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Science, Medicine, and Anthropology
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Putting Science in its Place by Mackenzie Cramblit

16 Avril 2014 - 6:08pm

In some corners of anthropology, it has been said that science studies lacks a robust sense of place. But many capable ethnographers have brought labs, hospital suites, and production facilities to life, giving readers a granular sense for what distinguishes these sites from other milieux. What, precisely, might be missing? Consider the word “place.” As science studies scholars have repeatedly observed, there are no universal or value-neutral terms in the social sciences, and we ought to be relentlessly symmetrical in denaturalizing both scientific and social scientific terminology. The problem with social science terms is that most of them are not neologisms. Theoretical terms pass as ordinary language. Like wolves in sheep’s clothing, social science concepts continue to be paraded by many of us as harmless explanatory terms.

“Place” is one of these. Place doesn’t just mean “here” or “there.” It indexes a specific way of constructing the spatial, temporal, and political embeddednesss of ethnography. “Place” captures what ethnographers deem worthwhile or important in a given historical moment. In the mid 20th-century, anthropology’s geographic areas neatly recapitulated Cold-War era regional boundaries. In the global 21st-century, we hear more often about the constitution of place. “Place” no longer seems to be a cartographical given; today, it is both a texture and a topology in the making. The recent “Science Studies as Area Studies” workshop at Duke University (February 28, 2014) explored a related set of concerns, focusing on the role of place in ethnographic writing and its relationship to the universal claims of science.

Organized by Ara Wilson (Women’s Studies, Duke) and Harris Solomon (Cultural Anthropology, Duke), the daylong STS/Area Studies workshop was the culminating event of a yearlong program which included lectures, seminars, and course offerings for undergraduate and graduate students speakers, generously funded by the Andrew W. Mellon Foundation. The STS/Asia initiative was designed to explore the globalization of science and medicine in Asia and to ask how non-nationalist, non-reified ethnographic engagements with Asia can reframe STS theory through their attention to the specificities of place and region, particularly in ways that decenter Europe.

The workshop welcomed five anthropologists to discuss works in progress: Aihwa Ong (UC-Berkeley) on the development of bioethical norms in Singapore and Malaysia; Naveeda Khan (JHU) on the moral topography of silt dwellers in Bangladesh’s Jamuna River; Vincanne Adams (UCSF) on the affective entanglement of Western science and Tibetan medicine; Judith Farquhar (Chicago) on the politics of knowledge-in-translation; and Mei Zhan (UC-Irvine) on conceptual-empirical work in traditional Chinese medicine. Each guest speaker began by providing a précis of her paper’s development and aims. This brief presentation was followed by framing comments from one of the other guest speakers as well as discussion moderated by one of the other professors in attendance. Rather than examining the papers and discussion comments in turn, we discuss three themes which emerged as key sites of conversation and contention for this particular group of scholars: (1) ethics; (2) translation; and (3) ontology.

 

Ethics

Ethics is not a new subject for anthropology, although lately it has garnered increasing attention (see e.g. Cheryl Mattingly’s recent reading suggestions for this website), particularly within medical anthropology (Haraway 1989; Anderson 2000; Cohen 2011; Redfield 2013). Three of the papers at the STS/Asia workshop explored the contingent production of ethics and morality in diverse settings: from the gleaming research labs of Singapore’s Biopolis, to a riparian society of silt dwellers in Bangladesh, to the maternity ward of an inpatient hospital in Tibet. As a recurrent theme, ethics presented the opportunity to discuss the particularities of these social worlds in relation to the universalizing claims of biomedical and social sciences.

