In anticipation of the American Anthropological Association’s annual conference in Washington DC from December 3-7, we wanted to point out a number of panels on which various members of Somatosphere’s editorial team will be presenting, as well as several other interesting panels, roundtables, lectures, and events:
On Wednesday, December 3rd from 12-1:45pm in Jefferson will be the session “Uncertainty and scenario,” organized by Limor Samimian-Darash (Hebrew University) and Jon Bialecki (University of Edinburgh) and featuring Ryan J. Sayre (Yale University, Meg Stalcup (University of Ottawa), James D. Faubion (Rice University), Tomas A. Matza (Duke University), Elizabeth Angell (Columbia University), and Janet Roitman (The New School for Social Research).
On Wednesday, December 3rd from 12-1:45pm in Washington Room 4 will be the session “Anthropology of becoming,” organized by Joao Biehl (Princeton University) and Bridget Purcell (Princeton University) and featuring Angela N. Garcia (Stanford University), Lucas Bessire (University of Oklahoma), Adriana M. Petryna (University of Pennsylvania), and Michael M.J. Fischer (MIT).
On Wednesday, December 3rd from 2-3:45pm in Washington Room 3 will be the session “What possessed you: Sovereignties, selves, and spirits (Part II),” organized by J. Brent Crosson (New York University) and featuring Alexander Rocklin (Independent Scholar), Netta R. van Vliet (Duke University), Sara M. Bergstresser (Columbia University), Louis P. Romer (New York University), Bruce M. Knauft (Emory University), and Morten Axel Pedersen (University of Copenhagen).
On Wednesday, December 3rd from 2-3:45pm in Marriott Balcony B will be the session “‘Global’ knowledge, ‘local’ care, and subjectivity: Producing an anthropology of psychosis,” organized by Neely A. Myers (Southern Methodist University) and featuring Ippolytos A. Kalofonos (University of California), Michael Joseph D’Arcy V (University of California Berkeley), Emily Ng (University of California Berkeley), Mary-Jo Del Vecchio Good (Harvard University), Elizabeth Bromley (University of California Los Angeles), and Janis H. Jenkins (University of California San Diego).
On Wednesday, December 3rd from 4-5:45pm in Washington Room 5 will be the session “Metabolizing environment: Anthropology of metabolism between molecular and eco-political scales,” organized by Amy Moran-Thomas (Brown University) and Nadine Levin (University of Exeter) and featuring Michael A. Fortun (Rensselaer Polytechnic Institute), Ian Whitmarsh (University of California San Francisco), Michael Montoya (University of California Irvine), Harris S. Solomon (Duke University), and Lenore H. Manderson (University of the Witwatersrand).
On Thursday, December 4th 9-10:45am in Marriott Ballroom Salon 3 will be the session “What constitutes medical knowledge? Part 1 of a discussion of Affliction with Veena Das” organized by Clara Han (Johns Hopkins University) and featuring Janet F Carsten (University of Edinburgh), Sophie Day (Goldsmiths, London), Gregoire Hervouet-Zeiber (Johns Hopkins University), Anne M Lovell (INSERM University Paris Descartes), Veena Das (Johns Hopkins University), and Michael Lambek (University of Toronto).
On Thursday, December 4th 11-12:45pm in Marriott Ballroom Salon 3 will be the session “What constitutes medical knowledge? Part 2 of a discussion of Affliction with Veena Das” organized by Clara Han (Johns Hopkins University) and featuring Arthur M Kleinman (Harvard University), Michael M.J. Fischer (MIT), Aditya Bharadwaj (Graduate Institute of International and Development Studies), Vincanne Adams (University of California, San Francisco), Richard Rechtman (Ecole des Hautes Etudes en Sciences Sociales), and Veena Das (Johns Hopkins University).
On Thursday, December 4th from 11-12:45pm in Congressional A will be a roundtable honoring the work of Richard Shweder – “Universalism without uniformity, Part I: Best practices? Morality and Cultural Pluralism” organized by Julia Cassaniti (Stanford University) and Usha Menon (Drexel University) and Robert LeVine (Harvard University), John Lucy (University of Chicago), Fuambai Sia Ahmadu, Pinky Hota (Smith College), Thomas S Weisner (University of California Los Angeles), Jacob R Hickman (Brigham Young University), and Stanton E F Wortham (University of Pennsylvania).
On Thursday, December 4th from 11-12:45pm in Thurgood Marshall West will be the session “Re-imagining paths not taken: Conversations with Emily Martin on culture and mind,” organized by Emily C. Cohen (City University of New York) and featuring Karen-Sue Taussig (University of Minnesota), Monica L. Schoch-Spana (University of Pittsburgh Medical Center), Dana Walrath (University of Vermont), Emily Yates-Doerr (University of Amsterdam), Wenrui Chen (New York University), Dwaipayan Banerjee (New York University (NYU) and Dartmouth College), and Lorna A. Rhodes (University of Washington).
On Thursday, December 4th from 2:30-4:15pm in Virginia Suite A will be the session “Assembling the biosocial: Embodied environments, health and modes of interdisciplinarity in the life sciences and anthropology,” organized by Eugene A. Raikhel (University of Chicago) and Stephanie J. Lloyd (McGill University) and featuring Des Fitzgerald (King’s College London), Nikolas Rose (King’s College London), Ilina Singh (Kings College London), Elizabeth F. S. Roberts (Univerisity of Michigan), Daniel H. Lende (University of South Florida), Martine Lappe (University of California Los Angeles), and Maurizio Meloni.
On Thursday, December 4th from 6:30-8:15pm in Virginia Suite A will be the session “The role of anthropologist as teachers: Innovative strategies for helping students learn about violence,” organized by Catherine M. Mitchell Fuentes (University of North Carolina at Charlotte) and featuring M. Nell Quest (Rutgers-Robert Wood Johnson Medical School), Rachel A. Hall-Clifford (Agnes Scott College and NAPA-OT Field School), Christine M. Labuski (Virginia Tech), Nia C. Parson (SMU), Catherine M. Mitchell Fuentes (University of North Carolina at Charlotte), and Deanna E. Barenboim (Sarah Lawrence College).
On Thursday, December 4th from 6:30-8:15pm in Washington Room 2 will be the session “Encountering epidemiology: Risk, uncertainty, and the politics of evidence,” organized by Jennifer A. Liu (University of Waterloo) and Thurka Sangaramoorthy (University of Maryland) and featuring Katherine A. Mason (Columbia University and Brown University), Jennifer A. Liu (University of Waterloo), Adia Benton (Brown University), and James Trostle (Trinity College).
On Friday, December 5th from 9-10:45am in Roosevelt Room 5 will be the session “Producing data, cracking data cultures,” organized by Megan M. Foreman (University of Pittsburgh) and Natasha D. Schull (MIT) and featuring Helene Mialet (University of California Berkeley), Jamie Sherman (Intel Labs), Christopher M. Kelty (University of California, Los Angeles), and Lucy Suchman (Lancaster University).
On Friday, December 5th from 9-10:45am in Washington Room 5 will be the session “Microbes and (in)corporeal infrastructures: Producing visibility in the age of the microbiome,” organized by Alex M. Nading (University of Edinburgh) and Frederic Keck (Musee du Quai Branly and CNRS) and featuring Amber Benezra (New York University), Erin Koch (University of Kentucky), Andrew Lakoff (USC), David Napier, and Thomas D. Cousins (Stellenbosch University).
On Friday, December 5th from 1:00-2:15pm in Johnson the Science, Technology, and Medicine Interest Group of the SMA will hold its open business meeting.
On Friday, December 5th from 2:30-4:15pm in Taft will be a roundtable honoring the work of Richard Shweder – “Universalism without uniformity, Part II: One mind, many mentalities – Self, health, and emotion” organized by Julia Cassaniti (Stanford University) and Usha Menon (Drexel University) and featuring Byron J Good (Harvard University), Tanya M Luhrmann (Stanford University), Janis H Jenkins (University of California San Diego), Charles William Nuckolls (Brigham Young University), and Lene Arnett Jensen (Clark University).
On Friday, December 5th the Society for Medical Anthropology will hold its business meeting, awards ceremony, and presidential address in the Empire Ballroom from 8:30-10:30pm. A reception with a cash bar will follow
On Saturday, December 6th from 9-10:45am in Roosevelt Room 2 will be the session “Grammars of obligation: Substance, matter and life in anthropology,” organized by Aaron Goodfellow and featuring Jane Bennett (Johns Hopkins University), Sruti Chaganti (Johns Hopkins University), Columba Gonzalez Duarte (University of Toronto), Isaias Rojas-Perez (Rutgers University – Newark), Thomas D. Cousins (Stellenbosch University), and Sylvain Perdigon (American University of Beirut).
On Saturday, December 6th from 9-10:45am in Marriott Ballroom Salon 3 – Blue will be the session “Role playing games, interpersonal engagement, and wellbeing,” featuring Greg Batchelder (University of Alabama), Jeffrey G. Snodgrass (Colorado State University), and Nicholas J. Mizer (Texas A&M University).
On Saturday, December 6th from 9-10:45am in Jackson will be the session “Successful aging: The anthropology of a 21st-century obsession,” organized by Sarah E. Lamb (Brandeis University) and Jessica C. Robbins-Ruszkowski (Wayne State University) and featuring Susan R. Whyte (University of Copenhagen), Anna I. Corwin (University of California, Los Angeles), Mark R. Luborsky (Wayne State University), Chulanee Thianthai (Chulalongkorn University), Jessica C. Robbins-Ruszkowski (Wayne State University), and Janelle S. Taylor (University Washington).
On Saturday, December 6th from 2:30-4:15pm in Truman will be the session “Ordering, morality and triage: Producing medical anthropology beyond the suffering subject, part 2: Mental health and illness,” organized by Nolan Kline (University of South Florida) and Bo Kyeong Seo (Australian National University) and featuring Murphy J. Halliburton (Queens College and Graduate Center, CUNY), Zhiying Ma (University of Chicago), Hanna Kienzler (King’s College London), Jennie M. Simpson (American Anthropological Association), Katie Kilroy-Marac (University of Toronto Scarborough), and Shana Lessing (City University of New York Graduate Center).
On Saturday, December 6th from 2:30-4:15pm in Wilson A will be the session “‘Care’ful consideration: Examining notions of care within and toward ethnography,” organized by A. Elizabeth DeLuca (University of California Irvine) and Aaron T. Seaman (University of Chicago) and featuring Chloe Silverman (Drexel University), Janelle S. Taylor (University Washington), Mareike Winchell (University of California Berkeley), Matthew Furlong (University of Chicago), Athena McLean (Central Michigan University), and Andrea P. Sankar (Wayne State University).
On Saturday, December 6th from 4:30-6:15 in Marriott Ballroom Salon 2, Bruno Latour (Sciences Po) will deliver the AAA Distinguished Lecture: “Anthropology at the time of the anthropocene: a personal view on what is to be studied.”
On Saturday, December 6th from 6:30-8:15pm in Washington Room 3 will be the session “Bio-logics of American citizenship: Medicine, science and the state,” organized by Matthew J. Wolf-Meyer (University of California, Santa Cruz) and featuring Seth D. Messinger (CRSR and UMBC), Anna B. Zogas (University of Washington), and Karen-Sue Taussig (University of Minnesota).
On Saturday, December 6th from 6:30-8:15pm in Johnson will be the session “Critical engagements with ‘community’ in global public health,” organized by Anna M. West (Stanford University) and Lindsey J. Reynolds (Stellenbosch University) and featuring Damien Droney (Stanford University), Clare Cameron (UCSF/UC Berkeley), Salla Sariola (University of Oxford), and Oliver Human (University of Amsterdam).
On Sunday, December 7th from 8-9:45am in Maryland Suite A will be the session “The ‘Coefficient of Weirdness': Paranoia, conspiracy, and the unintelligible in rational institutions,” organized by Leo Coleman (The Ohio State University) and Noelle J. Mole (New York University) and featuring Bill Maurer (University of California Irvine), Talia Dan-Cohen (Washington University in St. Louis), and Elizabeth Anne Davis (Princeton University).
by Johan Asplund
Bokförlaget Korpen, 1987/2000, 268 pages.
Johan Asplund, whose work has been rather underrepresented in the international academic arena, is frequently seen as the “father” of contemporary Swedish social psychology. Remarkably productive, Asplund gained popularity in the 1970–1980s, and his books are still widely used in academic curricula across the country (Eriksson, 2005). The Elementary Forms of Social Life is one of Aslpund’s most famous and favored writings. Released in 1987, it introduces a distinctive view of the nature and mechanisms of sociality: the theory of social responsiveness. The concept is employed to explain a concrete social phenomenon – burnout – and, thus, has the potential to attract the attention of academics, policy makers, and the general public. The author refers to a variety of social and philosophical theories, as well as to fiction literature, although his ground is symbolic interactionism, which sees an individual as a social creature and thus virtually inconceivable outside relationships with others.
The book comprises three parts that are organized as a discussion of the fundamental aspects of human sociality. Each chapter is divided into a number of subsections, which facilitate the reader’s navigation. The book opens with an extended introduction that outlines the main concepts therein and provides a brief overview of the text. This is followed by a detailed presentation of the central theoretical framework (Chapter 1), a discussion of burnout in terms of the theory of social responsiveness (Chapter 2), and the author’s ideas on the implications of his findings for the foundations of social psychology as an academic field (Chapter 3). I will focus on the first two chapters as directly related to the issue of the social determinants of health and illness.
Asplund borrows the notion of “elementary forms” of social life – a collective basis of individual behavior (p. 30) – from the classics of social theory, striving to develop a distinctive social-psychological conception, grounded in the notion of social responsiveness. Social responsiveness is pre-normative but not pre-linguistic, potentially creative and destructive, driven by spontaneity to make up a social individual. Asplund explains: “That a human is a responsive creature means just that she has a general tendency to respond to stimuli” (p. 33, my translation here and throughout), although, in contrast to reflex, the response is never pre-programmed. Responsiveness is not a mechanistic and standardized reaction, and a responsive individual appears as an “interested creature” (p. 34).
To exemplify the concept of social responsiveness as an elementary form of social life, Asplund reflects upon an interaction between a kite and kite flyer. The kite’s free-floating movements in the sky and its erratic “reply” to the directions of the kite flyer help to illustrate the type of unstructured social exchange associated with social responsiveness. In the introductory chapter, the author warns the reader not to take the example literally: the kite flyer just “imagines the activity to be social,” “personifying” the kite or “taking its position,” in Herbert Mead’s terms (p. 15). Similarly, in another example of the interaction between a car and a driver, Asplund does not claim to acknowledge the agency of non-humans (objects and machines), as do Callon (1986) and Latour (2005), relying instead on elaborations of symbolic interactionism about an ongoing conversation between different parts of the self. This idea becomes especially useful in the further discussion on burnout, which I will turn to shortly.
Extreme forms of responsiveness may produce contradictory effects and, therefore, are frequently subjected to societal control. Asplund discusses the phenomenon of fetishism as an exaggerated manifestation of social responsiveness resulting from obsession with an object or stimulus and one’s eventual identification with it, followed by a stimulus-response stereotypy. He explains: “The fetishist emerges as a libidinous machine. The ambiguous and uncertain social responsiveness becomes unambiguous and deterministic. The fetish is confusingly similar to a key stimulus, something which triggers a fixed pattern of motions” (p. 74). When social responsiveness reaches its extreme, it transforms into social reflex and may play out as deviant actions that society tends to control by means of total institutions, such as psychiatric clinics and prisons. Asplund refers to the Foucauldian notion of “discipline” to explain a mechanism of the societal regulation of responsiveness. The spontaneity of stimulus-reaction relationships becomes restricted and organized. Discipline works through the invention of time scheduling, isolation, and the suppression of elementary affective replies.
Social responsiveness is considered in a complex relationship with its opposition, namely elementary asocial unresponsiveness or natural tiredness, leading to a switch of focus from the current to another stimulus (p. 13). Apart from that, the author elaborates on the notion of secondary asocial unresponsiveness as an effect of life in modern society. Natural attitude becomes restricted by in-socialized norms and developed rituals. The Little Prince, a fairy-tale by Antoine Saint Exupéry, is introduced as an example to ensure the reader’s comprehension of the concept. A childhood failure in getting adults to recognize a snake that swallowed an elephant uncovers a gap between the early-age social responsiveness and the secondary asocial unresponsiveness of the grown up and civilized individual. The prince appears as a “genius in social responsiveness,” whose behavior is authentic, informal, and meaningful (p. 115). His behavior contrasts with modern sociality, structured and limited by norms and (self-) regulations, a world of interactions characterized by self-absorption, lack of imagination, isolation, insensitivity, and standardization. Asplund emphasizes that ritualization of social life leads to the development of asocial unresponsiveness in society members suppressing social improvisation.
In the second chapter, the author replies to the Christina Maslach’s book Burnout: The Cost of Caring, published in 1985, with respect and a number of critical points, followed by a reformulation of the central phenomenon – burnout – in terms of the theory of social responsiveness. According to Maslach, burnout affects professionals whose labor content presupposes social interactions, such as in the sphere of welfare and service provision (e.g., a psychologist or social worker). Asplund immediately notices that many of these professions are relatively new, and, moreover, they deal with social interactions shaped by practices and ideologies of (post) industrial society. Burnout is “a process and a product of the social interactions” (p. 142). It manifests, according to Maslach, with three symptoms: emotional exhaustion, depersonalization, and a limited effectiveness of job performance (p. 143). Asplund is interested in emotional exhaustion, which is explained with the metaphor of an empty pot. This pot was once filled with water that had eventually evaporated. Thus, emotions appear as an internal resource of a person that is brought into social relationships from within and consumed. Asplund resists such a “mechanical” interpretation of emotions – “as if feelings would be petrol and that a social worker consequently would need to be filled up after the end of the workday” (Ibid.) – and the separation of emotions from interactions.
Work overloads, workplace conflicts, and unclear working requirements are some of the prerequisites of burnout for Maslach, but for Asplund, a tired social worker shouting at a client or a tired school principal who quits his job after several tough years does not necessarily suffer from burnout. What should be stressed instead, he insists, is an absence of feedback that would come as recognition of one’s existence: “If one is assumed as non-existing, so finds one oneself in a risk zone for burnout, or the experience of non-existence is already a full-developed burnout” (p. 149). Emotions are constitutive for feedback. They can be imagined as a “pendulum” in the interactive process: “When burnout has happened, the pendulum has stopped beating between ego and alter” (p. 150). Thus, burnout originates outside the individual as an outcome of social interactions; the absence of a response aborts emotionality (Ibid.).
What can cause this condition? One’s identification with their social role as a result of misbalanced relationships between the socialized and the affective part of the self, replies Asplund. In the context of the “abstract sociality” that emerged as a byproduct of the industrial-era modernization and the expansion of social sciences, people increasingly live in a “clean and empty, and abstract society”, “an invisible but omnipresent medium which pervades all specific social institutions, without coinciding with them and instead is somehow separate from them or stands above them” (p. 152). Asplund insists that burnout is a morbid state of an “abstract individual in an abstract society” (Ibid).
Abstract sociality is non-productive and blank. Interactions are not internally grounded and enacted for their own sake. Responses are “pure,” feelings are “empty”; they emerge and subside in a formalized exchange (p. 171). Concrete sociality, in contrast, is focused and meaningful. It is like a flow of the lively exchanges in which “[r]esponses and feelings do not need to consume themselves without power to speak outside” (Ibid.). Asplund acknowledges that concrete sociality is not without shortcomings (e.g., domestic conflicts). Furthermore, natural tiredness can cause a state of elementary asocial unresponsiveness, which is, however, differentiated from burnout. A doctor, who associates fully with the role of a mass-service provider, develops fixed routines and a style of reception of patients as “abstract social beings”, should be defined, according to Asplund, as suffering burnout; even beyond that, “[O]ne cannot harbor caring with abstract social creatures, empathize with them or treat them in a personal way, especially not if oneself is forced to act as an abstract social creature. Consequently, there will be not only burnout, but burnout plus a feeling of guilt” (p. 173).
Maslach’s book concludes with an emphasis on physical exercise and psychological relaxation, and Asplund does not find much new in this suggestion. He instead problematizes the role of relaxation courses as rather strengthening an individual’s experience of the self as an abstract being involved in an abstract activity. Burnout is not about the exhaustion that results from an overload of work; it signifies a shortage or lack of social responsiveness in contemporary society, which is dominated by abstract social relationships. “The pure, empty and abstract sociality is a reality and we cannot escape it. We cannot take off our social creature, our role-playing doppelganger, as if it was an overcoat” (p. 178). The only way to deal with burnout, as follows from the book, is by fostering social responsiveness in society members and the re-humanization of both private and professional interactions.
Asplund is rather an atypical writer, very popular, but hardly fully accepted within the national academic domain (Eriksson, 2005), probably due to his trans-disciplinary ambition and certain fascination with an underrepresented field of social psychology. However, his view on burnout and his critique of Maslach’s US-based studies can be seen as reflecting a particularity of the national intellectual and social-economic landscape. The developed Swedish labor protective legislation and practices, as well as the expansion of welfare state in the spheres of health care and social work (Lundström and Wijstrom, 1997) that tend to entail institutionalization, professionalization and, eventually, industrialization of service provider-consumer relationships, allow one to imagine the specific type of burnout described in Asplund’s theory. Work overload seems to be not the primary issue in the national context. Instead, the scholar views the formalization of social interactions as a major risk factor for people’s wellbeing at work. He is somewhat pessimistic in his prognosis and offers a rather limited range of solutions, since the reason for burnout is defined not as individual-psychological, but as emerging from a wide social transformation toward the standardization of different spheres of social life. Asplund appear to long for the unstructured interactions that he believes are essential and fundamentally healthy for the individual. Psychological troubles, in his view, result from suppressing and disciplining the elementary social spontaneity. This interpretation contrasts with yet another US-based exchange-type theory of overwhelming work duties and unsatisfying emotional feedback that service workers increasingly receive from their customers (Hochschild, 2005). Asplund’s book can hardly clarify whether burnout is the same for American flight attendants and health care workers in Sweden, but it certainly provokes this question and offers an alternative theoretical framework to assist the search for possible answers. The contextualization of Asplund’s writing allows the recognition of its value for a contemporary discussion of the issues of health and social-psychological wellbeing.
Lika Rodin is a lecturer in social psychology at the University of Skövde, Sweden.
The “Foreign Correspondents” series features reviews of books published in languages other than English. It is edited by Stephanie Lloyd (Laval University). If you would like to suggest a non-English language book for review or if you are interested in reviewing for “Foreign Correspondents,” please contact Stephanie directly at email@example.com.
Asplund, J. (1987). Det sociala livets elementära former. Göteborg: Bokförlaget Korpen.
Callon, M. (1986). Some elements of sociology of translation: Domestication of the scallops and the fishermen of St Brieuc Bay. In J. Law (ed.), Power, action and belief: A new sociology of knowledge? (pp. 196–223). London: Routledge & Kegan Paul.
Eriksson, B. (2005). Johan Asplund: Ideas and positions. Acta Sociologica, 48(4), 284–291.
