination of clinical measures of serum bilirubin, creatinine, and prothrombin time. It was implemented in the National Health System (NHS) in the United Kingdom in 2002 to replace the older system for assessing need for transplantation, which entailed a combination of the Child-Turcotte-Pugh (CTP) score and overall waiting time for a liver transplant. As a clinician explained, “Basically everyone just does it on a website now, you just type in your results and you get a score. And the higher the score, with a max of forty, the more likely a patient is to die.”
This is a conversation between Nick and Zoë. They cultivated this conversation especially for Commonplaces. Nick is an activist and writer who lives on ventilation. Zoë is an anthropologist and friend who does not.
nick: They say that the fundamentals of life support and CPR are ABC (Airway, Breathing and Circulation). I say that my A and B are just longer: the tube.
zoë: Remember, there was a moment when I was holding your breathing tube, keeping it out of the way of the chains attaching the sling to the lift as other friends and your support worker helped position you in bed? I was struck by how alive the tube itself felt as it wobbled on its own in my hand, much more like a creature than a machine. The tube felt alive, because it felt like it was breathing.
n: You asked me if I could feel it. The tube is an extension of me and I do feel it, and you’re right that it is alive because it’s me or at least part of my respiratory system.
z: So that was the feeling of you breathing. But also, in a way, of you being breathed, and the tube being breathed, and a whole sociomaterial assemblage in the midst of its animation. So many things and people and forces made the specificity of breathing in that moment: A multiple breathing apparatus; the scene of a multimaterial and multimodal arrangement of a world. How could breathing be anything else?
n: That brings to mind the discussion of the term “ventilator dependent.” Some (who are not on vents, notably) say the term vent-dependent should be excised, removed as part of a war on “the language of dependence.” How ridiculous! Are we so in thrall to rugged individualism and man being “an island unto himself” that even dependence on air, which is what vent-dependent means, is cast as negative? From my perspective, the term “vent-dependent” is not negative any more than “food-dependent,” “water-dependent,” “cellular metabolism-dependent.”
z: Ha! And if the alternative to “the language of dependence” is supposed to be a “language of independence,” or even a universal humanism, then the vent is particularly unsettling to the foundational liberal idea of the singular, bounded, whole, human, natural, rights bearing body proper that such languages voice.
The vent insists on a more-than-one-and-less-than-two-ness of more than human being in a way that exceeds other body penetrating technologies, like cochlear implants or spinal stimulators. Those can be cast as freely chosen personal and political additions and do not appear as supplement to the particular political biontology that cannot abide it. That form of the person is uncongenial to life support. It is stingy with life.
n: Part of the problem is that mainstream film and TV only presents the ventilator in the context of its heroic withdrawal as “worse than death,” “no way to live,” in an end-of-life storyline. The truth is far more multifaceted. The ventilator is used in support of early and middle phases of life, not just for dying.
z: You know, there’s an analogue to that death-boundedness in social theory.[i] But your description of ventilation helps us get a handle on the situation that isn’t hinged to life and death (and need not hinge them to each other). Like how your description of feeling by reference points out constitutional attachments: how life registers in and composes a body as bodies find and feel themselves together.
n: Feeling by reference is like this: the lungs don’t have nerve endings, but we still feel what’s going on with them by referencing changes in chest rise and fall, changes in the way that the air moves in the throat (which does have nerve endings) and the way breaths play against the carina (that weird flat place where the two primary bronchi meet, borderline above the lungs) which has some sensation, at least for me. The tube is, in a way, experienced as something akin to a hair: the tube moves or pulls or is touched, I feel it acutely with great sensitivity from its “root.” Meaning you move the tube anywhere or touch the tube even two feet down, I get feedback in the tracheostomy that I feel, feeling by reference.
z: So the feeling of your exo-airway can also be the touch of a friend like me participating in your life. My own breathing — with two quite robust and compliant lungs — is made up of other things, including regulatory regimes that police air and industrial emissions, which also articulate with forms of capitalism and their geographies, regulations, and desires in such a way that, for example, while I was in a jet on my way to an Orlando resort last month, the air in Shanghai had become toxic.