Aihwa Ong’s paper, part of a larger project on biomedical research in Southeast Asia, examined how research scientists in Singapore and Malaysia construct bioethical norms in relation to specific animal and human populations. Ong showed that bioethics must be developed through specific social and cultural practices because the meaning of “informed consent” is not universal. Maintaining appropriate bioethical standards is a necessary condition for globalized sites of science to attract foreign investment in the form of clinical research trials, but it is not sufficient to distinguish one site from its many competitors. Ong argued that in Malaysia, research scientists signal their ethical stature to an international scientific community by sustaining ongoing care relations with the indigenous people whose DNA they harvest, while in Singapore scientists shore up similar affective value by ethnicizing their own research protocols and materials––for example, through discussions of “Asian entrepreneurialism” and “Asian genes.” Focusing on the contingent production of bioethics, Ong’s paper convincingly argued for a “post-orientalist STS” that would emphasize the interaction between moral and technical norms in science.

Shifting the conversation away from bioethics, Naveeda Khan’s paper explored the “moral topography” of silt island dwellers (chauras) who live amidst the ever-shifting waters and sands of Bangladesh’s Jamuna River. Khan borrowed insights about morality and nature from Kant, Bergson, and Merleau-Ponty to give a nondeterministic reading of morality’s physical and social embeddednesss, exploring how the instability of riparian land – between floods and erosion – structures collective experiences of history, memory, and anticipation. In drawing out the materiality common to both nature and culture without assuming a division between them, Khan also nodded to now-classic STS accounts of the moderns’ (always incomplete) project to purify nature and culture (cf. Latour 1993). Khan’s paper is part of a larger project exploring the ethical dimensions of expert-produced climate science and lay experiences of meteorological changes. How, she asks, did climate change become an issue about which climate scientists were uniquely qualified to speak? And how do ordinary people experience the temporality of climate change as aberrations in observable weather or seasonal patterns? In the general discussion, Vincanne Adams drew a comparison to her recent work on market-driven disaster management in the aftermath of Katrina, observing that in New Orleans people imagine the wetlands as “man-made nature.” Adams’ comments emphasized that distinctions between what is natural and what is man-made entail different ethical obligations among social and nonsocial actors.

Discussion of Vincanne Adams’ paper further explored the subject position of the anthropologist and the ethical entanglements of her scholarship. Adams situated the recent rise of the “contemplative sciences” in the longer history of a kind of love affair between Tibetan Buddhism and Western sciences, two regimes of truth-making that “misrecognize” each other in their attempt at commensuration. Adams was courageous in her self-portrayal as she reflected on her early research in Tibet. She recalled passionately defending the efficacy of Tibetan medicine to American medical doctors, usually through appeals to Tibetan medicine’s “pharmacological complexity.” During the general discussion, Ralph Litzinger helpfully suggested the need to be specific about what “technology” means, particularly in the context of staging an epistemological romance between Western science and Tibetan medicine. Should roads, phone towers, and other industrial infrastructures count as “technology” in this reading? What role might non-medical technologies play in the transformation of Tibetan medicine? This final question suggests that as the affair between anthropology and science studies matures, we ought to remain aware of our own tendencies to cling to romantic ideals, whether we are inclined to celebrate the innocence of tradition, the purity of science, or the happy mess of nature-culture.

 

Translation

As a core concept in science studies, translation has been used to describe the process by which a particular problem becomes a matter of concern for a set of social and nonsocial actors (cf. Callon 1986). It is hardly surprising, then, that translation emerged as an important thematic throughout the workshop, most notably in the papers given by Judith Farquhar and Mei Zhan, and in the discussions that followed.