Hochschild, A.R. (2005). The managed heart: Commercialization of human feeling. Berkley, Los Angeles, London: University of California Press.
Latour, B. (2005.) Reassembling the social: An introduction to Actor–network theory. Oxford New York: Oxford University Press.
Lundström, T., and Wijstrom, F. (1997). The nonprofit sector in Sweden. Manchester and NY: Manchester University Press.
Two journals recently published special issues on the emergence of Global Mental Health as a coherent, recognizable “formation of knowledge and practice seeking to address mental illness on a global scale” (Bemme and D’souza 2012). Together, the articles address the contours of the category, as well as the challenges and possibilities it presents, from a range of perspectives.
First, the October issue of the International Review of Psychiatry is a special issue, “Globalization, Culture and Mental Health,” guest edited by Rachel Tribe and Stephen Melluish. The issue and its content arise out of a conference held at the University of Leicester in 2012. As Tribe and Melluish write in their editorial:
While much of the tone of this special edition is critical of globalization as aligned with neoliberal capitalism, there is acknowledgement that globalization has also created new momentum for defending local uniqueness, individuality and identity. Psychology and psychiatry in the West has obviously reflected the norms and values of this region, but there are increasing calls for psychology and psychiatry to concern themselves more with global issues and culture, and a call for protecting indigenous psychologies. This special issue aims, in a small way, to develop awareness of applied psychology and psychiatry across the globe. It offers a critical perspective on any universalizing approach or any misguided imposition of westernized notions and raises the importance of a psychological perspective on how cultural and social differences play out in a global context and impact on people’s mental health and well-being. The message from the papers in this edition is that applied psychologists can make a contribution to the debates and discussions around globalization by offering more nuanced understandings of cultural differences and of indigenous psychologies.
The twelve articles that follow, along with Dinesh Bhugra’s closing commentary, productively explore this tension of globalization and mental health.
Globalization, culture and psychology
This article outlines the cultural and psychological effects of globalization. It looks at the impact of globalization on identity; ideas of privacy and intimacy; the way we understand and perceive psychological distress; and the development of the profession of psychology around the world. The article takes a critical perspective on globalization, seeing it as aligned with the spread of neoliberal capitalism, a tendency towards cultural homogenization, the imposition of dominant ‘global north’ ideas and the resultant growing inequalities in health and well-being. However, it also argues that the increased interconnectedness created by globalization allows for greater acknowledgement of our common humanity and for collective efforts to be developed to tackle what are increasingly global problems. This requires the development of more nuanced understandings of cultural differences and of indigenous psychologies.
Surprisingly little has been published directly from user/survivors in the burgeoning (and sometimes contentious) field of global mental health (GMH). This is important both ethically and practically if GMH is to benefit from the experiential expertise that user/survivors can bring, especially when they come from those lower or middle income countries (LMICs) where GMH programmes are targeted. Whether user/survivors from higher income countries (HICs) (whose experiential expertise has usually been developed in cultural/social/health/ economic/political contexts which are very different to those in LMICs) could also provide useful input to GMH is less clear. In this article I consider this directly from my perspective as a user/survivor in a HIC. I discuss how, in spite of contextual differences, there appear to be striking resonances between GMH in LMICs and mental health in HICs, particularly areas of concerns, e.g. diagnosis, treatment and cultural difference. I illustrate this using aspects of my own personal experience in a reflexive narrative way, and suggest that such narrative-illustrations could provide useful input in GMH. I also touch on other ways in which HIC user/survivors might become involved in GMH. I conclude by stressing that, however HIC user/survivors become involved in GMH, they must do so ethically, ensuring that those in LMICs always remain at the forefront.
The concept of globalization has been applied recently to ways in which mental health may be developed in low- and middle-income countries (LMICs), sometimes referred to as the ‘Third World’ or developing countries. This paper (1) describes the roots of psychiatry in western culture and its current domination by pharmacological therapies; (2) considers the history of mental health in LMICs, focusing on many being essentially non-western in cultural background with a tradition of using a plurality of systems of care and help for mental health problems, including religious and indigenous systems of medicine; and (3) concludes that in a post-colonial world, mental health development in LMICs should not be left to market forces, which are inevitably manipulated by the interests of multinational corporations mostly located in ex-colonizing countries, especially the pharmaceutical companies.
Increasing mental health capacity in a post-conflict country through effective professional volunteer partnerships: A series of case studies with government agencies, local NGOs and the diaspora community
Rachel Tribe, Dilanthi Weerasinghe, and Shanthy Parameswaran
The focus of this paper is on working in partnership with local practitioners and communities to strengthen local capacity building in the area of mental health and well-being in Sri Lanka. This paper will examine the context, organizing concepts, organizational processes, and the development of good working relationships and partnership building behind this work. Our involvement was based on requests which came to the authors as a result of their previous work in Sri Lanka over several decades. This work had been undertaken on behalf of the UK–Sri Lanka Trauma Group (UKSLTG), a UK-based charity which was set up in 1994, and of which the authors are founding members (www.uksrilankatrauma.org.uk). In the first section of the paper, contextual issues will be discussed. The second section of the paper provides details of the training undertaken on mental health promotion among young people in Sri Lanka for the Directorate of Mental Health. The third section of the paper reviews work undertaken with a major psycho-social/mental health organization on issues relating to writing and implementing an ethical code for mental health practitioners and briefly discusses some of the dilemmas associated with this.
Current status of psychology and clinical psychology in India – An appraisal
Baboo Sankar Virudhagirinathan and Subbiah Karunanidhi
This paper provides an overview of the social and cultural context for the emergence and development of psychology in India and also more specifically of the development of clinical psychology. It details the range of universities offering psychology programmes and the various bodies involved in supporting the development of the psychology. The paper also describes the development of clinical psychology in India and the variety of roles undertaken by clinical psychologists. Finally, it raises a number of issues facing the development of Indian psychology into the future.
Developing cognitive behaviour therapy training in India: Using the Kolb learning cycle to address challenges in applying transcultural models of mental health and mental health training
Andrew Beck, B. S. Virudhagirinathan, Sangita Santosham, and Faiz Jahan Begum
Although mental health workers in India across all major professional groups have identified an unmet need for training in cognitive behaviour therapy (CBT), the uncritical export of models of mental health, therapy provision and training to low- and middle-income countries is a problematic process. This paper describes the context for the first stand-alone CBT training programme in India, based in Chennai. This paper includes an evaluation of the first phase of the training and information from trainees regarding the quality and applicability of the training to their working context. The paper provides an overview of some of the critiques that are pertinent to this process and considers the way that the Kolb learning cycle can be used as a framework within training to go some way to addressing these difficulties.
Globalization of psychology: Implications for the development of psychology in Ethiopia
Rachel Swancott, Gobinderjit Uppal, and Jon Crossley
The present article reports on the variation of mental health resources across the globe and considers the merits or otherwise of the process of globalization in low- and middle-income countries (LMIC), with a specific emphasis on Ethiopia. Although globalization has gained momentum in recent years, there is a concern that the globalization of Western mental health frameworks is problematic, as these concepts have been developed in a different context and do not accommodate the current diversity in understanding in LMIC countries. The importance of understanding the mental health frameworks of LMIC like Ethiopia, prior to considering if and how aspects of high-income countries (HIC) conceptualizations may be appropriately imported, is therefore reflected upon. Traditional approaches in managing mental health difficulties and possible reasons for the limited engagement with clinical psychology in Ethiopia are considered. Current developments within the fields of mental health and clinical psychology in Ethiopia are discussed, and the need to develop more local research in order to increase understanding and evaluate treatment interventions is recognized. Further consideration and debate by Ethiopian mental health professionals as well as those from HIC are recommended, to promote both reciprocal learning and new local discourses about mental health.
The introduction and development of psychology in Ethiopia has been mainly limited to Addis Ababa University in the capital city, and also to educational and school psychology which was highly influenced by the field of education at this pioneering university. Similarly, mental health services have been principally developed at the Amanuel Mental Hospital in Addis Ababa that has existed since the 1950s. However, the expansion of higher learning institutions on one hand, and the apparent growing prevalence of mental illness on the other, seem to have contributed to the development of both mental health training and services in other regional cities and towns. Although the influence of the education-oriented psychological training of the Addis Ababa University is still present, clinical psychology education and services are now being started in other universities. One of these is the master’s programme in clinical psychology opened for the first time in the University of Gondar. This article sheds light on the development of psychology in Ethiopia and addresses some of the issues raised about the factors that have influenced its development such as traditional beliefs, poverty and comparisons between mental health in lower middle-income countries and higher middle-income countries (Uppal et al., 2014). The paper also proposes future directions for the education, research, infrastructure and services of clinical psychology and mental health in Ethiopia.
Globalization has created great transformations, not only in economics, but also in social and cultural relations, and has influenced political practices and governments. If not critically analysed, globalization may at first appear positive, but, in parallel with its development, high levels of poverty and exclusion have occurred and these may affect men and women differently. The objective of this article is to reveal the subjective or individual consequences that derive from globalization and the contexts it creates. This analysis centres on a gender perspective within a Cuban context and tries to challenge the prevailing view of the most poor and excluded groups. Psychiatry and psychology have a long way to go in the search for an understanding of the impact of globalization on human well-being, but critical thinking and the social sciences can offer an alternative to the transformation of this constructed order by giving prominence to people’s own subjectivities and experiences.
Cuban internationalism – An alternative form of globalization
Maria Castro, Steve Melluish, and Alexis Lorenzo
This paper looks at how the principles of internationalism have been integral to the Cuban healthcare system and to Cuba’s cooperation and medical support in other countries around the world. The paper details the range and scope of Cuban health internationalism and the principles that underpin the Cuban approach of long-term collaboration, humane care, contextualization, trans-disciplinarity, respect for collective/historical memory and an ethical stance. The paper details the role of Cuban psychologists who have contributed to disaster relief work and gives an example of the Cuban approach in relation to Haiti following the earthquake in 2010.
Counterflows for mental well-being: What high-income countries can learn from Low and middle-income countries
Ross White, Sumeet Jain, and Catalina Giurgi-Oncu
Global mental health is a comparatively new area of study and research that is concerned with addressing inequities and inequalities in mental health provision across the globe. In recent years concerted efforts have been made to scale up mental health services in low- and middle-income countries (LMIC). As such, there has been tendency to view LMIC as recipients of mental health-related knowledge, rather than providers of knowledge. Critics have referred to the prevailing flow of information from high-income countries (HIC) to LMIC as a form of medical imperialism. To redress the apparent imbalance in knowledge exchange, this paper reflects on valuable lessons that HIC can potentially learn from LMIC in terms of supporting mental well-being. Specifically, the paper reflects on how a greater willingness to embrace pluralism in HIC may facilitate people to engage with forms of support that they believe to be appropriate for them. The paper also explores examples of what are termed ‘counterflows’ of knowledge; ideas that have originated from LMIC that are influencing mental health-related practice in HIC. Barriers to potential counterflows are discussed.
Using a cultural formulation for assessment of homicide in forensic psychiatry in the UK
Ali Ajaz, John Owiti, and Kamaldeep Bhui
Healthcare inequalities for black and minority ethnic (BME) patients in forensic mental health services in the UK are stark. Despite the level of attention given to this over the last 15 years there has been little progress to address disparities. There is a great deal of confusion over what is understood by culture, and what aspects of culture signal specific needs of BME patients. In addition, we have a lack of empirical research demonstrating what it means for psychiatrists to be culturally competent. These are all important barriers against progress in this area. Using a homicide case study that illustrates the typical issues encountered in practice, we explore how to use a cultural formulation in order to assess the role of culture within a forensic psychiatry setting. Finally, practical advice is offered to assist expert witnesses in preparing court reports that adequately consider the significance of defendants’ cultural beliefs and practices.
Globalization, culture and mental health
Individual changes due to the impact of globalization and also resulting cultural changes may be at conflicting positions, especially in the area of expressing and managing emotional and psychological distress. In this volume, Tribe, Melluish, and their colleagues have brought together a rich smorgasbord of intellectual thoughts on the subject of globalization. This topic is likely to give rise to a range of increasing possibilities, challenges, and discussions in the future and may require our continued attention as the inter-relationships between globalization, culture, and mental health continue to evolve. The heterogeneous response of cultures to globalization could be seen as a positive step. However, powerful and profitable vested interests resist criticism for their actions, but have to be challenged. As clinicians, each of us has a major responsibility to advocate for our patients to ensure that their interests are maintained and indeed protected.
Second, the December issue of Transcultural Psychiatry also addresses the subject in a special section entitled “Global Mental Health“. (For a write-up in Somatosphere of the conference that led to this publication, see Bemme and D’souza 2012). Abstracts for the articles, along with an introduction by Laurence Kirmayer and Duncan Pedersen, are below.
Toward a new architecture for global mental health
Laurence J. Kirmayer and Duncan Pedersen
Current efforts in global mental health (GMH) aim to address the inequities in mental health between low-income and high-income countries, as well as vulnerable populations within wealthy nations (e.g., indigenous peoples, refugees, urban poor). The main strategies promoted by the World Health Organization (WHO) and other allies have been focused on developing, implementing, and evaluating evidence-based practices that can be scaled up through task-shifting and other methods to improve access to services or interventions and reduce the global treatment gap for mental disorders. Recent debates on global mental health have raised questions about the goals and consequences of current approaches. Some of these critiques emphasize the difficulties and potential dangers of applying Western categories, concepts, and interventions given the ways that culture shapes illness experience. The concern is that in the urgency to address disparities in global health, interventions that are not locally relevant and culturally consonant will be exported with negative effects including inappropriate diagnoses and interventions, increased stigma, and poor health outcomes. More fundamentally, exclusive attention to mental disorders identified by psychiatric nosologies may shift attention from social structural determinants of health that are among the root causes of global health disparities. This paper addresses these critiques and suggests how the GMH movement can respond through appropriate modes of community-based practice and ongoing research, while continuing to work for greater equity and social justice in access to effective, socially relevant, culturally safe and appropriate mental health care on a global scale.
Why mental health matters to global health
Global health has been defined as an area of study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. This article provides an overview of some central issues in global mental health in three parts. The first part demonstrates why mental health is relevant to global health by examining three key principles of global health: priority setting based on the burden of health problems, health inequalities and its global scope in particular in relation to the determinants and solutions for health problems. The second part considers and addresses the key critiques of global mental health: (a) that the “diagnoses” of mental disorders are not valid because there are no biological markers for these conditions; (b) that the strong association of social determinants undermines the use of biomedical interventions; (c) that the field is a proxy for the expansion of the pharmaceutical industry; and (d) that the actions of global mental health are equivalent to “medical imperialism” and it is a “psychiatric export.” The final part discusses the opportunities for the field, piggybacking on the surge of interest in global health more broadly and on the growing acknowledgment of mental disorders as a key target for global health action.
Global mental health research is needed to inform effective and efficient services and policy interventions within and between countries. Ethical reflection should accompany all GMHR and human resource capacity endeavors to ensure high standards of respect for participants and communities and to raise public debate leading to changes in policies and regulations. The views and circumstances of ethno-cultural and disadvantaged communities in the Majority and Minority world need to be considered to enhance scientific merit, public awareness, and social justice. The same applies to people with vulnerabilities yet who are simultaneously capable, such as children and youth. The ethical principles of respect for persons or autonomy, beneficence/non-maleficence, justice, and relationality require careful contextualization for research involving human beings. Building on the work of Fisher and colleagues (2002), this article highlights some strategies to stimulate the ethical conduct of global mental health research and to guide decision-making for culturally responsible research, such as developing culturally sensitive informed consent and disclosure policies and procedures; paying special attention to socioeconomic, cultural, and environmental risks and benefits; and ensuring meaningful community and individual participation. Research and capacity-building partnerships, political will, and access to resources are needed to stimulate global mental health research and consolidate ethical practice.
Challenges of creating synergy between global mental health and cultural psychiatry
Joop T. V. M. de Jong
This article addresses four major challenges for efforts to create synergy between the global mental health movement and cultural psychiatry. First, although they appear to share domains of mutual interest, the worlds of global mental health and cultural psychiatry have distinct lineages. Expanding their horizons by learning from adjacent disciplines would be mutually beneficial. A second challenge concerns the conceptualization of a new classification system for mental health problems. Adopting a classification system that integrates new insights from socio-neurobiology and from a networks perspective could bring cultural psychiatry and global mental health closer and change the way each field addresses the mental health gap, which constitutes the third challenge. I summarize attempts to achieve comprehensive mental health coverage around the globe and question whether the strategies employed to achieve these goals have been successful, both in high- (HIC) and low- and middle-income countries (LMIC). In LMIC, the dominant strategy needs to be complemented by mobilization of other community resources including local practitioners. A fourth challenge is the lack of mathematical models to guide action and research and solve major preoccupations such as access to care or multi-level analyses in complex ecological or health systems.
Ritual healing and mental health in India
Ritual healing is very widespread in the Indian state of Uttarakhand, and is by far the most common option for those with serious behavioral disturbances. Although ritual healing thus accounts for a very large part of the actual health care system, the state and its regulatory agencies have, for the most part, been structurally blind to its existence. A decade of research on in this region, along with a number of shorter research trips to healing shrines and specialists elsewhere in the subcontinent, and a thorough study of the literature, suggest that such techniques are often therapeutically effective. However, several considerations suggest that ritual healing may not be usefully combined with mainstream “Western” psychiatry: (a) psychiatry is deeply influenced by the ideology of individualism, which is incompatible with South Asian understandings of the person; (b) social asymmetries between religious healers and health professionals are too great to allow a truly respectful relationship between them; and (c) neither the science of psychiatry nor the regulatory apparatus of the state can or will acknowledge the validity of “ritual therapy”—and even if they did so, regulation would most likely destroy what is most valuable about ritual healing. This suggests that it is best if the state maintain its structural blindness to ritual healing.
Global mental health and its discontents: An inquiry into the making of global and local scale
Doerte Bemme and Nicole A. D’souza
Global Mental Health’s (GMH) proposition to “scale up” evidence-based mental health care worldwide has sparked a heated debate among transcultural psychiatrists, anthropologists, and GMH proponents; a debate characterized by the polarization of “global” and “local” approaches to the treatment of mental health problems. This article highlights the institutional infrastructures and underlying conceptual assumptions that are invested in the production of the “global” and the “local” as distinct, and seemingly incommensurable, scales. It traces how the conception of mental health as a “global” problem became possible through the emergence of Global Health, the population health metric DALY, and the rise of evidence-based medicine. GMH also advanced a moral argument to act globally emphasizing the notion of humanity grounded in a shared biology and the universality of human rights. However, despite the frequent criticism of GMH promoting the “bio”-medical model, we argue that novel logics have emerged which may be more important for establishing global applicability than arguments made in the name of “nature”: the procedural standardization of evidence and the simplification of psychiatric expertise. Critical scholars, on the other hand, argue against GMH in the name of the “local”; a trope that underlines specificity, alterity, and resistance against global claims. These critics draw on the notions of “culture,” “colonialism,” the “social,” and “community” to argue that mental health knowledge is locally contingent. Yet, paying attention to the divergent ways in which both sides conceptualize the “social” and “community” may point to productive spaces for an analysis of GMH beyond the “global/local” divide.
On January 17th 2014, Catherine Eagles, a federal judge for the Middle District of North Carolina, struck down as unconstitutional a portion of North Carolina’s 2011 Women’s Right to Know Act. The portion in question would have required abortion providers in the state to perform an ultrasound and display and describe the images presented to every woman seeking an abortion. Eagles concluded that this so-called “speech-and-display provision” was “performative rather than informative” and therefore served no medical purpose. She determined this in part because the original text of the law suggested that women might choose not to look at these ultrasound images: “Nothing in this section shall be construed to prevent a pregnant woman from averting her eyes from the ultrasound images required to be provided to and reviewed with her.” In a 42-page memorandum outlining her decision, Eagles wrote, “Requiring a physician or other health care provider to deliver the state’s content-based, non-medical message in his or her own voice as if the message was his or her own constitutes compelled ideological speech and warrants the highest degree of First Amendment protection.”
Abortion rights advocates in North Carolina hailed the ruling as an important victory. Yet the remainder of the Women’s Right to Know Act still stands: women must receive counseling with specific, state-mandated information at least 24 hours prior to an abortion procedure. To comply with the law, then, an abortion provider must “deliver a content-based, non-medical message in his or her own voice.” In our ongoing project, we are examining how abortion providers in North Carolina have grappled with this legal mandate. We have been especially interested in the social, ethical, and communicative dimensions of scripted abortion counseling.
Scripts play a key role in anthropology and science and technology studies. Foundational concepts like cultural scripts and technological scripts reflect a disciplinary preoccupation with the ways in which certain domains of human social life are partially predetermined. Yet the potential for social actors to stray from the script to improvise new possibilities and create new modes of action is also embedded in these concepts. In other words, the very presence of any script implies its logical opposite: that we also speak and act in fundamentally unscripted ways. In this way, the script reflects longstanding tensions in contemporary theoretical debates—between structure and agency, determinism and emergence, constraint and possibility, compulsion and choice.
Scripts are ubiquitous in science and medicine. Hospital procedures, informed consent documents, experiment protocols, standardized therapies, and ultrasound technologies all rely on scripts to order work processes, guide thoughts, speech, and action, and specify roles and relationships. As institutionally authored documents, scripts enact and shape worlds by conveying the author’s intended meaning. Yet scripts do more than relay referential meaning. They also produce effects, sometimes unintended, through the ways that they are implemented and performed. Such productivity can help us to bypass the dualisms mentioned above and generate potential new sites of theoretical inquiry.
The script at play in state-mandated abortion counseling is a highly formalized version of a much broader techno-social category. Clinicians rely on various scripts in conversations with patients—for example, asking “What brings you in today?” A few things distinguish abortion counseling scripts from colloquial uses of scripts in medicine: their legally compulsory nature, their selection of particular speech elements, and their capacity to transform healthcare providers into agents of the state. The state, an amorphous political subject, has relatively little power to speak to citizens in everyday life. By compelling providers to speak its message, the state flips the script undergirding most clinical interaction.
Most abortion providers in our study found both the state’s intentions and the potential effects of the counseling script on patients to be objectionable. As one physician told us, “I find it very condescending. As if women aren’t being given proper informed consent or decision-making about their abortion care. While others, you know, like legislatures, are trying to take away their decision-making and autonomy.” Because of this disdain for the script, the many possibilities for undermining its content have been empowering and even liberating. Some providers prefaced the script with disclaimers and apologies. Others read the script “word by word” to show that the words were not their own. Still others set the script in front of the patient to distinguish it as a legal artifact that they viewed as falling outside of normal clinical practice. Each of these actions served to denounce authorship, disaffiliate speakers from the animated content, and invite patients not to listen. Several providers noted that such strategies had the unanticipated consequence of fostering patient-provider rapport, revealing a misalignment between perceived legislative intent and the script’s performance. This highlights how the rift between meaning and intent can cut both ways, working both for and against the author’s agenda.