Or take the colliding topographies of fungi and investment in California in which prisoners breathe in and are sickened from Coccidioides immitis 3,000 times more often than freely-mobile residents of the state, or the way geographies of class and capital make asthma endemic to impoverished urban neighborhoods. Which is only to point out the obvious: My breathing is made of (relatively) clean air in the places I willfully travel to and reside in, a historical and political state of affairs capacitated by, and collateral to, the production of toxic and illiberal breathing in places I willfully avoid.
n: Whenever I go up in airplanes, I become really aware that we are way, way above the breathable atmosphere, and realize that the breathable atmosphere is this low, thin envelope, a shared resource that’s much thinner, smaller and scarcer than typically presumed. All the methane, CO2, etc etc we pump into the envelope has no way to escape en masse. Only a small fraction can escape to outer space, so is inevitably taken into our bodies and the bodies of the numerous non-human species we rely on: the soil, the oceans, everything. It’s like this terrifying realization that the assumptions underpinning the socio-economic system of the entire world — the idea that the space for pollution is vast and includes everything from floor up to the ionosphere and outer space too — is as wrong as “flat Earth.”
z: So, if we try to breathe it all in: Your encompassing breathing apparatus — an apparatus that points to the bio- and necro-politics of breathing as much as its mechanics, feelingfulness, and sociability — productively confounds our ability to make distinctions between one (living?) thing and another. I was going to say that your breathing helps us think life support as something more expansive, but maybe it’s the other way around. Thinking life support with you makes breathing something more expansive.
n: It’s both. Technology has changed how serious disabling conditions, injuries and chronic illnesses are survived and lived. As we clumsily and uneasily stumble forward into a piecemeal cyborgian society, there will be more like me, whose existence as a co-existence with numerous relationships, social programs and technologies supporting life can’t be ignored. The interdependent “assemblages” that support all our lives — incompatible with the typical conceptions of individualism, self-sufficiency and self-defense — are, for most, luxuriously backgrounded and subtle. But when you’re wearing part of your respiratory system in front of you as easily as businessmen wear ties and every movement happens with assistance from the people around you, interdependence is irretrievably foregrounded, with breathing itself dependent on multiple outside factors. That most people’s lives are lived with more similarities to this “total interdependence” than differences means that even the air you breathe being outside of your direct control is a BIG IDEA with sweeping, sometimes terrifying implications.
Zoë Wool is a postdoctoral fellow and lecturer in the Department of Anthropology at Columbia. She works on the intimate, carnal, clinical and political making of fleshy life for severely injured American soldiers, and is also beginning a new project about scientific renderings of psychosomatic soldier bodies since the mid-1800s. Her first book, tentatively titled “Emergent Ordinaries: The Weight of Life at Walter Reed” will be published by Duke University Press.
Nick Dupree is an activist and writer in New York City. He has been on forms of mechanical ventilation since 1992, and is best known for his campaign in Alabama “Nick’s Crusade,” which ended in a new Medicaid program to extend home care past age 21 for vent-dependent Alabamians. He studied at Spring Hill College, a Jesuit college in his hometown, Mobile, AL on the Gulf coast. He continues to work on projects to articulate and advocate for the interests of people on ventilators, and blogs about topics as varied as The Constitution, Medicaid, and dinosaurs at www.nickscrusade.org
[i] In the few examples that come to mind, engagement with being on a ventilator arises at thresholds between life and death. See Agamben, Giorgio. Homo Sacer: Sovereign Power and Bare Life. Stanford University Press, 1998; Lock, Margaret. Twice Dead: Organ Transplants and the Reinvention of Death. University of California Press, 2002; Sharp, Lesley. Bodies, Commodities, and Biotechnologies: Death, Mourning, and Scientific Desire in the Realm of Human Organ Transfer. Columbia University Press, 2007.
Image: “Thin Line of Earth’s Atmosphere and the Setting Sun.” NASA, Wikimedia Commons.