In her paper, “Knowledge in Translation: Global Science, Local Things,” Farquhar outlined a genealogy of traditional Chinese medicine (TCM), highlighting the ways in which the “local” and the “global” comingle in TCM, often depending on its relation in a given historical moment to the Chinese state and to global politics. The translation of TCM terminology into the language of biomedicine was a central concern of the paper. Farquhar paired this conceptual translation with a more properly linguistic translation: that of TCM practitioner Lu Guangxin’s writings from Mandarin to English. As Farquhar pointed out in her introductory comments, one of the paper’s aims was to think about TCM as “subaltern,” and to show that TCM practitioners are often the objects of social denunciation. Farquhar related this idea to the broader global debate surrounding “indigenous knowledge” that emerged in the 20th century, but qualified this connection by pointing to the fact that contemporary TCM is profoundly modern. Not only that, as her discussion of Lu Guangxin’s medical theories made clear, TCM often seeks to make universal claims, an ambition that is generally assumed to be absent from ostensibly “indigenous” forms of knowledge. In her comments on Farquhar’s paper, Naveeda Khan reminded us of Farquhar’s attention to the ways in which indigenous knowledge movements pose a particular kind of threat to ostensibly universal forms of knowledge such as biomedicine. Michel Callon’s wordplay linking “threat” and “translation” becomes especially germane here. Local knowledge poses a threat to global knowledge precisely by proposing an alternate universality. Khan called our attention to the final line of Farquhar’s paper: “We must, in other words, rise to the occasion of being creatures who are always being translated and transformed into and out of the local.” For Khan, this provided a way to think about translation as a phenomenological state.

Mei Zhan’s paper linked translation to what she terms the inherent “transdisciplinarity” of traditional Chinese medicine. Terminologically, Zhan distinguishes between “traditional Chinese medicine” and “TCM.” While the former signifies a set of ancient somatic knowledge practices, the latter refers to the institutionalization and standardization of these practices in the post-Mao period. Zhan primarily sought to understand how traditional Chinese medicine is constituted as a transdiciplinary form of knowledge through continual epistemological translations between “traditional medicine” and “biomedicine.” (For example, a map illustrating connections between energetic points in the human body may be superimposed on an anatomical map that fixes these points according to standard positions of different organs and body parts.) In her introductory comments, Zhan highlighted her interest in understanding “how disciplines fold into one another.” This concern was inspired by what Zhan called an “anti-Cartesian” philosophy, which she attributed to Spinoza and Merleau-Ponty. The paper was also, for Zhan, the beginning of thinking about the possibility of using Tao philosophy as an analytic, and not merely an object of study. As Zhan pointed out in her introductory comments, even Heidegger read Tao philosophy.

 

Ontology

Several authors’ papers attempted to rethink ontologies in order to dissolve classic conceptual binaries: for Khan, this was the nature/culture binary; for Farquhar, the difference between symptom and disease; and for Zhan, the distinction between conceptual and empirical forms of knowledge. Materiality and holism were central theme in each of the papers. In exploring the continuous cycle of floods and erosions in the Jamuna River, Khan treated them not as objects standing outside, above, or beyond people’s daily experiences, but as active carriers transporting, suspending, generating and reproducing forms of life on the part of human beings. A central aim of Farquhar’s work on TCM was to negate the assumption that patterns of disorders (zhenghou) are mere expressions of diseases (jibing). By engaging the healing practice of her co-author Lu Guangxi, she brought our attention to energy (Qi – composed of orthopathic Qi and heteropathic Qi) as an essential form of materiality with the capacity to transform Western biomedicine. Farquhar suggested we might understand objects and subjects to be inherently interconnected, an idea that emerges from the Mandarin word for “object,” which can be translated as the image we face. Echoing this discussion, Mei Zhan called for a revision of the epistemological distinction between analyzer (subject) and analyzed (object). Her paper proposed a combination of thinking, doing, and being as a way to restore a sense of Taoist oneness, and in her comments she encouraged anthropologists to “think the empirical as conceptual.”