In our study, providers routinely distinguished scripted abortion counseling from the informed consent procedures that they were already doing prior to the law. As an enumeration of the risks and benefits associated with clinical treatment, drug research, or specimen donation, informed consent also relies on scripts. Providers distinguished the scripts used in state-mandated counseling and clinical informed consent on the basis of whether the content was medically relevant and necessary to women’s informed decision-making. This difference is also implicit in Judge Eagles’ distinction between the performative (i.e. non-medically relevant) and informative functions of the search-and-display provision. In making this distinction, both Judge Eagles and our interlocutors attempted to frame the law as an illegitimate instance of script-flipping—that is, appropriating the language, format, and authoritative voice of informed consent for another purpose. Yet insofar as informed consent is both one of the most routinized scripts in medicine and a paradigmatic example of information delivery in healthcare, this distinction begins to break down. Informed consent assumes the genre of disclosure that many patients in the United States have learned to view as a legal performance, an institutional requirement necessary to move along one’s clinical care. In other words, informed consent procedures have both informative and performative dimensions. By distinguishing between state-mandated abortion counseling and standard informed consent procedures, the providers in our study reified informed consent as purely informative, neglecting the performative dimensions of this everyday scripted practice.
State-mandated abortion counseling is a specialized case of the use of scripts in medicine. Medicine relies on many other taken-for-granted and routinized scripts. One strength of the script for scholars of science and medicine is that it “reads” across the ethical and legal, as in the case of informed consent. In doing so, it shows how the medical and the legal are not separate professional domains but necessarily co-constituted.
Mara Buchbinder is Assistant Professor of Social Medicine and Adjunct Assistant Professor of Anthropology at the University of North Carolina at Chapel Hill. She is author of Saving Babies? The Consequences of Newborn Genetic Screening (with Stefan Timmermans, University of Chicago Press, 2013) and All in Your Head: Making Sense of Pediatric Pain (University of California Press, forthcoming, 2015). Dragana Lassiter is a PhD candidate in the Department of Anthropology at the University of North Carolina-Chapel Hill. She researches bioethics, regenerative medicine, and organ transplant in Serbia. They are grateful for insightful comments from Keith Murphy and Stefan Timmermans, and for the editorial suggestions of Commonplaces Editors Tomas Matza and Harris Solomon.
 For the full legislative text of the North Carolina Woman’s Right to Know Act, see http://www.ncleg.net/gascripts/BillLookUp/BillLookUp.pl?BillID=H854&Session=2011.
 For the full text of this memorandum, see http://dig.abclocal.go.com/wtvd/docs/utrasound_rluling_011714.pdf.
 This work has been supported by grants from the Society for Family Planning and the Greenwall Foundation, in collaboration with Rebecca Mercier, Amy Bryant, and Anne Drapkin Lyerly.
 Madeline Akrich, “The de-scription of technical objects, in Shaping Technology / Building Society. Studies in Sociotechnical Change. W. Bijker and J. Law, eds. (Cambridge, MA: MIT Press, 1992); and Stefan Timmermans, “Saving lives or saving multiple identities?: The double dynamic of resuscitation scripts,” Social Studies of Science, 26(4) (1996): 767–797.
Carr (2011, 191) suggests that script flipping is an example of what Bakhtin (1984) calls vari-directional double-voiced discourse, “in which one’s speech has a semantic intent contrary to that which one mimics.” See E. Summerson Carr, Scripting Addiction: The Politics of Therapeutic Talk and American Sobriety (Princeton: Princeton University Press, 2011). See also Mihkail Bakhtin, Problems of Dostoevksy’s Poetics. C. Emerson, trans. and ed. (Minneapolis: University of Minnesota Press, 1984).
 Erving Goffman, Forms of Talk (Philadelphia, PA: University of Pennsylvania Press, 1981).
 Marie-Andrée Jacob, “Form-made persons: consent forms as consent’s blind spot,” Political and Legal Anthropology Review, 30(2) (2007): 249–268. doi:10.1525/pol.2007.30.2.249
Image: “Lacy Script, by Evelyn Flynt.” Flickr.
Somatosphere seeks a Managing Editor to help run the day-to-day operations of the website, as well as to develop new projects and initiatives. The Managing Editor will work with members of the site’s Editorial Collaborative, regular and guest contributors to: oversee the submission, editing, and formatting of posts; manage the site’s social media presence; and aid in developing new series and projects. We are looking for candidates with: strong written and verbal communication skills; experience in editing scholarly writing; familiarity with WordPress, HTML and social media; a background in a particular field of the social sciences and humanities of medicine, health, and science (anthropology, sociology, history, STS, geography, etc.); a commitment to Somatosphere’s aims and potential. Candidates with experience in academic publishing and/or SEO management are particularly welcome.
This is a part-time paid position, with an expected time commitment of approximately 7-10 hours per week. Candidates can be located anywhere geographically, but must have regular internet access.
Somatosphere (http://somatosphere.net) is a collaborative scholarly website which has been covering the social sciences and humanities of medicine, health, and science — and particularly medical anthropology — since 2008.
Please submit a cover letter, CV, and list of three references to Eugene Raikhel, Editor at eraikhel AT uchicago DOT edu by December 1.
Happy November! Please find below the first half of this month’s roundup including selections from American Ethnologist; Health; Philosophy, Ethics, and Humanities in Medicine; Sociology of Health and Illness; and Social Theory and Health. In addition, Medical Anthropology Theory (MAT) went live this month. There is a previous write-up on MAT on Somatosphere—you can find it here. Enjoy.
The paradoxical victim: Intimate violence narratives on trial in Italy
Victims’ testimony plays a pivotal role in domestic violence hearings in Italy. In examining this role, Gribaldo approaches the Italian legal field as a heterogeneous system of knowledge and power that engages in complex relations with techniques of subjection and discourses of truth and, thus, as eminently suited to investigating the production of the victim-subject. Paradoxically, the testimony of female victims of abuse is trapped between the normativity of justice system requirements and the confessional device, rendering it legally insignificant and thus essentially inadequate. In this context, the women’s credibility and agency are central. Gribaldo outlines one legal case in which race and class intersect and the required modes of testimony are disrupted through the use of communication styles drawn from popular culture.
The context of empowerment and self-care within the field of diabetes
Sasha Scambler, Paul Newton, and Koula Asimakopoulou
There is a growing emphasis within the diabetes literature on the importance of empowerment as a way of encouraging people to take control of and responsibility for the successful management of their disease. Patients are actively encouraged to become active participants in their care, and there is an expectation that health-care professionals will facilitate this process. This article uses Bourdieu’s concept of field, as a bounded social space in which actors conduct their lives day-to-day, to explore the context within which issues of empowerment are addressed and negotiated. The practice of empowerment within the biologically defined and biomedically ‘policed’ field of diabetes is explored using empirical data from a study of diabetes health-care professionals’ understanding and practices around empowerment. It is concluded that rather than promoting active self-management and empowerment, the nature of the field of diabetes, and in particular its privileging of the biomedical, can mitigate against people with diabetes negotiating the field effectively and taking control of the disease and its management.
Local status and power in area-based health improvement partnerships
Katie Powell, Miranda Thurston, and Daniel Bloyce
Area-based initiatives have formed an important part of public policy towards more socio-economically deprived areas in many countries. Coordinating service provision within and across sectors has been a common feature of these initiatives. Despite sustained policy interest in area-based initiatives, little empirical work has explored relations between area-based initiative providers, and partnership development within this context remains under-theorized. This article addresses both of these gaps by exploring partnerships as a social and developmental process, drawing on concepts from figurational sociology to explain how provider relations develop within an area-based initiative. Qualitative methods were used to explore, prospectively, the development of an area-based initiative targeted at a town in the north west of England. A central finding was that although effective delivery of area-based initiatives is premised on a high level of co-ordination between service providers, the pattern of interdependencies between providers limits the frequency and effectiveness of co-operation. In particular, the interdependency of area-based initiative providers with others in their organization (what is termed here as ‘organizational pull’) constrained the ways in which they worked with providers outside of their own organizations. ‘Local’ status, which could be earned over time, enabled some providers to exert greater control over the way in which provider relations developed during the course of the initiative. These findings demonstrate how historically constituted social networks, within which all providers are embedded, shape partnership development. The theoretical insight developed here suggests a need for more realistic expectations among policymakers about how and to what extent provider partnerships can be managed.
This paper critically appraises the discourse around international medical migration at the turn of the 21st century. A critical narrative review of a range of English-language sources, including grey literature, books and research reports, traces the development and spread of specific causative models. The attribution of causative relations between the movement of skilled medical workers, the provision of health care and population health outcomes illustrates how the global reach of biomedicine has to be understood in the context of local conditions. The need to understand migration as an aspect of uneven global development, rather than a delimited issue of manpower services management, is illustrated with reference to debates about ‘brain drain’ of Africa’s health-care professionals, task-shifting and the crisis in health-care human resources. The widespread presumed cause of shortages of skilled health-care staff in sub-Saharan Africa was overdetermined by a compelling narrative of rich countries stealing poor countries’ trained health-care professionals. This narrative promotes medical professional interests and ignores historical patterns of underinvestment in health-care systems and structures. Sociological theories of medicalization suggest that the international marketization of medical recruitment is a key site where the uneven global development of capital is at work. A radical reconfiguration of medical staffing along the lines of ‘task-shifting’ in rich and poor countries’ health-care systems alike offers one means of thinking about global equity in access to quality care.
Roslyn Weaver, Ian Wilson, and Vicki Langendyk
Previous research has pointed to the role television can play in informing health practices and beliefs. Within the academic setting in particular, some educators have raised concerns about the influence of medical dramas on students. Less research, however, draws on the perspectives of students, and this study therefore explores medical students’ perceptions of medical practice and professionalism in popular medical television programs. Qualitative data from surveys of Australian undergraduate medical students showed that students perceived professionalism in dichotomous ways, with three main themes: cure–care, where a doctor’s skill is either technical or interpersonal; work–leisure, where a doctor is either dedicated to work or personal life; and clinical–administration, where work is either direct patient care or administration. There continue to be imagined divisions between curing and caring for students, who express concerns about balancing work and leisure, and expectations that doctors should have little administrative work. Given students were able to identify these important contemporary issues around professionalism on television, there is pedagogical value in using popular images of the medical world in medical education.
The experiences of close persons caring for people with chronic kidney disease stage 5 on conservative kidney management: Contested discourses of ageing
Joe Low, Jason Myers, Glenn Smith, Paul Higgs, Aine Burns, Katherine Hopkins, and Louise Jones
Chronic kidney disease stage 5 is a global health challenge in the context of population ageing across the world. The range of treatment options available to patients at all ages has increased and includes transplantation and dialysis. However, these options are often seen as inappropriate for older frailer patients who are now offered the option of conservative kidney management, which is presented as a non-invasive alternative to dialysis, involving symptom management and addressing psychosocial needs. In this study, we conducted qualitative interviews with 26 close persons caring for someone with chronic kidney disease stage 5 in the United Kingdom to investigate how conservative kidney management interacted with implicit ideas of ageing, in both the experience of conservative kidney management and the understanding of the prognosis and future care of the kidney disease. Our findings highlighted participant confusion about the nature of conservative kidney management, which stems from an initial lack of clarity about how conservative kidney management differed from conventional treatments for chronic kidney disease stage 5. In particular, some respondents were not aware of the implicit palliative nature of the intervention or indeed the inevitable end-of-life issues. Although these findings can be situated within the context of communication failure, we would further argue that they also bring to the surface tensions in the discourses surrounding ageing and old age, drawing on the use of a ‘natural’ and a ‘normal’ paradigm of ageing. In the context of chronic kidney disease stage 5, more patients are being dialyzed at older ages, but conservative kidney management is being advanced as a better option than dialysis in terms of quality of life and experience. However, in doing so, conservative kidney management implicitly draws on a notion of older age that echoes natural ageing rather than advocate a more interventionist approach. The role of discourses of ageing in the provision of treatments for conservative kidney management has not previously been acknowledged, and this article addresses this gap.
Parent-led conferences as sites of medical work
Conferences are novel sites for understanding medical work. Through describing styles of presentation that take place at conferences attended by patients and parents, this article highlights how clinicians on stage present ordinary and extraordinary aspects of medicine. Attention is drawn to the reaction of the parents in the audience. The power of the presenter to direct proceedings highlights the potential vulnerability of the audience. The relationship between clinician on stage and parents in the audience reflects the clinical relationship between doctor and patient. But through identifying insiders and outsiders, the conference setting also enables new relationships and collective identities to be formed. Drawing on an ethnographic study of rare disease conferences, this article extends understanding of medical work by identifying how conferences offer new ways of witnessing the clinical gaze, the doctor–patient relationship and the formation and enactment of a conference community.
Timescapes of obesity: Coming to terms with a complex socio-medical phenomenon
Ulrike Felt, Kay Felder, Theresa Öhler, and Michael Penkler
Obesity is generally considered to be a growing global health problem that results from changes in the way we live in late modern societies. In this article, we argue that investigating the complexities of contemporary timescapes (i.e. the entanglement of physical, culturally framed and personally experienced times) is of key importance for understanding how ‘the obesity phenomenon’ is conceptualized, performed and acted upon. Analyzing both focus groups and print-media articles, we identified three major groups of temporal narratives that shape our perception of obesity: trajectories, temporalities and timing. Each group of narratives follows a different logic and performs a specific kind of ordering work: ontological work that defines what obesity ‘really is’, diagnostic work that assesses the state of contemporary society and moral work that assigns responsibility to act. We show how the narratives are assembled into distinct timescapes that distribute agency in specific ways. Combining data from both focus groups and media articles allows us to analyze how these two discursive arenas are intertwined, as it makes visible how stories travel and converge, but also diverge in quite important ways. This highlights the importance of a multi-arena approach to fully understand the tensions between different framings of health-related issues. The article argues that the difficulties of controlling body weight are closely entangled with a perceived lack of control over time on both collective and individual levels. In conclusion, we suggest time-sensitive approaches for the analysis of health phenomena and the development of corresponding policy measures.
Discourse on medicine: meditative and calculative approaches to ethics from an international perspective
David Cruise Malloy, Ronald Martin, Thomas Hadjistavropoulos, Peilai Liu, Elizabeth Fahey McCarthy, Ilhyeok Park, N Shalani, Masaaki Murakami and Suchat Paholpak
Heidegger’s two modes of thinking, calculative and meditative, were used as the thematic basis for this qualitative study of physicians from seven countries (Canada, China, India, Ireland, Japan, Korea, & Thailand). Focus groups were conducted in each country with 69 physicians who cared for the elderly. Results suggest that physicians perceived ethical issues primarily through the lens of calculative thinking (76%) with emphasis on economic concerns. Meditative responses represented 24% of the statements and were mostly generated by Canadian physicians whose patients typically were not faced with economic barriers to treatment due to Canada’s universal health care system.
Nonconsensual withdrawal of nutrition and hydration in prolonged disorders of consciousness: Authoritarianism and trustworthiness in medicine
Mohamed Y Rady and Joseph L Verheijde
The Royal College of Physicians of London published the 2013 national clinical guidelines on prolonged disorders of consciousness (PDOC) in vegetative and minimally conscious states. The guidelines acknowledge the rapidly advancing neuroscientific research and evolving therapeutic modalities in PDOC. However, the guidelines state that end-of-life decisions should be made for patients who do not improve with neurorehabilitation within a finite period, and they recommend withdrawal of clinically assisted nutrition and hydration (CANH). This withdrawal is deemed necessary because patients in PDOC can survive for years with continuation of CANH, even when a ceiling on medical care has been imposed, ie, withholding new treatment such as cardiopulmonary resuscitation for acute life-threatening illness. The end-of-life care pathway is centered on a staged escalation of medications, including sedatives, opioids, barbiturates, and general anesthesia, concurrent with withdrawal of CANH. Agitation and distress may last from several days to weeks because of the slow dying process from starvation and dehydration. The potential problems of this end-of-life care pathway are similar to those of the Liverpool Care Pathway. After an independent review in 2013, the Department of Health discontinued the Liverpool Care pathway in England. The guidelines assert that clinicians, supported by court decisions, have become the final authority in nonconsensual withdrawal of CANH on the basis of “best interests” rationale. The authors posit that these guidelines lack high-quality evidence supporting: 1) treatment futility of CANH, 2) reliability of distress assessment from starvation and dehydration, 3) efficacy of pharmacologic control of this distress, and 4) proximate causation of death. Finally, the authors express concerns about the utilitarian-based assessment of what constitutes a person’s best interests. The authors express their dismay at the level and the role of medical authoritarianism institutionalized by these national guidelines when deciding on the worthiness of life in PDOC. The authors conclude that these guidelines are not only harmful to patients and families, but they represent the means of nonconsensual euthanasia. The latter would constitute a gross violation of the public’s trust in the integrity of the medical profession.
Spanning our differences: moral psychology, physician beliefs, and the practice of medicine
Ryan M Antiel, Katherine M Humeniuk and Jon C Tilburt
Moral pluralism is the norm in contemporary society. Even the best philosophical arguments rarely persuade moral opponents who differ at a foundational level. This has been vividly illustrated in contemporary debates in bioethics surrounding contentious issues such as abortion and euthanasia. It is readily apparent that bioethics discourse lacks an empirical explanation for the broad differences about various topics in bioethics and health policy. In recent years, social and cognitive psychology has generated novel approaches for defining basic differences in moral intuitions generally. The authors propose that if empirical research using social intuitionist theory explains why people disagree with one another over moral issues, then the results of such research might help people debate their moral differences in a more constructive and civil manner. The authors illustrate the utility of social intuitionism with data from a national physician survey.
Ebola, epidemics, and ethics – what we have learned
G Kevin Donovan
The current Ebola epidemic has presented challenges both medical and ethical. Although we have known epidemics of untreatable diseases in the past, this particular one may be unique in the intensity and rapidity of its spread, as well as ethical challenges that it has created, exacerbated by its geographic location. The authors look at the infectious agent and the epidemic it is causing, in order to understand the ethical problems that have arisen.
Long-term ill health and the social embeddedness of work: a study in a post-industrial, multi-ethnic locality in the UK
Kaveri Qureshi, Sarah Salway, Punita Chowbey and Lucinda Platt
Against the background of an increasingly individualizing welfare-to-work regime, sociological studies of incapacity and health-related worklessness have called for an appreciation of the role of history and context in patterning individual experience. This article responds to that call by exploring the work experiences of long-term sick people in East London, a post-industrial, multi-ethnic locality. It demonstrates how the individual experiences of long-term sickness and work are embedded in social relations of class, generation, ethnicity and gender, which shape people’s formal and informal routes to work protection, work-seeking practices and responses to worklessness. We argue that this social embeddedness requires greater attention in welfare-to-work policy.
Increasing longevity and prevalence of long-term conditions contribute to older adults being the greatest users of health services. However, relatively little is known about the health and illness beliefs of the oldest old or how they decide to seek help in response to symptoms. Through analysis of in-depth interviews with day center attendees aged 80–93, we find that a moral, hierarchical approach to health problems and help-seeking exists; similar to Cornwell’s (1984) findings among 50–60 year-olds of a similar social group 30 years ago. However, when acting independently, those in their eighties and nineties report modifying their health and illness beliefs and behavior, in response to their own perceived old age. Some health problems are ‘demedicalized’, being increasingly attributed to age and by being self-managed. Others are perceived as potentially more serious, leading to increased consultation with medical services. When obliged to act outside their moral belief–behavior framework by others, the participants expressed feelings of disempowerment, yet resisted modifying their moral beliefs. This may represent resistance to adopt the ‘sick role’, while seeking to maintain control over uncertain health as functional dependence and frailty increases. This study furthers theoretical understanding of the health and illness beliefs and behavior of the oldest old, with important practical implications.
Inquiries in the UK into mistreatment of older people by healthcare employees over the last 30 years have focused on introducing or supporting employee whistle-blowing. Although whistle-blowers have made an important contribution to patient safety it remains a controversial activity. The fate of whistle-blowers is bleak, often resulting in personal and professional sacrifices. Here we draw on the views of healthcare and social care employees working with older people to explore perceptions of whistle-blowing as well as alternative strategies that may be used to raise concerns about the mistreatment of patients by co-workers. Whistle-blowing was perceived as a negative term. Managers said they promoted open cultures underpinned by regular team meetings and an open-door ethos. Others described workplace norms that were somewhat at odds with these open culture ideals. Whistle-blowing was considered risky, and this led to staff creating informal channels through which to raise concerns. Those who witnessed wrongdoing were aware that support was available from external agencies but preferred local solutions and drew upon personal ethics rather than regulatory edicts to shape their responses. We argue that the importance of workplace relationships and informal channels for raising concerns should be better understood to help prevent the mistreatment of vulnerable groups.
This article discusses men’s transition to first time fatherhood, with a focus on the way they recognise various in-tension moral demands and negotiate an appropriate role for themselves. The findings are taken from a longitudinal study, drawing on elements of grounded theory, comprising a series of face-to-face and telephone interviews with 11 men over a 9-month period from the 12th week of pregnancy to 8 weeks after the birth. The analysis focuses on men’s feelings and experience of exclusion and participation, and their response and reaction to that experience. The findings present two descriptive themes, ‘on the inside looking in’ and ‘present but not participating’, followed by third theme ‘deference and support: a moral response’ that exposes the dilemmatic nature of men’s experience and explains the participants’ apparent acceptance of being less involved. The discussion explores the concept of moral residue, arguing that while deference and support may be an appropriate role for fathers in the perinatal period it may also be a compromise that leads to feelings of uncertainty and frustration, which is a consequence of being in a genuinely dilemmatic situation.
For young adults with inflammatory bowel disease (IBD), perceived stigma has been found to be a salient concern. Drawing on interviews with individuals with IBD aged 18–29 (n = 16), this article uses rhetorical discourse analysis to explore how stigma is discursively constructed by young adults, with a focus on the moral underpinnings of the participants’ talk. Their representations showed both felt stigma and enacted stigma; principally related to the perceived taboo surrounding the symptoms of their condition, which often led to the non-disclosure or concealment of the condition. The different ways in which stigma is manifested in the accounts present a challenge to recent arguments questioning the relevance of this concept in chronic illness research, though it was found that it is not adequate to look at stigma alone and, given the unstable nature of IBD, negotiating stigma in relation to possible charges of deviance is a pertinent issue for these young adults. For instance, non-disclosure because of shame could result in individuals experiencing blame. Accounts were constructed through a range of discursive strategies, allowing the participants to present themselves in morally appropriate ways throughout. Suggestions are made about future directions in addressing stigma and deviance in relation to this cohort.