While the AAAs were winding up in Chicago, participants in the workshop, A Home for Science: the Anthropology of Tropical and Arctic Field-Stations, started to make their way north to an even colder part of the world. Hosted by the Department of Social Anthropology, University of Oslo, co-organized by Wenzel Geissler, John Manton, Ann Kelly and Gro Ween, and funded by the ESF- European Science Foundation (ESF), the workshop was held at the Finse Alpine Research Station. The research station, located in Norway’s Hardangervidda mountain plateau, regularly accommodates arctic and high altitude biologists, geologists and geophysicists from a range of Norwegian and international institutions. Over a mile from an isolated rail station and for the better part of the year only accessible on skis or by snow-mobile, Finse has also served as a training ground for polar expeditions since the early 20th century. During this stormy week in late November, the station and its welcoming staff lead by Erika Leslie and supported by two students from the University of Oslo, Mari Deraas and Ola Fjellstad, sheltered a group of historians, anthropologists, sociologists and artists who, among other things, sought to test their mettle in the arctic climes.
The workshop’s dramatic setting provided its intellectual focus: while the importance of place in scientific practice has received considerable historical and anthropological attention, in Finse, our aim was to explore how these places serve as homes and to shed light on the way in which the far-flung circuits of scientific travel become enmeshed in the mundane practices of daily life. As sites of reconnaissance, appropriation, and adventure — a frontier of scientific and technological possibility – field stations also are productive sites to think through the affective dimensions of science, the longings and hardships, camaraderie and loneliness, homeliness and homesickness that belie the production of knowledge. These theoretical concerns have formed central preoccupations of the research collective, the Anthropology of African Biosciences (AAB), and our hope was to gain some theoretical traction by extending this dialogue across regions and disciplines.
Participants took up the question of the home in a number of interrelated ways. Drawing on historical and empirical materials, Peder Roberts and Eric Paglia compared the domestic arrangements at the base of the 1950s Norwegian-British-Swedish Antarctic expedition in Maudheim and contemporary private and public arrangements at the arctic station of Ny-Ålesund. Across these two cases they track the subtle ways geopolitical and intellectual values are materialized in the built-environment of the station and in the tenor and texture of everyday life. Their work reminds us that while field-stations are extra-territorial, belonging to academic institutions in historical centers of exploration and conquest, the work conducted on these sites is rooted in everyday necessities and comforts. Contributions from Aïssatou Mbodj-Pouye, Ashley Ouvrier, and Noémi Tousignant and from Wenzel Geissler and Ann Kelly also reflect on the running together of scientific work and domesticity, drawing from material collected in the context of a collaborative project on the Memories of Medical Research in Africa. Bringing together work in East and West Africa, these papers reveal how in which researchers and their local staff dwell in the scientific sites over long periods and how their engagements with each other and with the particular sites of research change over time.
The contestations that arise during that process of mutual habituation were compellingly illustrated by Branwyn Poleykett and Peter Mangesho; their archival research in Amani, a laboratory in northern Tanzania, showed the struggles of African scientists whose expectations of Amani as a home, and their aspirations of civic advancement in the new Tanzanian nation, failed to tally with the colonial notions of ‘service’ still at the heart of the institutes agenda. The power of imaginaries of the home to support and shape scientific endeavours was further illuminated by Silvia Tomášková’s research on Russian revolutionaries exiled to Siberia at the end of the nineteenth century. Through impressive ethnographic efforts, these exiles immersed themselves in local life and, in so doing, found a living exemplar of a political vision, which had cost them their home.
The station as a micro-polis was a leitmotif of discussions. Drawing insight from Latour and Sloterdijk, Martin Skrydstrup shed light on the aesthetics and layout of North Greenland Eemian Ice Core Drilling (NEEM) to reflect on the ideological commitments of climate research, to forge both ideal citizen-scientists and responsive publics. Barbara Bodenhorn’s long-term ethnographic work with whaling Iñupiaq communities living in Barrow, Alaska, suggested the ways in which the siting of the research station – here, The Naval Arctic Research Lab (NARL) – can open a space for collaboration, transforming the interesting of visiting scientists to dovetail more closely with their local hosts. Those expressions of hospitality can also replicate historically sedimented asymmetries of epistemological, cultural, and political power; as Ferdinand Okwaro’s work on international research partnerships in Kenya made clear. While the value of knowledge may be framed as a common good, Okwaro reminded us that research is mediated by everyday practices of reciprocity and material exchange and delicate negotiations around access to sites and population, bodies and labour.