 

Conclusion

The three themes that we have chosen to read these papers through and with – ethics, translation and ontology – were by no means the only set of concepts that emerged from the rich discussions of this workshop. They were though, by our own reading, three central pivots that the discussions circled around throughout the day. Emplaced, ethnographic knowledge within broader (bio)ethical discussions of medicine and the body, the translation of knowledge through cultures and/or epistemologies, and the ways in which medical anthropology has and/or will continue to take up “the ontological turn” within STS and critical theory were vital to the discussion, and were often the issues around which the most fertile conversations unfolded. All of the discussions pointed to a kind of symbiotic relationship between STS and anthropology: while STS can help move anthropology beyond the narrowly defined (and Cold War produced) provinces of “area studies,” anthropology stands to challenge the Euro-American bias in STS scholarship. Crucially, this workshop was organized around an argument rather than a theme, and the priority given to discussion of the papers allowed participants to really dig in. This was an exceptional conversation indeed, and one whose continuing development we are excited to witness.

Mackenzie Cramblit, Yidong Gong, and Jay Hammond are PhD students in Cultural Anthropology at Duke University. 

Further Reading

Anderson, Warwick. 2000. “The Possession of Kuru: Medical Science and Biocolonial Exchange.” Comparative Studies in Society and History 42 (04): 713–44.

Callon, Michel. 1986. “Some Elements of a Sociology of Translation: Domestication of the Scallops and the Fishermen of St. Brieuc Bay.” In Power, Action, and Belief: A New Sociology of Knowledge?, edited by John Law, 196–233. Sociological Review Monograph 32. London: Routledge.

Cohen, Lawrence. 2011. “Migrant Supplementarity: Remaking Biological Relatedness in Chinese Military and Indian Five-Star Hospitals.” Body & Society 17 (2-3): 31–541.

Haraway, Donna Jeanne. 1989. Primate Visions : Gender, Race, and Nature in the World of Modern Science. Routledge.

Latour, Bruno. 1993. We Have Never Been Modern. Cambridge, MA: Harvard University Press.

Redfield, Peter. 2013. Life in Crisis: The Ethical Journey of Doctors without Borders. Berkeley: University of California Press.

 

Image: Fumihiko Maki, Tokyo: Science Center: Ext.: model, 1989. ARTstor

Conference: Comics & Medicine, From Private Lives to Public Health, June 26-28, 2014 by Todd Meyers

16 Avril 2014 - 2:36am

Comics & Medicine: From Private Lives to Public Health

June 26th to 28th, 2014

The Johns Hopkins Medical Campus, Baltimore, Maryland, USA

Keynote Speakers: Ellen Forney, Arthur W. Frank, James Sturm & Carol Tilley

The Johns Hopkins University School of Medicine Department of Art as Applied to Medicine in collaboration with Graphic Medicine invites papers for the fifth Comics & Medicine conference, a gathering of healthcare professionals, artists, academic scholars, comics enthusiasts, students, and various stakeholder groups.

Follow these links for conference information:

Top of the heap: Ken MacLeish by Maria Cecilia Dedios

14 Avril 2014 - 8:46pm

In today’s “Top of the heap,” Ken MacLeish, Assistant Professor of Anthropology and Medicine, Health and Society at Vanderbilt University, takes us into the world of war (and post-war) memoir, fiction and ethnography, also introducing us to some conceptual texts he’s been thinking with.

Ken MacLeish

Danny Hoffman, The War Machines: Young Men and Violence in Sierra Leone and Liberia (Duke University Press, 2011)

“War machine” is one of the most overused metaphors for the large-scale organization of bodies, images and material things for the production of violence. It’s also one of the most vivid and provocative concepts in Deleuze and Guattari’s writing, where it describes not the hyperrational state apparatus of violence but the potentials and forces that escape state regulation and ordering. Danny Hoffman’s ethnography of the aftermath of west African civil war makes a virtue of this ambiguity: it depicts decommissioned pro-government militia members’ lives of extreme precarity, showing the intimate, structural and social persistence of war far beyond cease-fires and national boundaries. These war veterans are accorded special status by the government but are feared and resented by their neighbors; their war is over but they live on guard against its revival or betrayal by the disarmament process meant to ensure peace; they migrate across national boundaries and vocations, moving through a series of networked conflicts the interrelated economies of mercenary warfare, civil conflict and resource extraction. Hoffman’s description of them is a bit like a marriage of Carolyn Nordstrom’s A Different Kind of War Story with Ana Tsing’s Friction. In both its theoretical dexterity and ethnographic vividness, it’s an incredibly compelling argument for seeing all war in terms of messy boundaries and lingering effects.