African American women’s preventative care usage: the role of social support and racial experiences and attitudes
Erin Pullen, Brea Perry and Carrie Oser
Research suggests that African Americans are less likely to utilize preventative care services than Americans of European descent, and that these patterns may contribute to racial health disparities in the United States. Despite the persistence of inequalities in preventative care utilization, culturally relevant factors influencing the use of these gateway health services have been understudied among marginalized groups. Using a stratified sample of 205 low-income African American women, this research examines the predictors of receiving a physical exam, with a particular emphasis on how differing levels of social support from friend and family networks and experiences of racial discrimination and cultural mistrust shape utilization. The findings underscore the importance of traditional predictors of utilization, including insurance status and having a usual physician. However, they also indicate that supportive ties to friendship networks are associated with higher predicted rates of having an annual physical exam, while social support from family and sentiments of cultural mistrust are associated with lower rates of utilization. Broadly, the findings indicate that even as traditional predictors of help-seeking become less relevant, it will be critical to explore how variations in discrimination experiences and social relationships across marginalized groups drive patterns of preventative care utilization.
Habitus of home and traditional drinking: a qualitative analysis of reported middle-class alcohol use
Lyn Brierley-Jones, Jonathan Ling, Karen E McCabe, Graeme B Wilson, Ann Crosland, Eileen FS Kaner, and Catherine A Haighton
There is evidence that alcohol consumption among those in middle-class occupations consistently exceeds safe levels, yet there has been little research into why this occurs. This article explores the meanings associated with alcohol use among professional, managerial and clerical workers. Qualitative data were collected from five focus groups of male and female employees aged 21–55 (N =49: 32 male, 17 female). Each focus group was conducted on the premises of a medium-scale or large-scale employer, four public sector and one private sector, in the north-east of England. Using Bourdieu’s concepts of ‘habitus’, ‘capitals’ and ‘fields’ we found that, among these middle-class occupational groups, alcohol use was associated with two habitus: a ‘home drinking’ habitus and a ‘traditional drinking’ habitus. Those of the home drinking habitus particularly used wine as a source of cultural capital and a means of distinction, whereas those in the traditional habitus consumed lager, beer and spirits to have fun in social settings. A small minority appeared to belong to a third, omnivorous, habitus where a wide range of alcoholic drinks were consumed in a variety of contexts. Existing public health initiatives to reduce alcohol consumption may require modification to accommodate a range of drinking cultures.
Mental health trajectories and their embeddedness in work and family circumstances: a latent state-trait approach to life-course trajectories
Stéphane Cullati, Delphine S. Courvoisier, and Claudine Burton-Jeangros
In this article we adopt a Bourdieu-based approach to study social inequalities in perceptions of mental and physical health. Most research takes into account the impact of economic or social capital on health inequalities. Bourdieu, however, distinguishes between three forms of capital that can determine peoples’ social position: economic, social and cultural capital. Health research examining the effects of cultural capital is scarce. By simultaneously considering and modelling indicators of each of Bourdieu’s forms of capital, we further the understanding of the dynamics of health inequalities. Using data from a large-scale representative survey (N = 1825) in Flanders, Belgium, we find that each of the forms of capital has a net effect on perceptions of physical and mental health, which persists after controlling for the other forms of capital and for the effects of other correlates of perceived health. The only exception is that the cultural capital indicators are not related to mental health. These results confirm the value of a Bourdieu-based approach and indicate the need to consider economic, social and cultural capital to obtain a better understanding of social inequality in health.
The importance of economic, social and cultural capital in understanding health inequalities: using a Bourdieu-based approach in research on physical and mental health perceptions
Wouter Pinxten and John Lievens
In this article we adopt a Bourdieu-based approach to study social inequalities in perceptions of mental and physical health. Most research takes into account the impact of economic or social capital on health inequalities. Bourdieu, however, distinguishes between three forms of capital that can determine peoples’ social position: economic, social and cultural capital. Health research examining the effects of cultural capital is scarce. By simultaneously considering and modelling indicators of each of Bourdieu’s forms of capital, we further the understanding of the dynamics of health inequalities. Using data from a large-scale representative survey (N = 1825) in Flanders, Belgium, we find that each of the forms of capital has a net effect on perceptions of physical and mental health, which persists after controlling for the other forms of capital and for the effects of other correlates of perceived health. The only exception is that the cultural capital indicators are not related to mental health. These results confirm the value of a Bourdieu-based approach and indicate the need to consider economic, social and cultural capital to obtain a better understanding of social inequality in health.
Challenging the field: Bourdieu and men’s health
Mark Robinson and Steve Robertson
This article considers how understandings of health promotion with men may be assisted by engagement with Bourdieu’s theoretical work. The article outlines leading concepts within Bourdieu’s work on ‘field’, ‘habitus’ and ‘capital’; considers subsequent critical debates among gender, feminist and sociological theorists around structure and agency; and links these to discussions within men’s health. A particular focus concerns structural disruption of, and movement of social actors between, ‘fields’ such as family, work and leisure settings. The article examines, through Bourdieu’s critical legacy, whether such disruption establishes conditions for transformative reflexivity among men in relation to previously held dispositions (habitus), including those inflected by masculinities, that affect men’s health practices. Recent work within Bourdieu’s heritage potentially facilitates a re-framing of understandings of men’s health practices. The article specifically explores masculine ambivalence within accounts of reflexivity, identities and practice, and considers how social and symbolic (masculine) capital are in play. Implications of Bourdieu’s leading concepts for theorizing settings-focused approaches to men’s health promotion are exemplified with reference to a men’s health project in a football stadium leisure setting. The article considers the benefits and challenges of applying gendered critical insights drawing on Bourdieu’s work to men’s health promotion, and discusses emerging theoretical dilemmas.
The debate about psychiatric nosology was reignited last year when the fifth edition of the Diagnostic and Statistical Manual (DSM) was published to widespread criticism. Critics cite a number of problems with ‘psychiatric diagnosis’, though it is sometimes unclear which classificatory practices are included under this broad heading. Although it may be possible to avoid the problems inherent in the DSM system, other difficulties associated with classification (labelling, stigma) may prove harder to escape. The first part of this article argues that some form of psychiatric classification is made inevitable by the communicative, epistemic and ethical pressures on psychiatry. In the second half it is suggested that there are ways to think differently about our relationship to psychiatric classification, and that these could play a role in mitigating the harms outlined by diagnosis’ critics.
Food industry and public health representatives are often in conflict, particularly over food labelling policies and regulation. Food corporations are suspicious of regulated labels and perceive them as a threat to free market enterprise, opting instead for voluntary labels. Public health and consumer groups, in contrast, argue that regulated and easy-to-read labels are essential for consumers to exercise autonomy and make healthy choices in the face of food industry marketing. Although public health and food industry have distinct interests and objectives, I argue that both contribute to the creation of the food label as a governmental strategy that depends on free-market logics to secure individual and population health. While criticism of ‘Big Food’ has become a growth industry in academic publishing and research, wider critique is needed that also includes the activities of public health. Such a critique needs to address the normalizing effect of neoliberal governmentality within which both the food industry and public health operate to reinforce individuals as ‘healthy consumers’. Drawing on Michel Foucault’s lectures at the Collège de France, I examine the food label through the lens of governmentality. I argue that the rationale operating through the food label combines nutrition science and free-market logics to normalize subjects as responsible for their own health and reinforces the idea of consumption as a means to secure population health from diet-related chronic diseases.
Relocation, realignment and standardisation: Circuits of translation in Huntington’s disease
Jamie Lewis, Jacki Hughes and Paul Atkinson
Based on complementary ethnographies of a biomedical laboratory and a clinic – both working on Huntington Disease (HD) – we discuss the circuits of translation evident in biomedical and clinical research. By examining a recent epistemological shift from understanding the disease as genetic to understanding the disease as a problem for neuroscience, as well as documenting the multiple framings of the disease that migrate between the laboratory and the clinic, we emphasize the complexity involved in the movement of biomedical science into clinical work. We stress that this is not a one-way flow from the colloquially known bench to bedside, but is dependent on a cluster of contextual activities and local actors. We also stress the extent to which global collaborations, standardization and regulatory frameworks can facilitate such framing and migration by aligning local practices and different disciplinary outlooks. We take a sociological perspective on translational processes – or rather to an expanded understanding of translation – to capture the material flows and conceptual transformations that are involved in the complex relationships between fundamental and clinical research.
Recently, A. David Napier and colleagues published their executive summary from The Lancet Commission on Culture and Health (The Lancet, Volume 384, Issue 9954, pp. 1607-1639, 1 November 2014). They write:
“This Commission is the first ever detailed appraisal of the role of culture in health, bringing together voices from different fields, including anthropologists, social scientists, and medics. Experts review health practices as they relate to culture, identify and assess pressing issues, and recommend lines of research that are needed to address pressing issues and emerging needs. The Commission examines three overlapping domains of culture and health: cultural competence, health inequalities, and communities of care. With reference to these domains, the Commission shows how inseparable health is from cultural perceptions of wellbeing.”
In the short time since the release of the report, four related initiatives have emerged from the publication. The first is an endorsement from the WHO, which the commission intends to take up strategically in January 2015. The second is an initiative to sponsor an NHS event to present and discuss the Commission’s 12 key findings and related recommendations. Third is to build a platform for the production of outputs such as white papers on each of their 12 findings. And fourth, to launch the first European Forum on Culture and Health in Ascona, Switzerland at the end of November––there, they will design a European strategy to guarantee sustained attention to the needs identifies in the report.Culture and Health Commission Members: A David Napier, Clyde Ancarno, Beverley Butler, Joseph Calabrese, Angel Chater, Helen Chatterjee, François Guesnet, Robert Horne, Stephen Jacyna, Sushrut Jadhav, Alison Macdonald, Ulrike Neuendorf, Aaron Parkhurst, Rodney Reynolds, Graham Scambler, Sonu Shamdasani, Sonia Zafer Smith, Jakob Stougaard-Nielsen, Linda Thomson, Nick Tyler, Anna-Maria Volkmann, Trinley Walker, Jessica Watson, Amanda C de C Williams, Chris Willott, James Wilson, Katherine Woolf You can download the full report here:
Image credit: Heather Lewis, Pay-per-view, 2011 (no coin), (McColl Center for Visual Arts) Mirrors, coin meter, light
by Élisabeth de Fontenay (trans. William Bishop)
University of Minnesota Press, 2012, 168 pages.
In the opening paragraph of Without Offending Humans, Élisabeth de Fontenay describes the first time she saw her mentor Jacques Derrida speak at the Collège de philosophie:
I reacted, all things being relative, as Malebranche did upon reading Descartes’s Treatise on Man: “His beating heart sometimes forced him to stop his reading,”…. From that moment on, I did not take leave of this work nor of this man, even if it would often cause me distress to place myself in certain of his footsteps. (1)
Besides its recursivity, which hints at the almost pathological dependence on citation that is to follow, such a reverent opening primes the reader to question whether a work so firmly situated in Derrida’s project can deliver an argument original enough to warrant its book-length runtime. The author does nothing to defuse this growing fear when, some pages later, she introduces her key intervention in the book’s first chapter as certainly the only point where she feels she is in disagreement with Derrida, adding that “it is not without a certain amount of anxiety that I wish to formulate these reservations, now that he does not have the time to explain himself further” (14).
As it turns out, de Fontenay’s cautious critique is an important one. In his writings on animals, Derrida observes that with few exceptions philosophers from Aristotle onward have built their conceptions of “the human” on an unexamined set of foundational assumptions that reduce nonhuman life to a single homogeneous category, “the animal.” Between the category of the human and the category of the animal—or l’animot, as Derrida playfully dubs the latter category—philosophers have presumed the existence of an abyssal rupture that serves to assure humans of their own uniqueness. In an interview with Jean-Luc Nancy in 1991, Derrida refers to this kind of thinking as a “sacrificial structure” that links the human domination of nature with the acceptance (and meaningfulness) of animal sacrifice. De Fontenay points out that for Derrida’s argument to work, he must treat all the diverse cultural and historical instantiations of sacrifice as tokens of a single transhistorical type, whereas anthropologists have shown us many different kinds of sacrificial functions that cannot be reduced to a single catchall category.
Unfortunately, this intervention into Derrida’s thinking does not lead to anything like a sustained thesis for de Fontenay. Lacking a coherent framework on which to hang on its many observations, Without Offending Humans instead reads like a series of riffs on a set of topics related to the animal question in philosophy. This is a familiar danger for academic volumes based on independent essays, but the problem is amplified here by the fragile internal coherence of each entry. Derrida’s inimitable style makes for some notoriously impenetrable prose, but there is a sense in his essays that even the throwaway moments will reward a careful reading. Not so with Fontenay, who writes with a complexity that seems only to distract. Most intrusive is her unrelenting use of quotation and paraphrase, a ventriloquism that at its worst—and I can think of no other way to say this—amounts to vapid name-dropping. For instance:
We know that after having displayed a strong interest in physiognomic research, Goethe distanced himself from Lavater, and that Diderot, at first tempted no doubt by the monism underlying the enterprise, ended up refusing to participate in the translation of texts by the illustrious Swiss pastor, and that Hegel was ferociously critical of him in the Phenomenology of Spirit…(79).
Such passages are characteristic—this one is taken from a paragraph that also mentions Lichtenberg and footnotes Proust—and after a while the effect is dizzying.
Among the most frustrating ambiguities of Without Offending Humans is whether de Fontenay herself wishes to give said offense or avoid it. I suspect that part of the allure of the book’s title, at least to some, is its apparent suggestion that the cause animale has not gone far enough. Has the animal rights movement held in reserve some fundamental anthropocentrism, some respect for humans and human sensitivities that limits the scope of its possible achievement? At least one previous reviewer concludes that the title in fact has the opposite (and much plainer) intent, signaling de Fontenay’s desire to critique animal rights without disturbing the species boundary.
Perhaps, however, there is a puckish element in de Fontenay’s choice of title after all. Someone like Peter Singer, whom de Fontenay takes to task for his ahistorical assertion of the natural rights of animal and man, courts mainstream backlash as a rhetorical strategy. But Singer does so recklessly, and for this his provocations often find the wrong target. Eva Kittay, a philosopher and the mother of a severely mentally disabled child, bristles at Singer’s assertion that if chimpanzees are not deserving of rights, then reason dictates that neither are severely disabled humans (Singer’s intent, clearly, is to argue for the rights of chimpanzees and not against the rights of disabled children, but for Kittay that is beside the point). De Fontenay’s criticism seeks out narrower and safer targets, but it would be unfair to call her efforts inoffensive or trite. Her denunciation of “banal, quotidian, and legal” forms of cruelty indicts anyone who has eaten factory-farmed meat or shopped at a pet store. The mass slaughters that followed from the “mad cow crisis,” traceable to the decision to feed meat and bone meal to herbivores, works, according to de Fontenay, “as a way of not having to point at the madmen that we have become” (129).
There is more than enough here to inspire and to provoke thought, especially for fans of deconstruction and perhaps also for fans of the Posthumanities series edited by Carey Wolfe, of which this book is a part. The book’s memorable moments are mostly disparate, however, and that lack of coherence is likely to limit the endurance of its appeal. Heavy use of citation, coupled with the absence of an organizing theme, makes the entire work feel like a kind of annotated bibliography, and perhaps that is how this book is best appreciated.
Les Beldo is an anthropologist and a postdoctoral lecturer in Comparative Human Development at the University of Chicago. He received his PhD from the University of Chicago in August 2014. His research interests include animal studies, environmental anthropology, and the anthropology of morality.
Derrida, Jacques. 1991. “‘Eating Well,’ or the Calculation of the Subject: An Interview with Jacques Derrida.” In Who Comes after the Subject?, edited by Eduardo Cadava, Peter Connor, and Jean-Luc Nancy, 97–119. New York and London: Routledge.
It is time we anthropologists of biomedicine broaden our analytical scope. If it is the case that there is more to life than DNA, cells, tissues and organs; that there is more to disease than mutations, dysregulations and dysfunctions, then how is it that social studies of medicine have attained such a bio bent in recent decades? Of course, medicine has itself in many ways become biomedicine through processes of biomedicalisation, molecularisation, geneticisation and pharmaceuticalisation, urging social scientists (including myself) into the laboratories, clinics and patient associations within and through which biological knowledge, biomedical practice, biosocial groupings and biological citizens are being formed, or co-produced. So, perhaps the bio-turn is merely a product of the times (hegemonies?) we are living in. Anthropologists (and other social scientists) of medicine might well protest at this point, especially those who study the lived experience of their informants as they fall ill and struggle to get better, devising coping strategies and mobilizing therapy support groups along the way. The only bio-turn to be found in these studies often concerns the chronic failures of biomedicine in terms of its availability, accessibility, quality, efficacy and relevance. We have learned how biomedicine is but one among many medical strategies pursued by the ill and also how stark inequalities continue to shape medical landscapes throughout the world.
Whatever views one might have on the bio-turn within social studies of medicine (including on whether there has been such a turn at all), there is one line of analytical pursuit which remains strikingly idle, namely the question of knowledge of living. Canguilhem once wrote: “Human life can have a biological meaning, a social meaning, and an existential meaning. In an assessment of the modifications that disease inflicts on the human being, all these meanings can equally be retained. A man does not live only like a tree or a rabbit” (2008:121-22). Point being: not only is life sustained, it is also lived. If Canguilhem’s archaeological readings of biologists and medical scientists have generated dizzying insights into the formation of “knowledge of life” in its biological meaning; what then of its social and existential meanings? I would suggest that the time is ripe for analyses of the ways in which knowledge of living – that is to say knowledge of living as a social activity and a personal experience – has come to be formed, as well as how it has transmogrified or spilled over into practices of living, and vice versa. For, alongside molecularisation and biomedicalisation, we have seen an upsurge in knowledge of how it is to live with disease – morbid living – a subset of what I have more broadly called knowledge of living. In distinguishing between knowledge of life and knowledge of living, I am not alluding to the distinction between ‘bare life’ (or zoe) and ‘qualified life’ (or bios), which has been extensively fleshed out by Agamben, Fassin, Biehl and many others who rightly point out that there is more to the politics of life than the bio prefix indexes. Neither am I pointing to the styles of ethical activity that make up contemporary ‘regimes of living’ (Lakoff & Collier 2004). Instead I am making a methodological distinction between how ‘knowledge of life’ and ‘knowledge of living’ is generated.
And this is where it can get a bit tricky since it is exactly (us) medical anthropologists who have been at the forefront when it comes to generating knowledge about morbid living. From Rivers onwards, anthropologists have researched the ways in which individuals and communities experience, cope with and tackle disease. They have shed light upon the struggles, tragedies and inventiveness of the ill as they seek therapy, meaning or restitution. Indeed, Kleinman has argued that the distinction between disease and illness was exactly intended to highlight an individual or community’s experience of living with disease: “Disease… is an alteration in biological structure or functioning” whereas “illness refers to how the sick person and the members of the family or wider social network perceive, live with, and respond to symptoms and disability” (Kleinman 1988: 3, 5-6). We need, I suggest, to study the productive effects of our own knowledge production practices as medical anthropologists – i.e. we need to be as attentive to the effects of interview techniques and observation as we have been to the effects of sonography or DNA amplification. We also need to archaeologically examine the key concepts of medical anthropology – not reflex, regulation or pathology, but rather coping, symbolic efficacy or coherence.
To be sure, I am not advocating some kind of history of medical anthropology, at least not solely. For, not only have we seen an upsurge in the production of knowledge about how it is to live with disease, we have also seen a swarming of practices aimed at working on the lives of those living with disease. Such practices include the ‘Living with’ guides that patient associations and others increasingly prepare to provide practical advice for how patients and loved ones can cope with the challenges of living with a particular disease (tip: type “Living with …” adding almost any disease into Google and see what happens). The internet has become an important resource for many patients and carers, with sites like WebMD, NHS Choices, PatientsLikeMe and NetDoctor providing patients with advice and the opportunity to share their experiences on how best to live with particular diseases and conditions. We have also seen the proliferation of so-called ‘expert patient’ courses or training programmes for the chronically ill offered by hospitals and community clinics which provide training in the proper intake of medicines, motivation for lifestyle modifications as well as counselling support. In addition, we have seen an influx of rating scales, indices and instruments that have been developed to calculate the impact a disease has on the quality of life and wellbeing of an individual or population, such as the QALY, EuroQol, DALY or Quality of Life Scale. And let us not write this off as a ‘Western’ phenomenon of the privileged. Efforts to improve the lives (as something further to saving lives, which nonetheless remains crucially urgent in these times of Ebola and grave health inequality) of those living with disease are to be found globally. For example, Whyte and colleagues (2014) and Nguyen (2010) have shown us how healthcare programmes in Uganda and Burkina Faso are not only biomedically treating HIV patients but also helping them to ‘live positively,’ as living with HIV in many parts of Africa today entails learning how to live with antiretroviral therapy, in many cases against all odds. What I am advocating is more social studies of the ways in which practices of morbid living intersect with knowledge of morbid living as they are co-produced in clinics, patient associations, homes, communities, GP consultations and more.
I am, of course, not the only one to have noted this blind spot within contemporary social studies of biomedicine. Rabeharisoa and colleagues recently put together an important special issue of BioSocieties on what they call ‘evidence based activism’ in which they argue that “patients’ organisations… collect experiences and build experiential knowledge, and that is how they give shape to concerned groups and delineate their preoccupations” (2014:115). More recently, Angela Martin and colleagues held Experience as Evidence? A Symposium on the Sciences of Subjectivity in Healthcare, Policy and Practice at the University of Oxford in October 2014 to explore “What does it take to turn experience into evidence? What new methods and expertise are emerging in this field?” I have myself contributed to this emerging field of social studies of the ways in which knowledge and practices of living come to be co-produced in a medical arena through publications including “Above and Beyond Superstition” (2008), “Measuring Progress” (2007) as well as a forthcoming piece (with Nikolas Rose) in Economy and Society entitled “Global Health and the Governmentalisation of Living”. More broadly, Charles Camic and colleagues have called for an expansion of STS attention to the social sciences by suggesting further studies of “the mundane actions and processes by which the makers of social knowledge carry out their work[,] … the daily routines of knowledge production, evaluation, and use” (2011: 8). I, for one, look forward to following this growing subfield (within STS and anthropology) as it unfolds and to contributing to those ‘social studies of’ – approaches which train analytical sights on the co-production of social science knowledge/practice in the medical field. We must attend to the effects of knowledge of living with the same commitment that the effects of knowledge of life have been cartographically and analytically pursued in recent decades.
Ayo Wahlberg is Associate Professor at the Department of Anthropology, University of Copenhagen, Denmark. His comparative research has focused on the different ways in which herbal medicine (in Vietnam and the United Kingdom), and more recently reproductive medicine (in China and Denmark), have been mobilized, normalized and routinized in the past few decades. He is co-editor of Contested Categories: Life Sciences in Society (2009) and Southern Medicine for Southern People: Vietnamese Medicine in the Making (2012) and has published numerous journal articles on the social study of herbal medicine, reproductive medicine and quality of life measurement.
Camic C, Gross N, & Lamont C. 2011. Social Knowledge in the Making. Berkeley: University of California Press.
Canguilhem G. 2008. Knowledge of Life. New York: Fordham University Press.
Kleinman A. 1988. The Illness Narratives: Suffering, Healing, and the Human Condition. New York: Basic Books.
Lakoff A & Collier S. 2004. Ethics and the anthropology of modern reason. Anthropological Theory. 4(4): 419–434.