The papers drew from a diverse range of geographical expertise – from Guillaume Lachenal’s historical reflections on an ecological station in Cote D’Ivoire to Götz Hoeppe’s work with vising astronomers at an Observatory in the Chilean Atacama desert – but the spur of discussion was comparative. The arctic and the tropics represent radically distinct spaces of nature, conquest and imagination and yet these antithetical landscapes are similarly anchored in the research outpost, scientific fieldstation and ethnographer’s tent. Giving the ethical questions and geopolitical concerns attendant to circumpolar and equatorial a mundane material focus we hoped to elaborate new conceptual vocabularies that link northern and southern marginal spaces. Peter Redfield’s discussion of medical kits and offered a clear entry point into that creative dialogue, suggesting how research infrastructures extend temperate milieu’s across space. Rémy Rouillard and Vanessa Heggie, describing processes of acclimatization undertaking by Russian oil workers and Alpine Research respectively, showed how the body can also perform that work of stabilization and extension in extreme climates. Gro Ween’s collaboration with the artist Sabine Popp described experiments of embodiment work to reflect upon the many meanings of physical presence in extreme contexts.
Sabine Popp was one of a group of artists who in the evenings following dinner (often involving elk and reindeer meat) showed their work. Evgenia Arbugaeva, a Siberian photographer presented some startlingly beautiful images from her childhood home, Tiksi a once-important Soviet military and scientific base. Mariele Neudecker presented work from a recent trip to Greenland, encouraging the audience to speculate about what defines the line between nature and landscape, and contemplating on how to define the contemporary sublime. Deborah Robinson presented work conducted at the Wellcome Sanger Institute in the UK; her multi-screen installation Parasite created in response to malaria, raised a number of questions about the disentanglement of research populations from the sites of knowledge production. We also had the pleasure of hearing about the work of Hugh Broughton Architects from Gianluca Rendina and marveling over the recent designs of mobile arctic stations and watching a screening of Lars Einar Skageberg’s documentary, An Arctic Space Odyssey, which provides a window in the isolation and political pressure of research in the arctic station Ny-Ålesund, on the remote island of Svalbard during the height of the Cold War.
Skageberg’s project as well as that of the other artists gave expression to the visceral dimensions of life at the fieldstation, which often escape scholarly analysis. From photographs and super-8 films, installations and multi-media interventions, we were able to reconceptualise the unpredictable forms of contact between humans and their surroundings in these ‘dark’ and ‘unspoilt’ areas and begin to come to terms with the multiple ways in which the fieldstation yokes laboratory to outpost, exploration to domesticity, inquiry to survival. A domus of a very particular kind, field stations generate zones of shared living between humans and landscape, scientists and their local collaborators. An experience that we were privileged to sample during our week together in Finse.
Paul Wenzel Geissler is a Professor at the Institute of Social Anthropology, University of Oslo, and works as Director of Research, at the Department of Archaeology and Anthropology, University of Cambridge. Ann Kelly is a Lecturer of Anthropology in the Department of Sociology and Philosophy at the University of Exeter. John Manton is a research fellow in the history and anthropology of African biosciences at the London School of Hygiene and Tropical Medicine. Noemi Tousignant is a Research Associate with the Anthropologies of African Biosciences at the Department of Archaeology and Anthropology, University of Cambridge.
University of Chicago Press, 2013, 324 pp.
The specter of “tradition versus modernity” returns as a conundrum for understanding and signifying HIV/AIDS in post-apartheid South Africa in Claire Decoteau’s sociological monograph, Ancestors and Antiretrovirals. Interpretive social scientists like Decoteau are well trained to referee this dueling dualism, which reappears in policy discourse, popular media, and peoples’ stories about their pasts and futures. The dualism does not always appear in the same form and is dependent on the discursive domain of its articulation, and the work of the social scientist is to situate its historical re-emergence in light of the many different meanings it may evince for different social groups. In the South African case of medical pluralism, “tradition” as indigenous healing, and “modernity” as biomedicine are uneasily paired and wielded in opposition to shore up projects of identity formation on levels of individual, community, and nation. The two medical systems evince a broader “postcolonial paradox” that haunts peoples’ subjective choices for healthcare and reveals their biopolitical inscription.