 

Saïd Sayrafiezadeh, Brief Encounters With The Enemy (Dial, 2013)

Will Mackin, “Kattekoppen,” The New Yorker (2013)

Will Mackin, “The Unwanted Food Shelf,” Tin House (2013)

O.A. Lindsey, “Evie M,” Iowa Review (2013); Best American Short Stories (2014)

There is a lot of really good contemporary war memoir and fiction around at the moment, some by veterans and servicemembers and some not. This is an area where authenticity and verisimilitude (not to mention tragedy, redemption and melodrama) seem to be most prized, and there are excellent books in this vein. But I really like the way that these particular short stories “get it right” by being surreal, opaque and absurd in various measures, and in the process constitute an implicit challenge to the facile and critically deadening “you don’t understand because you weren’t there” common sense that so much literary and ethnographic writing also refutes. Saïd Sayrafiezadeh’s collection describes an America and a contemporary war that are unnamed but eminently recognizable, one where citizenship feeds on earnest spectacle and the casual violence of privilege. In these stories war is a scene of national purpose and individual transformation, but only sort of: the characters are bored, venal, self-consumed but unreflective, and largely unimportant people, but no less brutal and brutalized for all this. And somehow the way Sayrafiezadeh treats them is consistently funny and kind.

Will Mackin is a former Navy officer who spent a lot of time in Iraq and Afghanistan providing technical support to various special forces operations. His stories revolve around relatively familiar tropes of war-zone loss, terror and camaraderie, but conveyed through hallucinatory and incongruous details (especially regarding food) and a macho, near-affectless narrative voice full of disorienting technical terminology. If Sayrafiezdah’s stories highlight the ordinariness of war, Mackin’s equally deadpan ones make it seem like life on another planet.

O.A. Lindsey is a writer and Desert Storm veteran, and a close friend; this story is so spare that describing it much at all might spoil it, but it’s somewhere between these other two: war traced out in psychic numbness, mundane detail, self destruction, and the labor of normalcy. He talks about it here.

 

Mel Chen, Animacies: biopolitics, racial mattering and queer affect (Duke University Press, 2012)

My work kind of unexpectedly took me to questions about the stuff people wear, the objects that are designed to hurt them, the ways their bodies themselves turn into pieces of equipment, and from there to bigger questions about what military bodies are, what they feel, and who they “belong” to. Bodily objectification here is, among other things, an institutional program, a form of violence, a rhetoric, a set of metaphors, and a source of tremendous positive identification all at once. Mel Chen’s book is a fantastic antidote to the common notion that untangling such knots depends on privileging meaning over sensation, or materiality over ideology, or any other similar invented distinction in how it’s possible to think what things are and what they do. Instead, Chen approaches objects, feelings and bodies through the specifically linguistic category of animacy hierarchies. It’s a fantastically productive way for thinking about contaminating objects, transgressive bodies and bestializing categories, but also a provocation to let one’s own theory be a little more usefully contaminating.

 

An-My Lê, Small Wars(Aperture, 2005)

This book is actually three collections of landscape photographs with uncannily interrelated subjects: villages and countryside in Vietnam, Vietnam War reenactors in the contemporary northeastern US, and US Marines training for deployment to Iraq and Afghanistan at 29 Palms in southern California. Lê shoots with a large-format camera, so while some of the scenes have a documentary feel to them, they have a carefully staged and composed quality that is incredibly different from journalistic photography, especially combat photography. So the focus is on exile (Lê and her parents left Vietnam during the American evacuation), nostalgia (in an interview she talks at length about the reenactors’ intense attachment to their craft), and training or rehearsal. Like with the stories I mentioned above, I like the turn this suggests away from the fetishization of authenticity and/or its suggestion that “being there” always entails some relationship with absence, artifice and intermediation.