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One of the insights into teaching provided to me by Donald Morse, one of my undergraduate professors, was to never teach the same class twice. But, simultaneously, not to overburden oneself by developing a new course every year. His model, which I’ve entirely stolen, was to teach one-third texts he knew intimately, one-third texts he was familiar with, and one-third texts that were strange to him – he might have learned about them through a citation or a friendly recommendation. He’s a literature professor, and so the task of swapping out one novel for another is a little easier than it is in the social sciences when a swap-out requires finding a monograph on a similar-enough topic; but I find that the framework does two things to the classes I teach: first, it forces me to cast my classes as thematically expansive rather than topically narrow, and secondly it provides a mechanism for me to dig up old texts that I may have avoided previously – or parts of familiar texts that I don’t typically use – as well as guide my engagement with contemporary scholarship.
The downstream effects are more profound, and have led to me rethink my own scholarly work, both in terms of my contributions to the anthropology of medicine and science, and my ongoing research projects and what unifies them. The best example of this is a course I teach entitled The Biology of Everyday Life, which is an upper division anthropology course, and which I developed because faculty and students kept asking me to teach a course on sleep – which was the last thing I wanted to do after a decade of doing research on sleep in American society – the basis for my first book, The Slumbering Masses. A course on sleep seemed too narrow, both in that there is very little social scientific research on sleep and that I would always know exactly how the course would end – there was simply no surprise in it for me.
The Biology of Everyday Life is organized around as many basic biological functions as I can fit into a 10-week quarter, brought together by a frame provided by Marcel Mauss’ The Notion of Body Techniques, Norbert Elias’ The Civilizing Process, Jean Briggs’ Inuit Morality Play and Mary Douglas’ Purity and Danger. So, in weeks one through five, we work through this theoretical frame about socialization, the relationship between biology and society, and how disgust is socially constructed. Then, in weeks six through ten, we focus on one or two biological processes in each week – you can see a version of the syllabus here – to explore how particular biological experiences vary around the world and over time. The gist is that as much as biological processes are universal, cultural expectations of the normal, and social organization lead to very different expressions of those biological processes, akin to Margaret Lock’s theorization of ‘local biologies.’ Sleep is the obvious one: whereas modern Americans tend to be consolidated nightly sleepers, people around the world sleep in very different ways and this impacts ideas about health, normalcy and everyday life. The course focuses in turn on breathing, sex, eating, menstruation, sleep, and excrement.
There were some challenges in developing the syllabus. One of them is that it’s an anthropology course, and so I really tried to get as many readings as I could from scholars in the field. Unfortunately, anthropologists haven’t written extensively about all of the biological processes I wanted to include. There is a ton of anthropological scholarship about sex (or at least sexual identity, if not actual sexual practices) and food (if not eating), but breathing and excreting seem to escape anthropological attention for the most part. Over time, mostly predicated by necessity, I’ve loosened my reliance on anthropologists, as I’ve found other scholarship that helped fill gaps, and feel more confident about the anthropological content of the argument of the course if not all of the individual authors.
The first time I taught The Biology of Everyday Life, I tried to use one ethnography as a case study to structure weeks five through ten, but I had a hard time finding one that worked perfectly. I supplemented the ethnography with a bunch of articles and book chapters, and found it to be an uneven teaching experience: I found I kept needing to make excuses for why the ethnography I had chosen didn’t cover the topics we were talking about in class that day or week. So, the next time I taught the course, I switched out the one ethnography for six, and allowed students to pick which one of the six ethnographies they would read. In class, we would draw out examples from each of the six ethnographies. This worked okay, but since I allowed democracy to rule, half of the class decided to read one ethnography and only handfuls of students read any of the other ethnographies, placing an undue burden on the small groups of students who read the less popular books. In the third iteration, I dropped the ethnographic monograph and substituted more articles and book chapters, which ended up working the best. It ensured that students all had a broad swath of reading to draw from, and stopped that awkward problem of not having an ethnography fit all of the requirements. Now, after four iterations, the class has finally reached some kind of homeostasis.
Over the first few revisions of the class, I didn’t think too much about the intimate/familiar/strange division – it pretty much fell into that ordering without any effort on my part. But now, as I plan for the next iteration of the class, the need to update some of the material is starting to feel pressing. There are some readings that I know are impossible to remove – like Mauss and Elias. But others seem like they might be able to be substituted, and in so doing, I push myself to find equivalent material. It can be hard to lose something that I’ve become intimate with, but it seems like Briggs’ Inuit Morality Play is on the chopping block next time around. And as much as I enjoy Purity and Danger, most students don’t – beyond the central concept of purity and danger they find the references too obscure. The double whammy of Elias and then Douglas is a little much for most students; but what can I put in its place? In addition, a number of the articles and book chapters have begun to show their age, and they might be swapped out for newer scholarship. And as much as I love showing my students David Cronenberg’s The Fly just when they think they’re beyond disgust, it’s probably time to switch it out for something new – maybe John Waters’ Pink Flamingos.
This is basically the state of my Introduction of Medical Anthropology course, where the foundation of intimate texts is well established, and what changes with regularity are the ethnographies that we read. Over the first few iterations, I had a hard time finding an ethnography of Traditional Chinese Medicine that ran parallel to the books on American biomedicine and Ayurveda that structured the course. Similarly, I had a difficult time finding an ethnography of medicine in Africa that wasn’t about biomedicine. But now that I use Karen Flint’s Healing Traditions, an excellent history of transnational medicine in South Africa, and Mei Zhan’s Other Worldly, it might be time to switch out the biomedicine and Ayurveda ethnographies…
This intimate/familiar/strange structure means that as a teacher I can never get totally comfortable – there’s always something new on the syllabus. And, for the most part, that’s okay with me. I don’t know if I would suggest it to someone with a much greater teaching load than mine, since adding new content is a burden. With one or two classes under revision, it’s not a huge burden, but if it were more than that it might prove too much of a distraction. But, the up side of constant revision is that it provides me with a framework to read both new and old scholarship. I found in the past that my interest in other people’s scholarship was egocentric: I was just looking for people who were working on what I work on or that could do something for me in relation to something I was writing. Now, when it comes time to integrate new material, the impulse is more ethnological, and it means I’m constantly expanding the frameworks I’m fitting material into.
The biggest challenge lies ahead: this spring I teach our 400-student, 8-teaching assistant Introduction to Cultural Anthropology course. Right now, all of the material is in the familiar stage, and my aim is to have my lectures reach a kind of homeostasis over the first two years. Instead of changing what I’m lecturing about, the moving parts will be ethnographies selected by the teaching assistants to use in their sections – they’ll each choose an ethnography to focus on in their sections, hopefully choosing something that they find relevant to their own research, and which they can use to explore key ideas from the main lecture. This means that every couple of years, as the teaching assistants leave for fieldwork and new ones take their places, new ethnographies will be added to the syllabus, which I’ll need to become familiar with, and may make their way onto the foundational syllabus, slowly changing it over time.
I find the real benefit of this intimate, familiar and strange way of doing things is that it helps me think about my own research and scholarship in a much more expansive way. It also gets me to think about the field and other people’s work in a much different way than I used to, and often from a different perspective than how they think about their work – I’ll get a little fixated on some minor reference to toileting behaviors or breathing techniques that an author mentions in passing. Now I frame all of my research under the rubric of ‘the biology of everyday life,’ which you can see in my book about sleep, which is framed as much around the biology of everyday life as it is the history and contemporary practice of American medicine – and that is entirely the function of teaching The Biology of Everyday Life. Moreover, it pushes me to be much more ethnological in my thinking, and this in turn has led to very different arguments and new article manuscripts based on these arguments. Embracing the familiar and the strange also means that I can rely on other scholars to provide me with data – which, in a discipline that continues to overvalue the individual ethnographer, helps me think beyond myself as a scholar and to think critically about the larger world that my work, and my student’s lives, are a part of.
If you have any suggestions for new, strange stuff to read, listen to, or show – or old things I might have missed – please suggest them in the comments section below.
Matthew Wolf-Meyer is Associate Professor of Anthropology at the University of California, Santa Cruz. His work focuses on medicine, science and media in the United States to make sense of major modern-era shifts in the expert practices of science and medicine and popular representations of health. His book The Slumbering Masses: Sleep, Medicine and Modern American Life was the first book-length social scientific study of sleep in the United States. A longtime contributor to Somatosphere and a member of the Editorial Collaborative, his last piece for the site was a review of Jonathan Crary’s 24/7.
The “Experiments with pedagogy” series is edited by Hanna Kienzler.
From rape as a tool of terror in situations of war and armed-conflict, to the largely unchecked epidemic of sexual assault on and off college campuses, “rape” finds its way into our collective political and social (and popular and legal and cultural and aesthetic) consciousness. In a study that is exhaustive, intimate, and exacting, Sameena Mulla’s The Violence of Care: Rape Victims, Forensic Nurses, and Sexual Assault Intervention (New York University Press, 2014) takes up the narrative and embodied dimensions of sexual assault and its afterlife in Baltimore. Mulla tells a story of “fragile relationships” across multiple domains and crafts a highly original account of the affective, representational, and abstracting elements which form the forensic inventory of sexual assault. We are happy to present a lively and critical exchange, and look forward the discussions generated by this second Book Forum. The entire forum is also available as a single pdf here and is embedded below.
Comments on Mulla, Sameena. The Violence of Care: Rape Victims, Forensic Nurses, and Sexual Assault Intervention. New York University Press, 2014.
An Awkward Relationship: The Case of Feminism and Nursing
The Violence of Reductionism
Response to comments:
Duke University Press, 2014, 264 pages.
In her remarkable book, Speculative Markets: Drug Circuits and Derivative Lives in Nigeria, Kristin Peterson sets out to explore and resituate the pharmaceutical industry, and pharmaceutical markets, in Nigeria. The outcome is a highly-detailed, carefully analyzed and enlightening piece of work, illuminating much of the complexities of African drug markets (and of markets and industries beyond Africa), with insights that will appeal to a broad audience.
In media and policy discourses, Nigeria has often been offered as a prime example for the problems of its pharmaceutical industry, and the circulation of fake and substandard medication in its markets, to other localities in Africa and beyond. Kristin Peterson seeks to move beyond easy conclusions, and simplified narratives, to locate the problems faced by drugs markets in Nigeria within a tangle of historical, political and economic events. Through a rich mixture of skillful ethnography and an extensive set of historical and economic data and conceptual tools (including those drawn from STS and critical economy), she attends to various facets of the complexity of the Nigerian pharmaceutical trade.
The book starts with an analysis of how one of the largest informal markets for drugs in Nigeria, Idumota, came into existence. In the history she traces, Peterson navigates local and global events, and explores how such diverse events as the civil war, the oil boom (and bust), and global economic and monetary policies influenced and reshaped the Nigerian drug market between the 1960s and the 1980s. Specifically, she shows how these events transformed the networks of the drug market from a reliance predominantly upon Nigerian pharmacists and their links with the global pharmaceutical industry (as well as a growing local drug industry) to one based on informal traders and foreign generic industries, producing conditions in which the local industry declined. Governmental responses, including the deregulation of pharmaceuticals, in turn created the conditions for the perpetuation of the market in its current form. Peterson writes, “Deregulation was a result of panic, not just an unpleasant answer to a worsening drug supply situation” (p.51).
Throughout the 1980s, Structural Adjustment Programmes (SAPs) fueled the troubling dynamics of the market, the loss of government control over its economy, and the abandonment of the Nigerian market by multinational companies. Peterson’s analysis pays critical attention to the position of populations in this context, and through the concept of “risky populations” attends to the inherent violence of the economic processes (as well as the response to resistance). She also traces compellingly the ways in which the speculative strategies of the multinational industry became key in the progressive abandonment of the Nigerian market and population. Throughout, the rich critique of global economic strategies and corporate speculation provides significant resources for understanding the arrival of the Nigerian market in its current shape. As Peterson suggests:
Corporations’ and military governance’s management of risky populations had effects that lasted well into the future. With the market for brand-name drugs drying up after the implementation of the SAP, Nigerians had to build a new drug market and new livelihoods. The pharmaceutical market was reconfigured to meet the needs of a newly impoverished consumer base. It was also reconstructed to meet the needs of companies, which had to ascertain what could sell in Nigeria in light of the reduction in customers’ purchasing power. (p.79)
As generic producers from Asia replaced European and North American drug companies, and as traders, including those active in narcotics markets, replaced pharmacists as the key agents of the Nigerian pharmaceutical market, the drug trade became something seen as both illicit and normalized. This in turn generated new spaces where the fragility of the regulated/unregulated dichotomy, as well as the complexity of the notion of market itself, became apparent. Peterson provides striking illustrations of how terms and definitions were negotiated in formal and informal settings (including agencies and courts), showing the complexity of those debates and their relationship to spaces of medicine.
Throughout, Peterson draws attention to the “essential vitality in the market and other remade urban areas that many people depend on, a quality that evades legal definition and bypasses regulatory capacity.” (p.102) As she zooms into the day-to-day of the practices of sales within the current markets of Nigeria, she exposes these movements through her core concept of “derivative life.” The volatility and fragility of the market, and the constant negotiation of risk for its actors, are brought to the forefront of her analysis––bringing yet another problematic to these market dynamics, and challenging further easy assumptions readers may have about the motivations and rationales behind individual actions. Forms of risk that are seldom talked about are brought to the fore as key elements in daily strategies. As illustrated throughout, economic and market changes are deeply influential on populations and social dynamics: “new subjectivities came into formation and new forms of individual risk emerged with changes in the Nigerian economy. Today, people must manage their own risk.” (p.107) These, in turn, are loaded with consequences in the daily practices of sales and distributions that easily disappear from sight and Speculative Markets carefully makes visible.
These movements, in turn, are deeply entangled within both global connections, and within drugs themselves. The fragility and negotiations that surround medicines, flowing from much of the above, and as cheaper generic drugs entered a volatile market, is carefully explored through the notion of chemical arbitrage (one of the many strengths of Speculative Markets is that it leaves none of the complex dimensions of the fragility and negotiation of the market unexplored). This notion of chemical arbitrage opens an analysis of how pricing is the outcome of constant strategic decisions, how drugs and human biologies may become disconnected in those processes – turning for example to inadequacies of drugs and resistance – and how more generally market fragility moves from economic questions to the making of drugs. The chemistry of drugs––shaped, modified, and often fragilised by those decisions––in turn becomes a constant source of anxiety and attention by the population. “These dynamics of drug resistance and market structure are not separate articulations or discrete events but rather a dynamic continuum, or a social life of bioequivalence.” (p.129)
However, as Peterson demonstrates, this is not the product of any single or straightforward process that can be isolated within Nigeria itself, but a much more convoluted set of happenings that find their roots in multiple sites and political and corporate decisions. One of the key strengths of the critical exploration of drugs through the notion of arbitrage is to complexify narratives of fakeness in conversation about drugs:
So, perhaps in rejecting the discourse of evil fake drug traders and concomitantly India and China as paradigmatic sites of drug faking, perhaps we can look to the ways that poverty drives fakes in the face of limited price arbitrage that gives way to chemical arbitrage. Perhaps we can see how arbitrage shapes the contours of the West African drug market – a market that is necessarily intertwined with activities driven by downward pricing pressures such as offshoring. Perhaps we can see just how fake drugs are the outcome of the speculative nature of the drug industry. (p.154)
Finally, Peterson turns to the question of monopolies, marketing strategies, and intellectual property (IP) to wrap-up an important remaining angle of the analysis of the pharmaceutical industry in Nigeria. She powerfully demonstrates the inherent links between the market of Nigeria and the strategies of drug companies on European markets, showing how strategic decisions that affect Africa are often taken with other markets in mind. The use of legal and regulatory tools, including patents, are linked to these strategies and the final chapter of the book highlights how these legal tools become used for purposes that are neither those they have officially been designed for, nor those that may be expected by focusing in any particular market in isolation of global movements. Here one of the contributions of the book is to lend back to conversations on intellectual property and drug markets in Africa some of the complexity that was missed in early legal commentaries which associated IP regulation too tightly with the constraints of jurisdiction.
Overall, the book makes an impressive contribution to the analysis of drug markets in Africa and demonstrates why any commentary that attempts to isolate their problematic from further temporal or geographical considerations inevitably misses essential elements. One of the most fascinating aspects of the book is its effort to move away from any of the classic dichotomies and causalities found in much of the discussion of drug markets in Africa, to replace them with a well-demonstrated set of fragile boundaries and entangled events. As she makes clear in her conclusion, Peterson stays away from the languages of corruption and criminality that have become common in studies that explore counterfeit medicines and drug markets in Africa. This is both illustrative of and conducive to the fresh eye that she turns toward the notions of legality and illegality in her analysis. The implications are important here not only for those interested in drug markets, or those interested in African markets, but to readers wanting to open-up the question of regulation in its practice, and to explore new sites where the fragility of the boundaries that law often seeks to establish (and that commentators often take for granted) is made visible. Her analysis beautifully demonstrates the entanglement of practices, histories, economics (official and non-official, regulated and unregulated, legal and illegal), to a point where drawing lines becomes impossible.
I thoroughly enjoyed reading this book and would most strongly recommend it not only to those with an interest in drug markets, in health in Africa or in global health, but also to those seeking to explore the complex dynamics of sites commonly described as “unofficial,” “unregulated,” or that in any way operate at the borders of law.
Emilie Cloatre is Senior Lecturer in law at the University of Kent, working on law and STS. She is the author of Pills for the Poorest: an exploration of TRIPS and access to medication in sub-Saharan Africa (Palgrave McMillan 2013) and co-editor of Knowledge, Technology and Law (with Martyn Pickersgill, Routledge 2014)’
If there really has been a ‘collaborative turn’ between the social and biological sciences, then the stakes of that turn are still very much to be negotiated. ‘Collaboration,’ of course, is not a practice or a structure simply to be aimed for: like all ethical and methodological commitments, collaboration is made in the turning – and thus the actual forms in which ‘biosocial’ accounts are made and registered become inseparable from the different ways in which scholars are and become turned. We have been increasingly frustrated at a lack of attention – indeed, a very specific inattention – to these kinds of questions, as well as the ever growing corpus of bureaucratic and quasi-scholarly encomia for ‘collaboration’ as such. Our article, which we recently published in Theory, Culture and Society, brings our frustration into the public sphere, and advances what we have come to call ‘experimental entanglements’ between the social sciences and the neurosciences as one way to reimagine the bonds of collaboration. Our wager is that collaborating might be imagined not simply as working in conjunction with an other or others, but might also unsettle the sedateness of such ‘conjunction’. (Let us not forget the subterfuge, uncertainties and complex relationalities that enfold the collaborator who works with the ‘enemy’).
Our article is the product of four to five years of shared distress at being, on the one hand, moved by technological and conceptual developments that hold out the hope of radically re-mapping dynamics between the social and biological sciences; and, on the other hand, a deep frustration, at every attempt to begin that cartographic work, where we seem to be endlessly confronted with a deadening bureaucratic and technocratic edifice of ‘interdisciplinarity’ – whose major purpose is to evacuate these possibilities of any real sense of experiment, risk, joy or play. The article, and our call for an attention to ‘experimental entanglement,’ is intended to stir a discussion about what we find sorely lacking in the rush to collaborate – and this is what it actually means to do collaborative work: what it can look and feel like, which ways of characterizing it expand its range of possibilities, and which ones radically foreclose them. Here, as a further contribution to that conversation, we pull out five themes of that article on which we’re inviting further dialogue. We want to use that dialogic space to maybe move beyond this sense of frustration – or, if not, at least to elaborate more clearly its contours. We want to think, in more detail, about the structures, feelings, and modes of collaboration that we would like to bring into being. And we as also want to locate other experimental modes of collaboration, beyond our own, which are already out there, but which are not recognized through the dominant rhetoric of ‘interdisciplinarity.’
(1) Experiments, not collaborations.
At the heart of our discussion is a realization that the increasingly black-boxed logics of ‘interdisciplinarity’ and ‘collaboration’ are not solutions to anything – that in fact those terms hold together sets of practices and registers that need to be opened up, problematized, and (in several cases) dissolved (here we think, for example, of the pernicious logic of ‘consilience’). But rather than get caught, as are so many others, in arid discussion about ‘forms of interdisciplinarity’, we propose moving to a new ground, and this is the ground of experiment. Because if there have been many rich elaborations of how the space between the neurosciences and social sciences might be re-configured in an era of (for example) social and cultural neuroscience, there has been much less attention to what this might actually look like methodologically and in practice. Or as we put it in the article, ‘there has been little suggestion that experimental labour itself might be worthy of sustained attention from social scientists and humanists.’ What if, instead of endlessly poring over maps of the shifting border of these sciences, vainly trying to reach a consensus on where those borders are at any given moment, we re-focused our attention on the neuroscientific experiment, as an already thick, ambiguous rubric for making sense of the biosocial intricacy of human life? Might this help us to think some more creative and entangled ways of exploring this space? And, then, could other practices and archives of experimental labour show us some interesting ways of understanding the contours of this still-emerging space? In our preference for an attention to ‘experiment’ over ‘collaboration,’ we are indebted to an article by Andreas Roepstorff and Chris Frith in Anthropological Theory, which insists on experiment as a form of avant-garde performance – an aesthetic as much as methodological rubric, which shifts the turning of collaboration to the specificity and intricacy of particular kinds of creative intervention.
(2) The world is entangled, whether we want it to be or not.
To the extent that we affiliate with a ‘collaborative turn,’ this – the clause above – is our entry-point. The purpose of a term like ‘entanglement’ is that it foregrounds a world, and also processes of world-making. And it provincializes the stratagems, anxieties, and sectional interests of people trying to make sense of that world – as well as the competitive jostling that goes on around different modes of sense-making. Our direct inspiration here is, of course, the work of Karen Barad (and, by implication, a broader swathe of queer and feminist science studies, which has thought for many decades – indeed has had to think – much harder about the political economy of collaboration than most). We have been especially struck by Barad’s insistence that the inseparability of agencies might well be the most basic ontological property of the world – that there is therefore no ‘under’ or ‘before’ of something like ‘collaboration.’ This is what has gotten lost in what we call ‘the regime of the inter,’ with its endless attention to, and concern for, precisely the forms of the ‘before.’ And so a ‘collaborative turn’ is – even as we remain dutifully suspicious of these namings – at least parallel to an ‘ontological turn,’ which has been much analysed here and elsewhere. Our claim is that, for those of us in the medical humanities and social sciences at least, ‘collaboration’ is the work that comes after the ontological turn. And thinking collaboration through ‘entanglement’ insists on this temporality: the starting-point is that this situation is given to us. Our predicament is thus more existential than it is disciplinary.