The postcolonial paradox as enacted by the ANC state reflects “a simultaneous need to respect the demands of neoliberal capital in order to compete successfully on the world market and a responsibility to redress entrenched inequality, secure legitimacy from the poor, and forge a national imaginary” (7). Through a critical analysis of neoliberalism focused primarily on state and non-state organization discourses, Decoteau traces how tradition and modernity were used as, “powerful tools in the tricky political maneuvering required of leaders who [had to] represent the interests of the people while subscribing to the economic policies of global capital” (14).
Decoteau shows how Presidents Thabo Mbeki and Jacob Zuma differently trafficked in tradition to cohere politico-cultural capital nationally and globally. The former was zealously anti-imperialist and promoted indigenous healing solutions to the emerging problem of HIV, aligning with unorthodox Western scientists to deny the efficacy of biomedical ARVs and delaying its rollout to the public. The latter, Zuma, gained eventual traction with the increasingly ill majority as Mbeki’s traditionalism was globally scorned. By simultaneously embracing modernist tropes in biomedical solutions to HIV and human rights, as well as shoring up his own traditional identity as an undereducated ethnically Zulu man, Zuma was able to garner popular support to succeed the presidency. “Wrapped up in the promises the nationalist fantasies of independence foretell,” the masses continued to vote for the ANC and support its leaders “because they desperately [needed] something to hope for” (17). Similarly, White (2012) argues popular affect for Zuma was structured by political economy: “the dynamics of identification with Zuma’s ethnic person should be understood as features of a broadly post-Fordist social situation.”
Zuma’s embrace of modernity in biomedicine and human rights, of course, followed up on years of successful community activism and legal battles against the Mbeki state and pharmaceutical manufacturers by the non-state organization, the Treatment Action Campaign (TAC). TAC initially struggled to leverage wider legitimacy because of its administration’s majority white racial make-up, a facile corollary to the tradition-modernity divide, but became instrumental in constituting biomedical hegemony for national health policy and programming.
For Decoteau, the eventual supremacy of biomedicine in health policy shifts the nation toward a model of “biomedical citizenship” where the population may access healthcare by adopting Foucauldian biomedical technologies of the self. For those at the social margins, these technologies become the means to access life itself. Antiretroviral therapy, CD4 checkups, participation in salvific NGOs, and adhering to prescriptions, “like a machine” in the words of one informant, feign inclusion in a healthcare system that is still exclusionary. The socially marginal are expected to participate responsibly and entrepreneurially, even if “their lives are subsumed by constant risk and unmooring contingency” (110). This shift in citizenship is congruent with the postcolonial yoke of the global neoliberal “rationality of rule.” “Capitalism is… implicated, constituted, and transformed through” (11) several social forces, rather than their singular foundation, and she notes that Mbeki, Zuma, and the TAC all channeled in capitalist-inspired and marginalizing projects, even if indirectly. “By granting minimal inclusionary provisions on the basis of behavioral change, the state and civil society are absolved of responsibility—they have washed their hands. If people die, it’s their own fault” (161).
In documenting the discursive political strategies involving tropes of traditional and modern healing, Decoteau shows how both state and non-state actors worked to cement their ideologies. Despite their macro-level, structural extensions, “the failures and fissures involved in population regulation and processes of incorporation [left] open important spaces of potential for radical social change” (11). Beyond a nuanced reading of the holes in state and civil society discourses, she takes on a micro-level analysis of indigenous healers and “the poors,” members of social movements “who fight on the front lines of a war against neoliberal capital and the postcolonial compromises made by the state and its ruling elite” (15). Interview and focus group data with these individuals and others from activist and health NGOs constitute her ethnographic sample.