 

Jarett Zigon and Jason Throop, eds. Special issue of Ethos on Moral Experience (Ethos 42:1, 2014)

I was really excited when the e-mail announcement about this issue arrived in my inbox the other day, and I confess I haven’t read anything beyond the introduction yet. In my current work I think a lot about the psychomedicalization of war violence, and the mutually reinforcing naturalization that occurs when the moral and the technical intersect to explain experiences of intense violence and loss. All sorts of strange things happens when people seem not to be feeling the things we would expect them to feel. This is the kind of messiness that the issue seems to be concerned with: accounting for what the editors refer to as the affectively dense “moral experience of persons,” especially those aspects that trouble or exceed social-science-ready categories and stable ethical dictates of goodness and right.

 

Ken MacLeish is an Assistant Professor of Anthropology and Medicine, Health and Society at Vanderbilt University. His book Making War at Fort Hood: Life and Uncertainty in a Military Community was published by Princeton University Press in 2013. His current work examines contemporary military mental and behavioral health interventions, including efforts to instrumentalize resilience, police suicide, and define so-called “moral injury.”

Image: Alicia Martín, “Contemporaries,” 2007.

Stefan Ecks’ Eating Drugs by Erica Rockhold

9 Avril 2014 - 10:54am

Eating Drugs: Psychopharmaceutical Pluralism in India

by Stefan Ecks

New York University Press, 2013. 233 pp.

 

In Stefan Ecks’ poignant ethnography, he illuminates the relationship between digestive health and mental health in Calcutta, paying particular attention to the contributions this relationship has made to a pharmaceuticalized India. He traces three medical systems––Ayurvedic, homeopathic and allopathic––as they each locate the belly as the somatic center in Bengali society.  In doing so, Ecks offers reflections on the role psychopharmaceuticals play in daily life in Calcutta, including the resistance from patients these drugs evoke, the doubt they instill in non-allopathic practitioners, and the way they are framed by psychiatrists as familiar, essential, and nutritious.

Eating Drugs opens by establishing the ethnographic context. In India, and Calcutta in particular, psychopharmaceuticals have been signified metaphorically as “moner khabar” which translates from Bengali into “food (khabar) eaten by the mind (mon)” (2). Ecks argues that this semiotic association eases the ideological discomfort of consuming synthetic substances by bringing psychiatric medications into the fold of the everyday, namely in relationship to food. Thus, likening psychopharmaceuticals to something as familiar as food serves to naturalize medications in the minds of patients and helps practitioners build rapport on the grounds of common experience. Psychopharmaceuticals as “mind food” bind sentiment toward food with the activities of bio-psychiatry and drug consumption through a mimetic relationship.  Not surprising, Ecks argues that such an association raises some concern; not only does the rhetorical strategy naturalize “drugs” as efficient and potent treatment but the association of food and psychopharmaceuticals also lends undue stability to the medical encounter (9).

Through close fieldwork, Ecks shows how psychopharmaceuticals work within the logic of Ayurvedic and homeopathic traditions to create meaningful plurality within Indian society, especially in the treatment of psychiatric conditions.  To demonstrate the scope of this plurality, Ecks is principally considered with language––and with metaphor in particular­­––as a way of illuminating the “popular perceptions of mind, body, and different medications” that Bengalis hold (18).  Ecks maps a semiotic network that travels between traditional Indian practitioners and their respective medicines and psychopharmaceuticals. While these practitioners may not encourage their patients to generally seek treatment in allopathic settings, “almost everything they say lends support to a biopolitical regime that sees mental illnesses in urgent need of medication” (195), resulting in three formerly separate systems of beliefs convening around the use of pharmaceuticals.