(3) The neurosciences are a potent site of entanglement
We do not limit our proposal to the space between the social and the neurobiological. (And indeed, much of our preoccupation is with shifting the focus away from prepositions such as ‘between’ so as attend more closely to other modes of relation). But what has invariably held our attention about the neurosciences, and in particular about neuroscientific experiments, is that they present a range of sites, a series of claims, and a set of practices, that bring precisely this entanglement of biological and social phenomena to the fore. It is, of course, sadly still the case much social scientific engagement with the effects and practices of the neurosciences (although there are some notable exceptions) understands the capacity for critique to be its singular contribution. We are not interested here (or, indeed, anywhere) in re-hashing debates about what critique should mean for a sociology or anthropology of the biosciences. In any event, whatever the potency of critique, it remains the case, as we put it in the article, ‘that many facets of human life that were, for much of the twentieth century, primarily understood through the abstractions of ‘culture’ or ‘society’ – commercial and economic life, governance, historical change, identity, distress and suffering – are increasingly understood as functions of the cerebral architecture of individuals or of groups of individuals.’ If there are risks associated with collaborating in such projects, we have been convinced (and our own experience bears out this conviction) that, as Nikolas Rose (2013) has put it, there is a sense of dynamism, complexity and unpredictability within these bioscientific forays that critics either don’t see, or don’t want to see. Becoming entangled with the neurosciences has been our own way of attempting to attend to this complexity.
(4) Many of the most conservative intellectual spaces you will find today are those that call themselves ‘interdisciplinary.’
We have been convinced of the need for a ‘collaborative’ turn for some years now. We first met – and began our own collaboration – at a networking event for junior social scientists, neuroscientists and humanists. And, since that meeting, we have been heartened by the number of funders, university departments, journal editors etc, who claim to share the same goal. But if we have ‘been inspired by broad calls for social scientists to take up new possibilities for collaboration,’ nonetheless, as we put it elsewhere, ‘we have often been dismayed by the narrow rhetorics and frameworks of interdisciplinarity that seem to govern actual, real collaborative spaces beyond those calls.’ And, at the risk of self-aggrandisement, it has become apparent that the risky and experimental space that we were trying to inhabit was not always what other people had in mind: a fairly typical ‘interdisciplinary’ interaction today is still to, for example, find a ‘philosopher’ who can ‘do’ some concept that will more narrowly parse the results of an imaging experiment – and match her with a neuroscientist with a broadly similar agenda. While this programme is wonderful in many ways, not only does it not cross any meaningful boundaries (there is, of course, often little if any epistemological separation between cognitive neuroscience and an analytic philosophy of mind) – but actually, in the way it parcels out labour and expertise, this kind of interdisciplinary interaction stridently re-enforces the very boundaries it claims to transgress. Partly the issue here is structural and temporal. (Submit a grant proposal that uses social sciences methods to push at the boundaries of neuroimaging, and – we promise you – it will be reviewed separately by a social scientist and a neuroscientist, both of whom will hate it. But this will likely change in time). More broadly, though, there is a general limit of imagination in self-established, increasingly self-congratulatory interdisciplinary spaces, and also a collective horror of risk. The regime of the inter is an entirely – and quite self-consciously – self-cancelling space.
(5) Collaboration as/and subjection
We have never understood the desire for collaborators to be – and, worse, the well-meaning advice that they should be – scrupulously honest, fair, and on a par with one another. If we were endlessly upfront with our colleagues from different disciplines, or if we insisted on fairness vis-a-vis recognition of our desires, we would, in all frankness, have hardly any collaborators by now, and even fewer friends. We are confident that the same can be said on their parts (i.e. that our collaborators have bitten their tongues many times in conversation with us). This is, of course, a fairly mundane reflection on what it means to get along with different kinds of people – but still it tends to get lost in intellectual and disciplinary contexts (i.e those in the humanities and social sciences) that are not much practised at tongue-biting. The point here is that collaboration happens in an (ethically, methodologically, conceptually) ambiguous mode, and much of the work of collaboration is thus learning to live ambiguously. The subject of collaboration, in her turn, lives an ambiguous life, and not always (indeed, perhaps only rarely) a happy one – so here we resist calls to distinguish between, as Anthony Stavrianakis articulates it in this case, the collaborator and cooperator. Living well in a collaborative mode is about resisting the urge to sort things out – it is about quelling the desire to be clear, at all times, on who ‘I’ am, and what ‘I’ am doing, and whether or not ‘I’ am getting anything out of this anyway. Indeed, much of our own learning to live in this mode has not at all been about clarifying things, but about learning to play with them – and play, as Andrew Balmer reminds us in his association of collaboration with BDSM, is a complex and at times violent ethical structure. Certainly, it allows the collaborator to confuse her subjectivity and her subjection. It might even help her to learn to find joy and insight in that confusion.
Des Fitzgerald is a postdoctoral research associate in the Department of Social Science, Health and Medicine at King’s College London, where he works at the ‘Urban Brain Lab’ , a project attempting to re-vitalize the relationship between sociology and psychiatry through a study of mental life and the city. He completed his doctoral work in 2013, where he focused on attempts to understand the autism spectrum neurobiologically – describing the ways in which neuroscientific knowledge negotiates the space between the biological and diagnostic definitions of autism, the hopes and disappointments of high-tech bioscience, and the intellectual and affective labours of laboratory research.
Felicity Callard is Reader in Social Science for Medical Humanities at Durham University and has wide-ranging research interests in 20th- and 21st-century psychiatry, neuroscience and psychoanalysis. One strand of her research comprises an interrogation of new models of self and the experimental subject within the cognitive neurosciences and biological psychiatry. She is Group Leader of the ﬁrst residency of The Hub at Wellcome Collection, which will conduct interdisciplinary experiments (on ‘rest’ and its opposites) across the social sciences, humanities, arts and neurosciences. She is also incoming Editor-in-Chief of History of the Human Sciences.
Further reading and listening
Des Fitzgerald and Felicity Callard, 2014. Social Science and Neuroscience beyond Interdisciplinarity: Experimental Entanglements. Theory, Culture, and Society, doi: 10.1177/0263276414537319
The entanglements of interdisciplinarity: An interview with Des Fitzgerald and Felicity Callard. Theory, Culture, and Society blog, September 17, 2014.Neuroscience and Social Science: Experimental Imaginations: Des Fitzgerald and Felicity Callard talk to Will Viney, Pod Academy, July 6, 2014
A French version of this piece was originally published in Libération on 18 September 2014.
“It is useless to laboriously interpret disaster movies in terms of their relation to an ‘objective’ social crisis or even to an ‘objective’ phantasm of disaster,” wrote Jean Baudrillard in 1981. “It is in another sense that (…) it is the social itself that, in contemporary discourse, is organised along the lines of a disaster-movie script.” In its Saturday, 13 September edition, the French daily Libération devoted several columns of its paper to the analysis of apocalyptic films, which reflect our anxiety in the face of pandemics. The Ebola virus epidemic which is raging in several western African countries calls for a more radical critique.
The current crisis is not a nightmare unfolding in front of our eyes, as in a “disaster movie.” It is not an anomaly or an accident which has afflicted public health services unexpectedly. It is also not, to use development gobbledygook, an organisational, financial and political “challenge” for the international community and humanitarian workers. Quite the opposite: the Ebola crisis is the result of two decades of political choices and actions. It is a disaster, well-prepared not only by the systematic undermining of African health-care systems by neoliberal reforms, but also by the strong mobilisation of public and private public health stakeholders to bring about a new era of “global health”. With this mobilisation, marked since 2005 by the incredible increase in health aid to the global South, Africa became a priority in the name of global health security. The time had arrived (or returned) for success stories, the eradication of disease, and glossy pamphlets with pictures of laughing children. Bill Gates and Big Pharma shared the podium; a new era was opening before us where smartphone applications, “public-private partnerships” and “responsible innovation” were going to solve Africa’s health problems, one after another. Forget rundown clinics, power failures and drug shortages: global health was the poster child for a better African future. The disaster unfolding under our eyes is the direct result of these security-oriented, spectacle-driven, scripted health policies, which have been implemented at the expense of African health systems and the people working in them.
“Pandemic preparedness” was one of the most important instruments of global health, both in the North and in the South, since the SARS and avian flu crises in 2003-2005. In the wake of the American post-9/11 mobilisation, research funds devoted to “bioterrorism” and “emerging diseases” – for which, by definition, pathogens do not yet exist – have drained public research funds, especially under the Bush administration. Contrary to what you may have read recently, Ebola was not neglected: since the first epidemic in 1976, the virus was an extraordinary means of obtaining funds for fundamental research in virology (notably the construction of high-security laboratories, beginning in the early 80s) and to render preventive and social-action medicine obsolete. No press release on ‘bio-security’ would fail to mention the Ebola virus as it embodied the quintessential emerging threat.
For 20 years, Ebola has been, along with SARS, smallpox and avian flu, the “raison d’être” of government pandemic preparedness programmes. With full-scale simulation exercises and secured warehouses filled with disposable gloves and surgical masks, preparedness was the political rationale of the new century, partly inherited from Cold War military programmes. In 2009 it developed full-scope during the H1N1 flu outbreak episode. Never had the world prepared so much.
Africa did not remain a bystander in these efforts. Under the aegis of the WHO, the US Center for Disease Control and Prevention (CDC) and European research institutions, African states “prepared” with the same enthusiasm. And the continent did not lack experts to lead the initiative: in several African countries the ‘search for emerging viruses’ employed scores of international researchers and their local partners; in recent years, it led to considerable progress in the knowledge of animal-borne pathogens (derived from bats and large apes), such as Ebola and HIV. As in Europe, the threat of new pandemics, especially influenza, drove the implementation of preparedness programmes. Most of them began with “simulation exercises” – scripted role-plays intended to test the readiness of authorities in the face of a (virtual) pandemic. However, in the context of African states, the simulation was indeed a simulation. Ministers and WHO experts, gathered in a large conference room and simulated military, police and public health interventions – with all participants knowing full well that these were devoid of any real bearing on the ground due to the woeful lack of equipment, troops, police personnel, and medical infrastructure. The very idea of preparedness was ultimately absurd: public health amounted to a simulated struggle against an imaginary threat. Never had Africa prepared so much: in fact, it did only that.
A major issue is that these pandemic preparedness exercises siphon off a large part of African health authorities’ energies and resources, even as they are confronted with far more urgent health emergencies. Thanks to Wikileaks, we now know that the US Embassy in Sierra Leone was already worrying about this state of affairs in 2007. But the main problem with these simulation exercises is that they represent, in pure and unadulterated form, the new paradigm of global health, Africa style: a type of intervention where real action on real diseases has become secondary to vast, assumptive and speculative programs. Some classic examples of this kind of speculation include the “Global Viral Forecasting initiative” of the Californian virus hunter, Nathan Wolfe,”Treatment-as-prevention” programs for HIV, and “mobile-health” projects which saw smartphones as a way of overcoming distance, the lack of personnel, and the shortcomings of African institutions. Lets take an analogy: global health is just as disconnected from “real” health as finance is from the “real economy”. Ebola 2014 has the appearance of a crisis – the bursting of a speculative bubble.
“Just as in a disaster movie”, as Baudrillard writes, reality and fiction are intertwined. With pandemic preparedness, the scenario and role-play have become a full-fledged political technique, a way to “organize the social itself”. It pushes the preventive approach of “old” public health services into the background, thus laying the groundwork for old epidemics like cholera (25 000 cases in 2013 in Africa) to resurface. The advent of global health is nothing but the last phase of a destructive historical sequence initiated by structural adjustment plans in the 1990s, which morphed African hospitals into a Mad Max scene of ruin and rust. The key to survival is telling a good story, perhaps the only thing that matters in the world of global health.
The superstars of the struggle against future pandemics, like the biologist Nathan Wolfe in the United States, completely blur the lines between fiction and reality, public health action and cash machine: Dr Wolfe, who forged a career thanks to his work on emerging viruses (including Ebola) in Cameroon, has appeared on numerous television shows in the past 10 years to promote his project on the surveillance of African pathogens. The fact that his work did not result in anything tangible is irrelevant. His latest book, The Viral Storm, earned him a 6-digit deal with his editor; he transformed his research team into a start-up, financed among others by the Google Foundation, which offered to pay him 1 million dollars for each new virus he identifies; his nicely-staged TED conferences play in a loop on YouTube and move the audience; and he was the scientific consultant for the apocalyptic zombie movie I Am Legend, featuring Will Smith. His small company, Metabiota Inc. rapidly positioned itself in the current Ebola epidemic. As of May 2014, the virologists of this start-up were contracted by the US Department of Defence to organize the “preparedness” of Sierra Leone at a time when the Ebola epidemic was raging in neighbouring Guinea: “a success story”, they declared on May 12. Sierra Leone “is uniquely prepared.”
We know how the movie ends.Guillaume Lachenal is a Lecturer at the Université Paris Diderot, a Junior Fellow of the Institut Universitaire de France and an Associated researcher at the Centre d’Etudes des Mondes Africains. He is the author of Le médicament qui devait sauver l’Afrique. Un scandale pharmaceutique aux colonies, (La Découverte, 2014) and co-editor – with Céline Lefève and Vinh-Kim Nguyen of La médecine du tri. Histoire, anthropologie, éthique (Presses Universitaires de France, 2014).
With Halloween just days away, October’s roundup will look at some of the macabre and spooky insights the web had to offer this month. Fear being a sensory experience–a pounding heart, shortness of breath, sweaty palms and vision problems are among the physiological markings of fear–it’s no surprise that science, medicine and the media valiantly make attempts each year to explain away the reasons we scare easy, and why some people seek out horror and gore.
Antiquity Now points to a connection between increased dopamine receptors in the brain and thrill-seeking activities, including, of course, a love for horror films and haunted houses (a fun addition to the post is a 2,000 year old scary story by Pliny the Younger). A long and interesting post on the beloved history of the horror genre at Wales Online attributes the power of legendary horror films like House of Wax and The Texas Chainsaw Massacre to playing on “basic instinctual fears,” but what is lost when we make assumptions about consistent and standard sets of fears that come from the discursive power of the concept of “instincts”? Finally and maybe most importantly, Wired discusses the circulation of web snuff films (like ISIS beheadings) as acts of war, where we are tempted by politically-charged horrific images (both real and imagined) that have space to run rampant in a way that is both viral and leaden with depraved meaning.
Specific fears are also getting their due: New York magazine and the Atlantic both take on the fear of clowns (citing Freud’s The Uncanny and the deeply unsettling “frozen” smile); TechTimes looks at the trope of the haunted or evil toy (the fear of the uncanny is mentioned here again, attributed to German psychiatrist Ernst Jentsch. The article also underlines the Ouija board and possessed doll as touching on our long-rooted cultural anxiety around necromancy and communication with the dead); Slate covers taphophobia–the fear of being buried alive–and the true and terrifying history of premature burial; Psychology Today unpacks the ‘mad scientist’ trope, getting at very real fears around mental illness and the collision of that fear with the absolute knowledge and power conventionally attributed to science; Guernica’s fantastic piece “Consumed” argues that “the horror of being eaten outpaces the horror of death by any other means” because of the power relations caught up in the act, again relying on primal imaginaries.
Don’t forget to keep up with the Somatosphere Ebola Fieldnotes series, which includes regular web roundups!
More Links of Interest:
“The History Behind ‘American Horror Story: Freak Show'” – The Geek Anthropologist
From the dragon’s perspective: an initial report on China’s response to the unfolding Ebola epidemic by Emilio Dirlikov
On a steamy mid-August afternoon, Mariatu Kargbo, a Sierra Leonian expat residing in Beijing, stood at the front of a packed hotel ballroom. As reported by Xinhua News (新华网), Kargbo addressed the crowd, saying:
I know everyone has come because they would like to support us, but I really didn’t know that today so many people would come, thank you everyone! What we’ve done today is to say to Ebola ‘You cannot go forward, you need to stop’!
Kargbo had organized the event as a fundraiser to support ongoing efforts to stop the Ebola epidemic in Sierra Leone. To this end, a variety of donated items were auctioned off, including art pieces from Chinese artists and several embassies of African countries, flights departing from Shanghai to Africa, pottery and ceramics, and a set of gloves donated by Chinese short-track speed skater Yang Zhou. Kargbo was no stranger to fundraising: as Miss Sierra Leone 2009, she set up a foundation to donate school supplies and other things to those in need. Nor was she a stranger in China: she has appeared on Chinese variety shows, fielding questions about Africa and singing her song in Mandarin Chinese, “Marry a Chinese” (嫁给中国人).
In this initial report, we provide insight into China’s response to Ebola as the epidemic unfolds. We focus on three key areas: 1) print media coverage, 2) social media commentary, and 3) brief stories of Africans living in Guangzhou. We finish with a discussion on the role of anthropology in engaging the ongoing epidemic, following Sharon Abramowitz’s recent post on Somatosphere.
Why raise the issue of China, a country that, to date, has not had any cases of Ebola?
The answer to this question is brought into view by Kargbo’s event, “Combatting Ebola: Mariatu and her Chinese friends,” exposing two overlapping trajectories that have emerged in recent years. First, the Chinese state sees itself as a global power, and as such, it should play a key role in global affairs. As China “goes global” (Shambaugh 2013), it adds a “distinctive” approach to global health (Han et al. 2008, Florini et al. 2012, Liu et al. 2014). Across the African continent, Chinese medical aid has come in the form of bilateral collaborations, financial and technical aid, and infrastructure projects. For example, the Sierra Leone-China Friendship Hospital was inaugurated by President Ernest Bai Koroma on November 13, 2012, after three years of construction, and is now being used to treat Ebola patients (photos here).
Second, Sino-African political and economic relations are substantial. In 2012, the total volume of trade between China and Africa reached US$198.4 billion, with a year-on-year growth of 19.3% (Xinhua News 2013). Over more than a decade, the direct exports from Guangzhou to African countries (mainly manufactured products) have increased more than ten times, from around US$165 million in 1996 to US$2.1 billion in 2010 (Lyons, Brown, and Li 2012). As a result, there has been a substantial increase in migration between the regions (Mathews 2011, Lyons, Brown, and Li 2012).
The Ebola outbreak adds another layer to the Sino-African relationship, whereby China is beginning to take a more active role in foreign aid to African countries and respond to emergency situations there. Therefore, China’s role in the control of the Ebola epidemic, which is reported by Chinese media outlets, will influence future relationships with African countries.’ Further, we posit social media commentary is a reflection of local anxieties about the outbreak, which largely work themselves out by framing “Africa” and “Africans,” especially in China, as a threat.
“China is ready to join the international society to continuously work hard towards an effective prevention of this Ebola outbreak” (中方愿同国际社会一道, 为早日有效防控这场突发疫情继续努力): Chinese print media coverage of Ebola
On October 15, 2014 we conducted an electronic search for Chinese language articles that mentioned Ebola using the electronic search tools available for two of China’s top news outlets: China Daily (中国日报) and People’s Daily (人民日报)., Media coverage of Ebola is not new: since 2001, a total of 667 and 219 articles were returned for the China Daily and People’s Daily, respectively (Figure 1). In 2014, both outlets had low coverage until July. The number of articles peaked in August, with most being published in the middle of the month when President XI Jinping publically committed to aiding the international control effort in a meeting held in Nanjing with UN Secretary-General Ban Ki-moon. Curiously, as the number of cases increased and cases have emerged in Europe and North America, the monthly total of media reports for both newspapers decreased (Figure 2).
Though even early reports presented the outbreak of Ebola in West Africa as an international threat, direct mentions of China were largely absent from such discussions. Here, we would like to highlight a major subject emphasized in these articles: China’s role in the global response. The response has in part been about helping the global control effort: China has provided aid and, on October 20th, donated US$6 million to the World Food Program to alleviate food shortages in the three most affected countries. As reported in these two media outlets, China’s response included: financial and food aid, sending mobile laboratory teams, providing drugs, and treating patients. One report explained China’s support of Ebola control efforts in West Africa as a natural product of “the extent of China-Africa trade and investment, as well as the China-Africa history of friendship and collaboration” (因为中非贸易和投资日益扩大，也因为中非友谊的历史承诺).
Yet, the response has also been protectionist. At home, China is trying to prevent the importation of disease, seen most strongly through the imposition of travel restrictions for all people from Ghana, Sierra Leone, and Liberia; Nigeria, which the WHO declared free from Ebola on October 20th, did not face similar sanctions. In mid-August the Chinese Ministry of Foreign Affairs issued travel warnings, cautioning citizens against visiting West Africa. Finally, in mid-October, new preparedness protocols to combat Ebola were announced, which brought together a variety of governmental departments, including health, foreign affairs, and forestry.
Believe in all possibilities: African-ness in Chinese commentary on social media
An August 13th People’s Daily article detailed a problem concerning Ebola in China: the use of social media to spread rumors, which the author decisively concluded were “rooted in human weakness” (很多谣言，都是植根于人性的弱点). Economic growth in China and low-cost technology has spurred the rapid development of Chinese social media platforms (Table 1 provides an overview of the most popular social media platforms currently used in mainland China). At times, social media has presented a contentious challenge for the Chinese state, resulting in new measures of censorship and surveillance, though usage around the country is still uneven (see Svensson 2014). However, such measures and indignation have not quelled online rumors about Ebola. This fits into a longer tradition within Chinese thought, encapsulated in the saying, “宁可信其有，不可信其无,” meaning that it is better to belief that something will happen rather than that it will not. In other words, while no cases of Ebola exist in China, under this concept, it is better to believe cases will emerge and be prepared rather than hope that Ebola will not reach China.
Despite the lack of cases, the risk of an Ebola pandemic has created a public atmosphere of fear, as seen through online forums. Much of this fear is directed at people from African countries, both those far away as well as the people residing in China. The Guangdong-based Southern Weekly (南方周末), one of the most influential media outlets in China, posted a news article entitled “’Devil’ Ebola attacks the Earth” (“魔鬼”埃博拉袭击地球), which stated that the worldwide Ebola pandemic is in fact a real version of the film Outbreak (1995). In the article’s comments section, readers responded to the heartbreaking stories from Africa, described as “scary” (恐怖), and compared the current situation to the 2003 SARS outbreak (非典), urging a quick response from the government. One commenter posted: “Our government should stop all flights in and out between China and the Ebola effected countries, and quarantine people travelling from these places until it is confirmed that they are negative for Ebola”(“政府应该立即停飞所有疫区的所有直飞航班，对从疫区入境的乘客，应先隔离观察，确认无误后方可入境”)
Within China, Africans are rumored to have already imported the disease. For example, the People Daily article cited above mentions the false rumor that a case of Ebola had already emerged in Shanghai. On October 18th, one Weibo user identified the first case of Ebola as a Nigerian man at the Canton Import and Export Fair (Canton Fair, 中国进出口商品交易会) exhibition center. In response, the Guangdong Provincial Health Department (广东卫计委) issued a statement via several online news channels as well as the official Weibo account of the Southern Metropolis Daily (南方都市报), one of the largest newspapers in South China, stating that the rumour was not true.
Guangzhou, a bustling metropolis of 8.5 million and the capital of Guangdong Province, has been cited as a particularly risky site of infection by social media users. Many Chinese believe that there will be an Ebola outbreak, and there is a high possibility that an African currently living in Guangzhou could carry it. For example, several mentions of Ebola appear on the “Africans in Guangzhou Board” (广州黑人吧) discussion forum, and the “Ebola Board” (埃博拉吧) also frequently cited Guangzhou in its user posts. One Tianya Club user stated: “If China has an Ebola outbreak [I] guess it will begin explode out of Guangzhou’s African community” (如果中国爆发埃博拉病毒估计先从广州黑人群体爆发).