The first chapter grounds the obstacles behind this presumed “fault” by taking us into the slums of Sol Plaatjie and Lawley. Cold winds and dust blow through patchy shack walls. Households undergo forced and violent removals. “Upgrades” to cube-like smaller government flats are unannounced or never materialize. Electricity and water are only accessible through a prepaid system and long queues, and non-nutritious meals are prepared over noxious paraffin gas stoves. There is shit in the streets, literally, from poor or non-existent sanitation systems. There is also a malaise over the decline of neighborly exchange and moral relations of ubuntu, jealousy, and stigma. People face an ontological vulnerability, “a pervasive fear of something absolutely ubiquitous but unidentifiable,” along with “general unease about the loss of certain cultural practices and traditions” (70). Supported by fourteen striking pictures of the slums and her informants who lived there, eight tables derived mostly from the author’s own community survey data and many interview quotes, she paints a rough, convincing argument that poverty and AIDS are mutual pandemics: environment and wealth shape overall health.
Chapters four and five show especially how the poor move beyond discursive divisions between tradition and modernity. In the “Politicization of Sexuality,” Decoteau evidences that gender and sexuality have been socially reconstructed and revalued in young peoples’ exchange relationships, thus complicating public health concepts of transactional sex. In “Hybridity,” the traditional-modern healing dualism is said to generate culturally hybrid subjectivities for the poor: it “produces a whole series of disavowed hybridities… [P]eople infected with HIV are asked to ‘choose’ either indigenous or biomedical approaches to healing, but instead defy the state and the biomedical community by using both forms of healing simultaneously” (13). This chapter opens with several rich but short cases of people who have utilized both approaches. Their cases aim to align with descriptions of indigenous ontology in chapter one and its hybrid forms in chapter five, but the presentation of ontology is more a reiteration of secondary source literature, and concepts of bodily substances’ flow and permeability are not generally made concrete in sustained descriptions of peoples’ experiences with traditional healing. Fuller biographies and life trajectories of Pheello, Thulani, and Nozipho, or key others whose stories illuminate the text, rather than select interview quotes, would further realize how hybridized traditional-modern healing is affirmatively practiced and strengthen the linked micro- and macro-level analyses.
It was surprising to not come across more about Christianized faith-healers, congregations, or their ethical publics of healing in urban spaces, given their regional historical popularity, ubiquity and traffic in traditional materia medica especially in Zionist churches. One key informant Pheello is even said to visit a faith healer, but we don’t learn much more about the encounter. With scholars showing the powerful utility of Christian public life and NGOs for HIV/AIDS in Africa (Englund 2011, Pfeiffer 2004, amongst others), those who work on the new social movements and precarity might begin to consider how religion is real force—dialectical or otherwise—that differently animates political-economic life (cf. White 2013, Marshall 2009). The ancestors also don’t reveal their presence much beyond the book’s title, remaining spectral rather than vehicular for healing self and community through social action and embodiment.
Despite these points, which come from a cultural anthropologist of religion, Ancestors and Antiretrovirals is a highly accessible book for non-sociologists that does not sacrifice analytic rigor in its presentation of peoples’ lives. Decoteau is a gifted photographer and purveyor of mixed methods who skillfully interlaces seemingly divergent theorists to articulate complex distinctions and integrations of tradition and modernity. The two are more synergistic than syncretic for the poors and local healers, creating something historically new and offering possibilities to reach beyond what is prescribed by prevailing systems of governmentality. I would definitely teach several chapters in courses on South Africa, medical anthropology and medical sociology.
Casey Golomski, PhD (Brandeis University, 2013) is currently appointed at the University of Massachusetts Boston. He is a cultural anthropologist who collocates the roles of medicine and religion in socioeconomic reproduction. In June 2014 he will be a Postdoctoral Fellow at the University of the Witwatersrand, Johannesburg, in the Department of Anthropology, co-initiating a research unit, “Life Course, Obligation, and Dependency: Ethnographic Perspectives on Intergenerational Justice in South Africa.”
Englund, Harry, ed. (2011) Christianity and Public Culture in Africa. Athens: Ohio University Press.
Marshall, Ruth (2009) Political Spiritualities. Chicago: University of Chicago Press.
Pfeiffer, James (2004) “Civil Society, NGOs, and the Holy Spirit in Mozambique.” Human Organization 63(3):359-372.
White, Hylton (2012) “A Post-Fordist Ethnicity: Insecurity, Authority, and Identity in South Africa.” Anthropological Quarterly 85(2):397-428.
White, Hylton (2013) “Spirit and Society: In Defence of a Critical Anthropology of Religious Life.” Anthropology Southern Africa 36(3-4):139-145.