Ecks’ discussion begins with the idea of the belly as a place of cooking, refinement and gestation, where the body processes food and nutrients. Because humoral balance is one of the keys to good health for many Bengalis, keeping one’s center of digestion perfectly balanced is crucial––and if this balance isn’t maintained, it can disrupt the mind as well. Ecks illustrates the analytical tension between the belly and the mind, suggesting, “where the belly constantly threatens a person’s self-control, the mon is the part of the body that can bring self-control,” thus instantiating a form of integration, however antagonistic, between the two.  Ecks is primarily concerned with mon kharap (bad mind) (28), and for his interlocutors, a preoccupied mind hinders digestion, placing one’s whole state of health at risk. Just as digestion is often the center of medical discourse in India, the mind is also a concern in daily life, as it “feels” or “thinks” and works to express the self while maintaining health and control (26). Just as the right amount of heat keeps the belly functioning optimally, or “cooking” properly, the humoral temperature of the mind is also essential for good health.

Ecks delves deep into Ayurveda and homeopathy, revealing the ways in which India’s most prevalent forms of medicine have (perhaps inadvertently) influenced the spread of allopathic medicine, and pharmaceutically dominated forms of allopathic or bio- medicine in particular.  Ecks argues––again with thoughtful attention to language––that biomedicine has increasingly undermined Ayurveda through a discourse of modernity: “Ayurvedic drugs would work in a pure and simple body, but in the modern, complicated, polluted body, they are weak” (82). The relationship between digestion and health in the Ayurvedic tradition––namely good digestion as the seat of good health, putting “responsibility for health into the hands of the individual” (74)––has been overwritten by the prescriptive nourishment provided by “mind food.”

Homeopathy also plays a significant role in the pharmaceutical transformation Ecks describes.  Although there are more Ayurvedic than homeopathic practitioners in India, homeopathy is by far more prevalent in West Bengal (108). Despite this fact, homeopathy has received relatively little attention in the anthropological literature, something Ecks attributes to the difficulty of analyzing it using categories such as “traditional/modern” or “Indian/Western” (110). Without the seduction of such dichotomies, the appeal of making homeopathy an object of study fades. However Ecks manages to parse out the significant differences between homeopathic and allopathic traditions without applying any sense of absolute divergence. His homeopathic practitioner participants tell him that their form of therapy differs fundamentally from allopathy insomuch as its approach to healing is subtle, long-term and carries with it the precept that “likes cures like” (116). Homoeopathic remedies are said to take effect in the mind and as homeopaths “emphasize the vital force as a spiritual power that directs the material body”, they have the potential to “advance the plausibility of mind medications” (194). Discursively contrasting the defense metaphors of allopathy (“magic bullets,” fighting foreign entities like cancers and germs) with the understated claims of homeopathy might lead one to conclude that the latter is weaker in the globalized Indian health care market.  However its practitioners argue otherwise, suggesting that homeopathy espouses an “ideology of enlightened rationalism” (110) and depicting it as a “hypermodern medicine” (110). Here is where Ecks presents homeopathic practitioners as indirect advocates of psychopharmaceuticals, through their efforts to promote a modern form of medicine.