Statements that highlight Guangzhou as a particularly risky place are unsurprising: the city has a large African migrant population, which is well known throughout China. While estimates of the precise number of Africans residing in Guangzhou are unreliable for a variety of reasons, ranging from 15,000 to 100,000 (Bodomo 2012, Castillo 2013), the large African community there serves as a vital bridge for Chinese-African relations (Bodomo 2010). While some of these Africans are long-term residents, most are frequent travellers engaged in border crossing activities between the African continent and China, either formally or informally (Mathews, Lin, and Yang 2014). The high mobility and frequency of travel by African migrants has led to a widespread Chinese belief that Africans could bring the Ebola virus to China.
Under the umbrella of preventing Ebola, social media users have posted about African communities in China. Among these posts, many demand closely monitoring African entry to China, if not the complete restriction of entry. Posts also call for tighter control over Africans within China, especially Guangzhou. For example, one Tieba user stated: “The law enforcement in our country is always a late response. Maybe there is a need for an Ebola outbreak so that Africans can be more intensely managed” (我们的执法者向来是诸葛亮一一事后的。可能要来一次埃博拉，才会对黑人加大管理).
In China, rumors of the spread of infection go beyond the biomedical model of transmission, which focuses on preventing direct contact with active cases, as some online users highlight sexual intercourse. Here, women are seen as particularly vulnerable. In a popularly circulated WeChat posted on October 17th, entitled “Ebola will strike China by the end of this month; one article that helps you understand this terrifying disease with a mortality rate over 70%” (埃博拉很可能月底袭击中国，一篇文章读懂这种死亡率超70%的恐怖病毒), the author emphasizes:
The Ebola virus in the semen of the Ebola carriers can be alive for three months, even after the person is cured. Therefore, if you want to have sex with African men from West Africa, think twice before you do that and at least consider wearing a condom.
Note that gendered terms specify the Ebola carrier was male, reifying ideas of African men as dangerous and implying that casual (heterosexual) sex is a crucial site of contamination that is best avoided. This correlates with ongoing discussion and stigmatization of interracial marriages between Chinese and Africans, particularly between Chinese women and African men. For example, a post on Baidu Tieba warns: “Careful! Chinese race have been endangered by black people multiply intensively in China” (警惕：黑人在华无限繁殖危及中华民族); another posting in the thread reads: “The Chinese men’s crisis!: white and black people are grabbing our women” (黄种男人的危机! 白人黑人抢我们的女人).
Words travel beyond borders. The forwarding, sharing, and discussion of Ebola on Chinese media is at once reflective of local fears and anxieties, and also exemplifies the process by which new tools instantiate extant ideas and biases. To be clear, the quotes above have not been gathered systemically, but rather, have been selected for their discussions on the epidemic and Africans more generally. For Ebola, social media users ascribe risk onto an understanding of “African-ness,” whether it is located on the continent of Africa, or within African bodies when they come to reside in China, echoing previous racialized responses to HIV/AIDS (Hood 2011).
En brief: stories from African migrants
At the end of September 2014, Qiuyu Jiang returned to Canada from her fieldwork, which focuses on African migrants in Guangzhou. Below, she presents three short clips of how Ebola has already begun to affect this community. All names are pseudonyms.
Business as usual: the Nigerian merchant
Since 1957, Guangzhou has played host to the Canton Fair, a biannual business convention that attracts traders from around the world. The Fall Canton Fair is currently underway, attracting over 188,119 foreign visitors and generating US$31 billion in business turnover in its 115th session held in Spring 2014. Amongst the crowds, African traders, many of whom have traveled from Nigeria, Mali, Senegal, and other countries to attend, are easily identifiable.
Business is booming as usual, unimpeded by global media-grabbing events, such as the student protests in Hong Kong, on-going airstrikes against ISIS, or even the Ebola epidemic. That is, except for those that cannot attend due to travel restrictions. For these who can make it, there is perhaps less competition. “Oh, (Ebola to me has) no influence at all,” one Nigerian trader commented. “I just picked up my countrymen from the airport and put them in the hotels. They came without a problem. There are some screening procedures at the airport but not much warning.”
Closed borders: the Guinean trader
In Guinea, Mohamed, an African trader, has been waiting anxiously for his Chinese visa. He had returned to his hometown in May 2014 for his son’s birthday, and a much-needed vacation from his busy trading life in Guangzhou. He described his situation as follows:
Truly, I want to come back. Many of my Chinese friends and businessmen colleagues are calling me day and night, asking when I can be back. I have an apartment in Guangzhou; I am still paying rent but I cannot be back. You know how easy it used to be for me to get a visa…But now because of the disease, people are afraid. I pray to God every day to take away Ebola and let me back to do business again.
Since many neighbouring African countries began shutting down the border with Guinea due to the Ebola epidemic, he has largely lost hope. In his absence, Mohamed has asked his sister, who remains in Guangzhou as a student, to temporarily represent him in his business affairs. “Business is a secret; I cannot let other strangers into this.” Under Chinese immigrant law, however, student visas do not allow for employment, and thus, his sister runs the risk of being deported if she were to be found out by the authorities.
Not taking any chances: the Guinean student
Sitting outside of a local university’s enrolment services office in Guangzhou, Mamadou, an international student from Guinea, was disheartened to find out his transfer request had been denied. He had already been in the city for two years, residing there on a student visa. He had many reasons for wanting to transfer universities. Mamadou was excited to attend better language courses, and also be more integrated into the African community, who were enrolled at the university in larger numbers. Finally, like many other foreign students in China, he worked secretly in his spare time in order to cover his daily expenses; the university he was looking to transfer to offered a more convenient course schedule for his needs. He explained:
I want to change my school….but they say (that) because I am from Guinea, they are afraid that I will bring Ebola to them. But for almost two years, I have not been back to my hometown. I am in China! Where can I get this disease? Now I have to go back to the school I don’t like.
Discussion: Towards an anthropology of unfolding engagement
Ebola has not followed the trajectory that was predicted at the outset of the epidemic, and the response from anthropologists has similarly been unexpected. Normally critiqued for being slow and responsive, in this instance, anthropologists have been visibly involved in public health debates as well as ongoing reflection on the (potential) implications of the epidemic to the discipline. For example, on October 2 the American Anthropological Association (AAA) hosted a “webinar” on Ebola; Cultural Anthropology published a special series on October 7th; and since August, a number of essays have appeared here on Somatosphere in the series “Ebola Fieldnotes.” Anthropologists have also used less discipline-specific platforms, such as radio (2), print media, and YouTube to advocate for an improved response. In this report, we join the anthropological engagement as the Ebola epidemic unfolds, while adding an important geographic dimension that has been largely overlooked.
We position this initial report to capture some emergent trends in China surrounding the Ebola epidemic. As seen, while Chinese print media might have peaked in August, popular social media platforms, such as WeChat and Weibo, demonstrate a lively on-going discussion in China about Ebola. In spite of official warnings of the dangers of spreading rumors online, social media users are sharing a variety of kinds of information about the risks, modes of transmissions, and methods to manage Ebola. In Chinese, the disease is distinctly foreign due to its transliteration, and such rumors reflect the anxiety of importing a disease from the outside. Africans, as visible minorities, shoulder the burden of perceived risk, both abroad and within China. Conversations with African informants reveals that while some migrants continue to go about their business unaffected, the threat of Ebola has impacted the everyday choices of others. Coupled with online commentary, the perceived threat of Ebola may amplify existing racial schisms, which have escalated to violent incidents in recent years.
We are guided by previous social science work on recent epidemics in China, including SARS (Dirlikov 2005, Zhang 2006, Duan 2007), HIV/AIDS (Hood 2011, Hyde 2007), and avian influenza (Heffernan, Misturelli, and Thomson 2011, Dirlikov 2008), as well as historical examinations of disease (Heinrich 2008, Landsberger 2010, Hinrichs and Barnes 2013, Rogaski 2004). We further position this initial report as part of a growing body of social science research that examines Chinese in Africa (Yan and Sautman 2013, Mohan and Tan-Mullins 2009), as well as Africans in China (Ma and Bodomo 2012, Bodomo 2012, Bodomo 2010, Mathews 2011, Mathews, Lin, and Yang 2014, Han 2013, Haugen 2012, Lyons, Brown, and Li 2012).
Finally, we would like to offer an example in which anthropologists make contributions that at once are unique to anthropology and informative to public health experts, policy makers, and the public at large. Here, we follow Sharon Abramowitz, who argues that anthropologists can “systematically observe, report on, interpret, and explain local perspectives on the Ebola epidemic response.” This requires a different type of anthropological engagement that is timely, proactive, and useful beyond the confines of the discipline. Yet, the cornerstones of anthropological research remain central. Indeed, in preparing this report over the course of one week, we have both reached out to contacts in China, and have drawn on background information derived from long-term fieldwork and personal experience in China.
As China is a major player in Africa and global (health) affairs more generally, we argue for a fuller analysis of the consequences Ebola has had and will continue to have in China, as well as on the citizens of China and of African countries who live there.
Emilio Dirlikov is a PhD Candidate in McGill University’s Department of Anthropology and Social Studies of Medicine. He is currently finalizing his dissertation, for which he spent two years conducting field research on tuberculosis control in China.
Qiuyu Jiang is a PhD Candidate in McGill University’s Department of Anthropology and the Center for Society, Technology and Development. She is currently writing her dissertation based on fieldwork on African migrants in Guangzhou, China.
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Lyons, Michal, Alison Brown, and Zhigang Li. 2012. “In the Dragon’s Den: African Traders in Guangzhou.” Journal of Ethnic and Migration Studies Journal of Ethnic and Migration Studies no. 38 (5):869-888.
Ma, Enyu, and Adams Bodomo. 2012. “We Are what We Eat: Food in the Process of Community Formation and Identity Shaping among African Traders in Guangzhou and Yiwu.” African Diaspora no. 5 (1):3-26.
Mathews, G., D. Lin, and Y. Yang. 2014. “How to Evade States and Slip Past Borders: Lessons from Traders, Overstayers, and Asylum Seekers in Hong Kong and China.” City and Society no. 26 (2):217-238.
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 In this report, we follow the Chinese discourse on Africa, which generally homogenizes the enter continent into one as 非洲. Further, we translate 黑人 (lit. “black person) as “African.”
All media in China falls under state control, with the People’s Daily serving as the government’s official news outlet, and the China Daily serving as a more outward looking news source that is also published in English and French.
 There are two terms for “Ebola” in Chinese: 埃博拉 (āibólā) and 伊波拉(yībōlā). Both terms are transliterations of the English pronunciation, and it appears that the former is used more frequently in mainland China, while the latter is used more extensively in Hong Kong and Taiwan.
Below you will find Part II of our journal coverage for October…
Disability and the Global South
China Mills and Suman Fernando
This commentary sketches out the politics of the expansion of affordable, fast-moving nutraceutical products into rural India, with a focus on fortified foods and beverages. It examines the relationships between industry, government and humanitarian organisations that are being forged alongside the development of markets for nutraceuticals; the production of evidence and the harnessing of science to support nutraceutical companies’ claims; the ways in which nutraceuticals are being marketed and distributed in rural areas; and the concepts of health and well-being that are being promulgated through those marketing campaigns. Lastly, it asks what kinds of impact fast-moving nutraceuticals are likely to have on the lives of India’s rural poor. It concludes by questioning how smooth a transition to nutraceutical consumption Big Food marketing strategies can really facilitate and how readily low-income families seeking to feed their families and safeguard health will actually adopt concepts of wellness and internalise micro-nutrient associated risks.
Thomas W. Crawford, Stephanie B. Jilcott Pitts, Jared T. McGuirt, Thomas C. Keyserling, Alice S. Ammerman
Greater accessibility to geospatial technologies has led to a surge of spatialized public health research, much of which has focused on food environments. The purpose of this study was to analyze differing spatial measures of exposure to supermarkets and farmers׳ markets among women of reproductive age in eastern North Carolina. Exposure measures were derived using participant-defined neighborhoods, investigator-defined road network neighborhoods, and activity spaces incorporating participants׳ time space behaviors. Results showed that mean area for participant-defined neighborhoods (0.04 sq. miles) was much smaller than 2.0 mile road network neighborhoods (3.11 sq. miles) and activity spaces (26.36 sq. miles), and that activity spaces provided the greatest market exposure. The traditional residential neighborhood concept may not be particularly relevant for all places. Time–space approaches capturing activity space may be more relevant, particularly if integrated with mixed methods strategies.
Jessica L. Adler
When Walter Reed United States Army General Hospital opened its doors in 1909, the Spanish-American War had been over for a decade, World War I was in the unforeseeable future, and army hospital admission rates were steadily decreasing. The story of the founding of Walter Reed, which remained one of the flagship military health institutions in the United States until its 2011 closure, is a story about the complexities of the turn of the twentieth century. Broad historical factors—heightened imperial ambitions, a drive to modernize the army and its medical services, and a growing acceptance of hospitals as ideal places for treatment—explain why the institution was so urgently fought for and ultimately won funding at the particular moment it did. The justifications put forth for the establishment of Walter Reed indicate that the provision of publicly funded medical care for soldiers has been predicated not only on a sense of humanitarian commitment to those who serve, but on principles of military efficiency, thrift, pragmatism, and international competition. On a more general level, the story of Walter Reed’s founding demonstrates a Progressive Era shift in health services for U.S. soldiers—from temporary, makeshift hospitals to permanent institutions with expansive goals.
(Extract) The history of medical genetics has long been narrated as a story of the unfortunate entanglement of human genetics with the morally dubious practices and scandals of eugenics from which it finally freed itself. Such a master narrative—which often refers to a legitimizing “medical turn” in the middle of the century after World War II—is deeply mistaken, argues Nathaniel Comfort. Eugenics was never “overcome,” as if it were some sort of “contaminant” that could finally be left in the dustbin of history, and at no time “did medical genetics break suddenly with its eugenic past.” Rather than assume a clear shift from “a focus on human improvement to one on relief of suffering,” Comfort argues that we have always been eugenical: “human improvement and the relief of suffering [are] the two goals of all eugenics—and all medical genetics.” The Science of Human Perfection offers a powerful revisionist account that highlights the key role played by an ever-present “eugenic impulse” in the emergence of medical genetics, which identifies how such an impulse remains an important and insidious feature of biomedicine even today. According to Comfort, “the promises of genetic medicine are the promises of eugenics.”
Andrew J. Hogan
(Extract) Over the past four decades, increasing numbers of Americans have faced the prospect of undergoing genetic testing in the context of reproduction, risk assessment, and clinical diagnosis. Paralleling this rise in new genetic technologies, historians of science and medicine have made many important contributions in recent years to our understanding of twentieth-century genetic medicine. Scholars have traced the direct ties between the history of eugenics and the field of medical genetics (Nathaniel Comfort, The Science of Human Perfection, 2012), the recasting of all human disease as genetic, and thus susceptible to technological control (Susan Lindee, Moments of Truth in Genetic Medicine, 2005), the role of prenatal and carrier testing in facilitating the birth of healthy children (Ruth Schwartz Cowan, Heredity and Hope, 2008), and the entanglement of genetic medicine with racial categories and assumptions (Keith Wailoo and Stephen Pemberton, The Troubled Dream of Genetic Medicine, 2006). Largely absent from this literature, however, has been an in-depth account of the field of genetic counseling as it grew up alongside and played a direct role in shaping the clinical uptake of new genetic technologies.
Nicholas Bartlett, William Garriott & Eugene Raikhel
Recent years have seen the emergence of a ‘global mental health’ agenda, focused on providing evidence-based interventions for mental illnesses in low- and middle-income countries. Anthropologists and cultural psychiatrists have engaged in vigorous debates about the appropriateness of this agenda. In this article, we reflect on these debates, drawing on ethnographic fieldwork on the management of substance use disorders in China, Russia, and the United States. We argue that the logic of ‘treatment gaps,’ which guides much research and intervention under the rubric of global mental health, partially obscures the complex assemblages of institutions, therapeutics, knowledges, and actors framing and managing addiction (as well as other mental health issues) in any particular setting.
Marieke van Eijk
Health care institutions are often severely criticized for regulating the lives of individuals who deviate from socially sanctioned norms. In teaching people where they fit in the conventional scheme of things, institutions often reproduce socially dominant ideologies of normality, health, and self. Drawing on ethnographic fieldwork conducted at a university-based gender identity clinic in the United States, I demonstrate that while some institutions adopt dominant cultural frameworks, others critically assess these. To understand the intricacies of the clinic’s psychotherapeutic practices, I analyze the clinicians’ constructions of health and suffering. Instead of viewing transgenderism as a psychiatric condition, these clinicians approach it as a normal human condition that is marginalized by society’s heteronormative values. The analysis, attentive to the interaction among social context, institutional work, and psychotherapeutic ideologies, shows that while some institutions reproduce hegemonic cultural frameworks, others, in their attempts to alleviate people’s suffering, do challenge dominant social norms.
Dedicated to a South Indian goddess, devadasis are priests in a healing cult, whose nonconjugal sexuality has been designated ‘prostitution’ and subjected to eradication by the state. Drawing on ethnographic research, I consider two ways in which they cross the threshold of the clinic, as ‘vectors of disease’ and as sex worker peer educators, in order to think about the bio-politics of citizenship in postcolonial India. If biopolitical citizenship describes the way the state takes hold of their bodies, dedication describes how their bodies are claimed by the Devi Yellamma. I juxtapose these different ways of embodying power as a means to mark the limits of secular social scientific terms of recognition.
Heather A. Howard
The construction of illness as an inscription on the body of colonization figures importantly among Indigenous community-based service and health care providers. While residential schools and diabetes have both been characterized as products of colonization, little work has been done to examine how they are connected to and informative for health provider practice. The research data presented in this article come from a collaborative urban Indigenous community-based study examining the legacy of negative relationships with food that was instilled in residential schools and used in diabetes intervention. I illustrate how residential school disciplined eating, providing a context for understanding the contemporary production of Indigenous health knowledge and practice in the urban setting, and the diet-related management of diabetes.
In this article, I examine the self-positioning of many New Zealand mothers of children with asthma as parent-experts whose authority supersedes that of implementing the self-management strategies advocated by medical professionals. In a socio-political context that emphasizes neoliberal values of autonomy and self-responsibility, these parent-experts experiment with a variety of pharmaceutical regimes, determining familial modes of care that privilege the achievement of what they consider to be ‘normal childhoods.’ While some families accept asthma as a chronic condition and encourage children to adopt standardized, daily preventative regimes, others craft alternative strategies of pharmaceutical use that allow them to experientially maintain asthma as a sporadic and temporary, if frequent and sometimes dramatic, interruption of everyday life. Childhood asthma care practices are thus not only vested in kinship networks, but often arise out of familial-based experiments whose goal is to determine regimes that enable the preservation of ‘normality.’
Biomedicine is typically defined as the branch of medicine that is based on the principles of biology and biochemistry. A central tenet for biomedicine is the notion of disease and therapeutic specificity, i.e. the idea of tailored treatments for discrete disorders underpinned by specific pathologies. The present paper is concerned with how notions of disease and therapeutic specificity guide biomedical reasoning. To that end, the author proposes a model – the specificity triad – that draws on late philosopher and physician Ludwik Fleck’s concept of “style of thought” to offer a frame for investigating the intricate process through which links between disorders, mechanisms, and therapeutics are established by biomedicine. Next by applying the specificity triad model to scrutinize research efforts in two discrete areas of medicine–psychiatry and regenerative medicine–this paper seeks to stimulate pertinent discussions in and about biomedicine. These include discussions on the ambiguous epistemic status of psychiatry within contemporary biomedicine, as well as the relationship between developmental biology — historically relatively disjointed from biomedical enterprise — and the burgeoning field of regenerative medicine.
Ever since records began, accounts of other peoples and their institutions and customs have included comments about their mental characteristics. The present article traces this feature from the 18th century to roughly the First World War, with a brief sketch of more recent developments. For most of this period two contrasting positions prevailed: the dominant one attributed human differences to ‘race’, while the other one explained them in terms of psychological, environmental and historical factors. The present account focuses on the latter, among them those who asserted ‘the psychic unity of mankind’. Generally it is shown that from the early period when writings were based almost entirely on secondary sources, to the beginnings of empirical studies, ethnological theories were indissolubly linked to psychological concerns.
This article charts the history of mental testing in the context of the rise and fall of Russian child science between the 1890s and the 1930s. Tracing the genealogy of testing in scientific experimentation, scholastic assessment, medical diagnostics and bureaucratic accounting, it follows the displacements of this technology along and across the boundaries of the child science movement. The article focuses on three domains of expertise – psychology, pedagogy and psychiatry, examining the key guises that mental testing assumed in them – namely, the experiment, the exam and the diagnosis. It then analyses the failed state-bureaucratic harnessing of mental testing in early Soviet attempts to manage mass education, discussing the peculiar dynamics of the (de)legitimation of testing, as it swung between black-boxing and instrumentalization, on the one hand, and scandal and controversy, on the other. The article argues that mental testing thrived in Russia as a strategically ambiguous and flexibly interpreted ‘boundary object’, which interconnected a highly heterogeneous field, enabling the coexistence and cooperation of diverse occupational agendas and normative regimes.
This article examines three key aetiological theories of autism (meta-representations, executive dysfunction and weak central coherence), which emerged within cognitive psychology in the latter half of the 1980s. Drawing upon Foucault’s notion of ‘forms of possible knowledge’, and in particular his concept of savoir or depth knowledge, two key claims are made. First, it is argued that a particular production of autism became available to questions of truth and falsity following a radical reconstruction of ‘the social’ in which human sociality was taken both to exclusively concern interpersonal interaction and to be continuous with non-social cognition. Second, it is suggested that this reconstruction of the social has affected the contemporary cultural experience of autism, shifting attention towards previously unacknowledged cognitive aspects of the condition. The article concludes by situating these claims in relation to other historical accounts of the emergence of autism and ongoing debates surrounding changing articulations of social action in the psy disciplines.
Ari Väänänen, Michael Murray, and Anna Kuokkanen
Stress at work is a frequent subject of scientific research. In most of this, the unit of analysis has been the employee and his or her work stress. Historical, cultural and macro-contextual approaches have rarely been included in the analytical framework. In this study, we examined secular trends in scientific publications on work stress, and analysed how, over a period of 50 years, a new discursive, institutional, intellectual and subjective space has developed, in which questions related to workers’ diminished mental energy became the centre of attention. Our interpretation links the occupational health debate to the broader historical and cultural processes that took place in western countries and work organizations in the period 1960–2011. Our quantitative analysis shows how the number of work stress publications rose steeply until the early 2000s and how the growth evened out and even started to decline in some data sources in the early 2010s. It would seem that work stress research is reaching its peak and that other conceptualizations in the domain of occupational health (e.g. resource-based views) are becoming more important. This historical study provides new insights regarding the nature of work stress and its links with societal changes for all those interested in the changing nature of health at work.
Call for papers: Dreaming of Health and Science in Africa: Aesthetics, Affects, Poetics and Politics by Ann Kelly
This conference seeks to open a conversation on forms of possibility and violence that are enabled and take effect through dreams of health and science in Africa. Dreams are often of transformation, critical of the present and articulating alternative and imaginative futures towards which expertise, knowledge and care might lead. Dreams can also engender violence and turn into nightmares. Aspirations to health and advancement can be stoked as fictions while their achievement is systematically postponed, or trivialised as pipe-dreams, whittling down science and medicine to fit the present tense of urgent priorities and scarce resources. Dreams can also clash with each other, sparking violent contests over the future. Through dreams good and bad, deferred, broken or attained, reached for and pushed out of reach, tenacious and erased, forgotten and rekindled, we propose to explore emerging and future possibilities for the study of medicine and science in Africa.
We ask: can dreams help us reopen and critically examine the past and potential horizons of possibility that have animated bio-scientific activity in Africa? Dreaming and recapturing dreams together as historians, anthropologists, geographers, scientists, architects and artists will animate connections between politics and aesthetics, affective relations and materiality, suggesting paths ahead for interdisciplinary inquiry. How can we understand which, how and why futures for African science and health have been delayed, narrowed and closed off, and to expand the boundaries, of time and possibility, of current imaginations beyond the constraints of “global health”?
We invite participants to engage the dreams and nightmares that fuel(ed) medical science in Africa.
Abstracts, with contact details, to firstname.lastname@example.org by 30th November 2014
“Tolerance” never made it into Raymond Williams’ Keywords, a rare mistake: it should have been a tempting subject for his critical sensibility. By the late-eighteenth century, the word often had come to substitute in English for the older “toleration,” meaning forbearance, patience, and indulgence of the opinions of others. Later, physiologists took up its connotation of the endurance of hardship, transferring the concept to the scene of medical investigation: they gauged the tolerance of large doses of drugs and other noxious agents. Early in the twentieth century, microbiologists requisitioned the term. They used it to signify the host’s survival despite infection with a parasite — in effect, the ability to become a healthy carrier of some microbe. Tolerance soon became a key word in microbiology and animal ecology. According to Australian virologist F. Macfarlane Burnet, the most intriguing aspect of the immune system was its tolerance of its own body, what he called the “self,” and not its mundane mechanisms of resisting foreign agents. One could not know the immune self — the absence of self-antigenicity — without understanding tolerance. Indeed, the sovereign self of an organism was in effect whatever its immune system would tolerate. Thus “tolerance” has been one of those vagrant concepts or metaphors like “self,” “resistance,” and even “immunity” that ambulate gainfully, if awkwardly, through various domains, doing work in political, philosophical, literary, and scientific discourses.
In 1948, after musing for more than a decade on the production of antibodies, or the nature of the vertebrate immune response, Burnet decided that “recognition of ‘self’ from ‘not-self’ is probably the basis of immunology.” But still he wondered how this tolerance of self, or lack of self-antigenicity, could develop. The following year, with protégé Frank Fenner, he speculated that recognition and tolerance of self must occur principally during embryonic life. “If in embryonic life,” they predicted, “expendable cells from a genetically distinct race are implanted and established, no antibody response should develop against the foreign cells when the animal takes on independent existence.” That is, the organism as it formed had the capacity to tolerate foreign elements. A few years later, Peter Medawar and his colleagues managed to induce experimentally this immunological tolerance, to show that embryonic mice became “indifferent” to cells transplanted into them. For their studies of immunological tolerance, Burnet and Medawar secured the 1960 Nobel Prize in Physiology or Medicine.
Gradually, though, there has been a slippage from tolerance to self. Commonly, Burnet is perceived as the advocate of the immune self, which proved an alluring concept. But his fame as the theorist of self devalues his curious speculations on tolerance, a far more supple notion. In effect, “self” has stabilized and locked in “tolerance” and made it a tool of sovereignty, a figment of the Cold-War imaginary. The ramifications of tolerance could render possible a more extensive and ecological, even selfless, self — encompassing the others within, such as the gut microbiome, and could explain those failures of self-recognition, the autoimmune diseases. The immune self has turned tolerance into a stage one goes through, not a life-long negotiation or struggle.
“Tolerance” was a word long familiar to Burnet. He mentioned the term in some articles in the 1930s and in Biological Aspects of Infectious Disease (1940), the founding text of disease ecology. Initially, his usage was conventional, referring to an organism’s tolerance of increasing doses of drugs and to the carrier’s tolerance of germs. Burnet’s Ph.D. supervisor at the University of London, J.C.G. Ledingham, had made a name for himself expatiating on how tolerance of microbes can allow asymptomatic infection in carriers. In the 1930s, Burnet also was reading widely in animal ecology. He must have heard of Victor E. Shelford’s “law of tolerance,” which stated that an organism survived only if environmental conditions remained within a range of tolerance. Charles Elton, whom Burnet read carefully, incorporated the idea of tolerance in his justification of the niche concept. By the late 1940s, tolerance came to infuse Burnet’s immunological speculations. While Burnet thus made efforts to translate ecological thought into immunological theory, the appeal of the immune self seems ultimately to have restricted the conceptual transfer. My sense is that his understanding of immunological tolerance started off ecological, but soon ran into an ontological impasse, getting stuck on notions of the preformed self. Certainly his later interpreters often let a rigid self, or autonomous biological individuality, blind them to the ecology of tolerance. Burnet himself could be equivocal.
In the past twenty years, ecological immunologists have ventured further down the path on which Burnet hesitated. The immune self has become more dynamic, interactive, and encompassing. “The problem centers on tolerance,” Alfred I. Tauber tells us. Rather than posit a self that must be defended, we should consider the communal and relational grounding of tolerance and immunogenicity. According to Janelle S. Ayres and David S. Schneider, “studies of tolerance will provide an improved foundation to describe our interactions with all microbes: pathogenic, commensal and mutualistic.” By tolerance they mean “a change in sensitivity to elicitors.” Scott F. Gilbert, Jan Sapp, and Tauber also argue that proposing such “interactive relationships among species blurs the boundaries of the organism and obscures the notion of essential identity.” Sadly, in these ecological visions, Burnet usually is seen as an enemy, not an ally; as a straw man, not a progenitor; as antigen, not complement.
Obsessed with immunological metaphysics in his last decade, Jacques Derrida distrusted mere tolerance, attributing to it ties to sovereign reason. Tolerance struck him as a “scrutinized hospitality, always under surveillance, parsimonious and protective of its sovereignty.” It represented a conditioned hospitality that the immune system protected against the wholly other. Derrida yearned for a different sort of immune system, one that harbored radical alterity: a commune system, perhaps. Yet rival philosopher Roberto Esposito is more sanguine about tolerance. In Immunitas, he writes: “At the heart of this historical, process-based conception of identity as a system open to the challenges of the outside world, and indeed ultimately formed by them, lies the complex function of immune tolerance.” He continues: “if tolerance is a product of the immune system itself, it means that, far from having a single-response repertoire, that of rejecting other-than-self, it includes the other within itself, not only as its driving force but also as one of its effects.” Through tolerance, one might refigure immunity as ecological community.
The passage from politics and philosophy to microbiology and immunology, and back again, is crowded and bustling. In the twenty-first century, tolerance appears finally to have prevailed in the commotion. Practicing tolerance, anthropologist A. David Napier tells us, makes possible our future. “This is why,” he writes, “we all need to start replacing competition with thoughts of others, with embryology, with tolerance and generosity, even with goodness—why science, in the absence of artful living, will wallow in its own entropy.” How apt, and yet so poignant: an embryonic manifesto for radical tolerance. How Burnetian—perhaps.
Warwick Anderson is an Australian Research Council Laureate Fellow and Professor at the University of Sydney. He is the co-author, with Ian R. Mackay, of Intolerant Bodies: A Short History of Autoimmunity (Baltimore: Johns Hopkins, 2014). He has written (mostly with Mackay) on immunological history for Isis, the Journal of the History of Biology, the Journal of Neuroimmunology, and the New England Journal of Medicine. In 1984, he was a medical resident on the Royal Melbourne Hospital’s clinical immunology ward, which Mackay directed.
 Raymond Williams, Keywords: A Vocabulary of Culture and Society (London: Fontana, 1975).
 Warwick Anderson and Ian R. Mackay, Intolerant Bodies: A Short History of Autoimmunity (Baltimore: Johns Hopkins University Press, 2014); and Warwick Anderson, “Getting ahead of one’s self: the common culture of immunology and philosophy,” Isis 105 (2014): 606-16.
 F.M. Burnet, “The basis of allergic diseases,” Medical J. Australia I (1948): 29-35, p. 30.
 F.M. Burnet and Frank Fenner, The Production of Antibodies, 2nd ed. (Melbourne: Macmillan, 1949), p. 31.
 Rupert E. Billingham, Leslie Brent, and P.B. Medawar, “Actively acquired tolerance of foreign cells,” Nature 172 (1953): 603-6.
 J.C.G. Ledingham, The Carrier Problem in Infectious Diseases (London: Longmans, Green and Co., 1912).
 Victor E. Shelford, Animal Communities in Temperate America (Chicago: University of Chicago Press, 1913).
 Charles S. Elton, Animal Ecology (London: Sidgwick and Jackson, 1927).
 Alfred I. Tauber, “Review of Thomas Pradeu The Limits of the Self,” Notre Dame Philosophical Reviews http://ndpr.nd.edu/news/31627-the-limits-of-the-self-immunology-and-biological-identity. Accessed 25 September 2014. See also Tauber, “The immune system and its ecology,” Philosophy of Science 75 (2008): 224-45.
 Janelle S. Ayres and David S. Schneider, “Tolerance of infections,” Annual Review of Immunology 30 (2012): 271-94, pp. 271, 273.
 Scott F. Gilbert, Jan Sapp, and Alfred I. Tauber, “A symbiotic view of life: we have never been individuals,” Quarterly Review of Biology 87 (2012): 325-41, p. 326.
 Jacques Derrida, “Autoimmunity: real and symbolic suicides,” in Philosophy in a Time of Terror: Dialogues with Jürgen Habermas and Jacques Derrida, interviewed by Giovanna Borradori (Chicago: University of Chicago Press, 2003), p. 128.
 Roberto Esposito, Immunitas: The Protection and Negation of Life, trans. Zakiya Hanafi (Cambridge: Polity, 2011), pp. 166, 167.
 A. David Napier, The Age of Immunology: Conceiving a Future in an Alienating World (Chicago: University of Chicago Press, 2003), p. 253.
Image: “The Oil and Vinegar Nebula.” Flickr.
Naoki Higashida’s The Reason I Jump: The Inner Voice of a Thirteen-Year-Old Boy with Autism by Whitney Laemmli
Translated by K.A. Yoshida and David Mitchell; Introduction by David Mitchell
Random House, 2013. 176 pages.
Naoki Higashida wants you to understand why he loves asking the same questions over and over: “Repeating these is great fun. It’s like a game of catch with a ball. Unlike the words we’re ordered to say, repeating questions we already know the answers to can be a pleasure—it’s playing with sound and rhythm.” He wants you to appreciate why he sometimes has trouble expressing himself: “it’s because the words coming out of my mouth are the only ones I can access at the time. These words are either available because I’m always using them or because they left a lasting impression on me at some point in the past.” And wants you to know the reason he jumps: “When I’m jumping, it’s as if my feelings are going upward to the sky. Really, my urge to be swallowed up by the sky is enough to make my heart quiver. When I’m jumping, I can feel my body parts really well, too—my bounding legs and my clapping hands—and that makes me feel so, so good.”
Higashida is a Japanese teenager with autism, and his book, The Reason I Jump: The Inner Voice of a Thirteen-Year-Old Boy with Autism, has recently captivated the attention of both academic and popular audiences. Published in 2007 in Japan, it was translated into English in 2013. Since, The Reason I Jump has become A New York Times bestseller, been featured on The Daily Show, and named among the best books of the year by, among others, NPR and The Wall Street Journal. At the time of its writing, Higashida was almost entirely nonverbal; he composed the text by spelling out words with the aid of a printed table of forty basic Japanese characters.
This intensive labor alone makes the text a remarkable achievement, but The Reason I Jump is more than just an object of curiosity. The majority of the book consists of very short chapters conceived as responses to questions like “Why do people with autism talk so loudly and weirdly?,” “Do you prefer to be on your own?,” and “When you look at something, what do you see first?” In bright and unselfconscious prose, Higashida answers, explaining, for example, that some autistic people flap their fingers in front of their faces because “light that reaches us like this feels soft and gentle, like moonlight. But ‘unfiltered’ direct light sort of ‘needles’ its way into the eyeballs of people with autism in sharp straight lines, so we see too many points of light. This actually makes our eyes hurt.” In other chapters, Higashida notes that—contrary to popular belief—he does not really like to be alone, that visual schedules provoke intense anxiety, and that “whenever anyone treats me as if I’m still a toddler, it really hacks me off.” Interspersed with these explanatory chapters are short stories and illustrations, the former by Higashida, the latter by artists Kai and Sunny.
Higashida’s memoir is not the only first-person account of the life of an autistic individual. Temple Grandin, the livestock expert and professor of animal science at Colorado State University, is perhaps the condition’s most famous spokesperson and has lectured and written prolifically about her experiences. Other relatively well known texts include John Elder Robinson’s Asperger’s memoir Look Me in the Eye, and less heralded works also abound: Daniel Tammet’s Born on a Blue Day, Ido Kedar’s Ido in Autism Land, Judy and Sean Barron’s There’s a Boy in Here, and Arthur and Carly Fleischmann’s Carly’s Voice, to name just a few. The Reason I Jump, however, is unique because of its author’s age, its straightforward approach, and the unusual attention it has garnered.
Higashida has a clear and compelling voice, and the book itself is beautifully produced. Striking black-and-white images of birds, leaves, and plants run throughout the text and adorn its cover. In a brief afterword, illustrators Kai and Sunny write that they were inspired by Higashida’s discussion of his exceptionally intimate relationship with nature. The two have received numerous design awards and have collaborated with such luminaries as Alexander McQueen; the aesthetic sensibility they bring to the physical form of The Reason I Jump has likely helped attract readers from beyond the usual audiences for works about disability.
It is also undeniable that—at least in the United States and Britain—the Reason I Jump owes some of its popularity to its introduction, penned by renowned British novelist David Mitchell. Best known for his 2004 novel, Cloud Atlas, Mitchell is the author of six books in total, including Black Swan Green and, most recently, The Bone Clocks. He is also the parent of an autistic son. In his introduction, Mitchell describes his own reaction to reading Higashida’s book in Japanese, recalling that “it felt, as if for the first time, our own son was talking to us about what was happening inside his head, through Naoki’s words.” Along with his wife, KA Yoshida, Mitchell translated the text for the English-speaking market, eager to help demonstrate that “locked inside the helpless-seeming autistic body is a mind as curious, subtle and complex as yours, as mine, as anyone’s.” None of this is to suggest that Higashida’s text is unworthy of the attention it has received, but rather to think through the conditions that allowed it to make inroads with an unusually broad readership. Works on disability often suffer from a lack investment from publishers, who tend to assume they have a dependable but narrow audience in the parents, families, and teachers of disabled individuals. Mitchell’s involvement brings cultural cachet, signaling that the subject might—and, in fact, does—merit broader interest.
Still, it is also important to remember that The Reason I Jump is not an academic text. Those hoping to find a thirteen year-old engaging in an explicit discussion of society’s rampant ableism or the social construction of disability will be disappointed. Scholars will also almost certainly take issue with Higashida’s occasional tendency to overgeneralize and his suggestions that autism represents a kind of atavism, that “we are a different kind of human, born with primeval senses,” redolent as it is with eugenic overtones. Still, as Mitchell reminds us in the introduction, “the author is not a guru,” he’s a kid, and Higashida’s most significant academic contribution may be the very act of writing itself.
The burgeoning field of disability studies has made one of its aims the representation of more diverse somatic, intellectual, and emotional experiences. Disabled voices of all sorts, scholars argue, have been too long absent from the critical discourse, stymieing deep discussion of disabled concerns and supporting the maintenance of misconceptions, structural barriers, and outright discrimination. As a result of both activist and scholarly efforts, however, change has begun to occur. Particularly in the past fifteen years, academic audiences have witnessed a profusion of historical and theoretical texts on disability, a substantial percentage of which have been authored by disabled individuals. Conferences within disability studies have also made concerted efforts to make themselves accessible to those with varied needs, offering ASL interpreters, rest and wellness rooms, and detailed guidelines that urge presenters to include textual and audio descriptions of all visual materials, use jargon-free language, provide large-print textual versions of spoken papers, and refrain from the use of scented products. Some conferences also feature presentations that do not hew to the standard academic format, incorporating theater, dance, documentary film, and other multi-sensory artistic products.
The Reason I Jump is yet another step in the direction of increased representation. Even though, in Mitchell’s words, writing for Higashida is “as taxing as, say, the act of carrying water in cupped palms across a bustling Times Square or Piccadilly Circus would be to you or me,” with the appropriate support, Higashida has managed to create an important, textured testament to his experience of the world. On the other hand, The Reason I Jump also suggests that we may have to go beyond conventional forms of textual representation to convey the full spectrum of human experience. Higashida’s explanatory prose is enlightening, but the The Reason I Jump would be colossally impoverished without the accompanying images and short stories—forms that, while perhaps less immediately legible to some readers, may more directly express Higashida’s world.
The book also—albeit implicitly—participates in scholarly efforts to demonstrate how the study of disability might shed light on embodied experience more broadly. Disability theorist Tobin Siebers, for example, has argued that because the material and social world is constructed around “normal” bodies, it is often difficult for non-disabled individuals to step back and examine the system. Disability, he argues, forces one to stand outside this framework, and thus disabled bodies make embodiment visible—and therefore ripe for analysis—in new ways. In essence, one of the reasons Higashida may be so successful in writing about his particular way of being in the world is that he is constantly made aware of how it differs from the majority of those who surround him.
Indeed, at its best, The Reason I Jump makes the reader consider his or her own body in new ways. When he writes about his seemingly erratic movements, Higashida explains that “both staying still and moving when we’re told to is tricky — it’s as if we’re remote-controlling a faulty robot…You can’t always tell just by looking at people with autism, but we never really feel that our bodies are our own…Stuck inside them, we’re struggling so hard to make them do what we tell them.” Elsewhere, he recalls the terrifying physical sensation of flashback memories and the comforting gravitational pull produced by a walk outside. Readers of these passages are made acutely aware of their own bodies, whether realizing the relative ease with which they have moved through the world or finding echoes of their own experience in Higashida’s.
As this small example illustrates, a move toward inclusive forms of conversation and representation will not only give disabled individuals their due, but also allow them to enhance and complicate other disciplines, theories, and realms of practice. It is already well known that Temple Grandin’s unique modes of sensory processing aided her in the design of innovative, humane equipment for the livestock industry. Even David Mitchell has spoken about the ways in which his boyhood stutter shaped the writer he became. “It’s true,” he remarked in a 2010 Paris Review interview, “that stammerers can become more adept at sentence construction. Synonyms aren’t always neatly interchangeable. Sometimes choosing word B over word A requires you to construct a different sentence to house it—and quickly, too, before your listener smells the stammering rat.” As disability scholar Susan Wendell puts it, “Like living with cerebral palsy or blindness, living with pain, fatigue, nausea, unpredictable abilities, and/or the imminent threat of death creates different ways of being that give valuable perspectives on life and the world. Thus, although most of us want to avoid suffering if possible, suffering is part of some valuable ways of being.” Through Higashida’s eyes, beauty, memory, nature, and the passage of time all look suddenly, strikingly different, a contribution he makes both despite and because of his clearly evident struggles.
Jason Taylor, the protagonist of Mitchell’s 2006 novel Black Swan Green, is also a stammerer and also—like Naoki Higashida—a thirteen-year-old boy trying to make his way through the morass of adolesence. Though mocked at school and miserable at home, Jason finds comfort and control in writing poetry, which he submits to the local parish newsletter. Always, but perhaps especially at thirteen, writing is a way of crafting the self, and The Reason I Jump reminds us that this outlet and others—art, music, even academic conference papers—should be accessible to individuals with varied abilities, needs, and gifts. These stories, though, need to be heard as much as they need to be written, and readers of The Reason I Jump will undoubtedly come away with a newly complicated sense of Higashida’s world, a fuller appreciation of the power of writing, and a more capacious understanding of the human experience.
Whitney Laemmli is a PhD candidate in the Department of History and Sociology of Science at the University of Pennsylvania. She is currently completing her dissertation, “The Choreography of Everyday Life: Rudolf Laban and the Analysis of Modern Movement,” which explores how a tool for inscribing dance on paper developed in Weimar Germany found new life in the psychiatric hospitals, anthropological practice, and corporate boardrooms of mid-century America.
Baynton, Douglas. “Disability and the Justification of Inequality in American History,” in The New Disability History: American Perspectives, ed. Paul K. Longmore and Lauri Umansky. New York: NYU Press, 2001.
Cooter, Roger. “The Disabled Body,” in Companion to Medicine in the Twentieth Century, edited by Roger Cooter and John Pickstone. London: Routledge, 2000.
Grandin, Temple. Thinking in Pictures. New York: Vintage, 2006.
Kudlick, Catherine J. “Disability History: Why We Need Another Other,” The American Historical Review 108 (June 2003): 763-93
Mitchell, David. “The Art of Fiction.” Interview in The Paris Review 193 (2010).
Mitchell, David. Black Swan Green. New York: Random House, 2007.
Siebers, Tobin. Disability Theory. Ann Arbor: University of Michigan Press, 2006.
Wendell, Susan. “Unhealthy Disabled: Treating Chronic Illnesses as Disabilities,” Hypatia 16 (2001): 17-33.
Wendell, Susan. “Who is Disabled? Defining Disability,” in The Rejected Body: Feminist Philosophical Reflections on Disability. New York: Routledge, 1996.
 Nevertheless, Higashida does express social constructionist ideas in a more casual way, noting that he sees his autism not as an inherent problem, but as a mismatch between his particular brain architecture and the world in which he lives. For an introduction to some of the key issues in disability studies, see: Susan Wendell, “Who is Disabled? Defining Disability,” in The Rejected Body: Feminist Philosophical Reflections on Disability (New York: Routledge, 1996); Douglas Baynton, “Disability and the Justification of Inequality in American History,” in The New Disability History: American Perspectives, ed. Paul K. Longmore and Lauri Umansky (New York: NYU Press, 2001); Catherine Kudlick, “Disability History: Why We Need Another Other,” The American Historical Review 108 (June 2003): 763-93; Tobin Siebers, Disability Theory (Ann Arbor: University of Michigan Press, 2008); Roger Cooter, “The Disabled Body,” in Companion to Medicine in the Twentieth Century, ed. Roger Cooter and John Pickstone (London: Routledge, 2000).
 Wendell, “Unhealthy Disabled,” 31.