Despite the evidence of thriving Ayurvedic and homeopathic industries that connect mental health with digestive health, Ecks found that allopathic psychiatry has established a prominent place in Indian mental health care. Dr. Roy, one of Ecks’ psychiatrist participants, expressed a desire to see psychopharmaceuticals help India’s citizens contribute to the dual project of nation-building and self-building, reaching an optimal mode of functioning through chemical enhancement (153). Through awareness campaigns and discursive paralleling of drugs with daily nutrition, Dr. Roy and other psychiatrist participants advocate for a “psychiatric enlightenment” (156). And yet these psychiatrists see the Bengali gut obsession as a possible impediment to this enlightenment, as they “interpret(ed) most—or even all—illness symptoms as caused by disturbed digestion” (157). Again we see the conflict of biomedicine as modernity with the Ayurvedic humoral tradition, which in turn becomes the archetype of how those who seek Ayurvedic treatment lack rationality (157). By linking these prevailing forms of medical practice and the attitudes held by the respective practitioners, Ecks is able to demonstrate the circulating discourses on health, digestion, and mental illness in Bengali society.  Ecks argues that bio-psychiatry “blurs the boundaries between medical ‘things’ and one’s authentic ‘self’, yet they are marketed as one more consumer commodity” (187). The potentially destructive force of psychopharmaceuticals justifies what Ecks calls a “globalized anxiety about drugs” (187). In his close analysis, Ecks attends to the mechanisms and metaphors through which psychopharmaceuticals influence self-concepts, and demonstrates a broader extension of modernity into the lives of Bengalis. Whether this modernity is a cause for the use of psychopharmaceuticals or a product of the economic motives of the industry remains an open question. What is clear is that mental health in Bengali society is the site of conflicted therapeutic philosophies that all draw on the importance of digestion and, perhaps unintentionally, contribute to a new psychopharmaceutical era in India.

 

Erica Rockhold is a Masters student in Anthropology at Northern Arizona University where her interests lie in emotion, language and medicine.

Bleach by Alex Nading

7 Avril 2014 - 10:26am

My friend Dr. Muñoz makes his own bleach.  He uses salt, water, and electrodes to render sodium hypochlorite.  To do this, he has colonized a small space in a garage-cum-storage unit nestled on the grounds of the Managua health center where he works.  His bleach-making is ad-hoc and off the books.  Dr. Muñoz doesn’t get extra money or time from his employers at the Nicaraguan Ministry of Health to perform this chemical labor.  Still, several weekends a year, he and his assistants load a bucket of homemade disinfectant into the health center’s ambulance and ply the surrounding barrios, handing it out by the plastic bagful.  Skillful gift-givers, they carefully calibrate the dilution and hence the intensity of their relationships to people and place.  As a medical, aesthetic, and domestic tool, bleach demands care: too much can be dangerous, too little can be ineffective.  It always risks overpowering or underperforming.

Bleach is alive, in places. | Barrio residents don’t need a doctor to tell them that cloro mata a microbios (“bleach kills germs”).  But bleach goes two ways.  By killing them for us, bleach also acts as a reminder that they live.  This lethal/lively technology draws Muñoz and the neighbors of the barrio into a particular kind of social relation.  The distribution and deployment of bleach instantiates what Heather Paxson calls a “microbiopolitics,” yet where does the chemical sit in relation to bios?[i]  One answer is that the chemical underscores the non-representational and material aspects of life, both embodied and emplaced.

Bleach is certainly “vibrant matter,” as Jane Bennett might put it, but talk of “life” or its politics oversimplifies the situation.[ii]  In its vitality, bleach undermines simple life/death, purity/danger binaries.  (Though I like to imagine Mary Douglas delighting in the sight and smell of a sparkling commode.)  Bleach doesn’t simply put things in and out of place.  It makes place.  It is fundamentally “basic” in the chemical and sociological sense, but bleach’s tactility and its symbolic name, NaClO, are the story of a relationship.

Chemistry’s position in human affairs is quite apart from that of plants, animals, and dirt.  The periodic table is our way of ordering radical elements.  In chemistry, purity (too much oxygen, too much chlorine) very often is danger. The elements we work with, fill our cavities with, or clean our houses and bodies with are always already related, compounded, multiplied.  In chemistry, we don’t think with elements so much as we free them to act with one another and with us.  So chemistry is key to bios as a catalyzing force, as a substrate, and as a medium.  If bios is relational, then chemistry calls attention to how the body’s “materiality plays an active role in the workings of power.”[iii]

Bleach is a verb. | There is craft in Muñoz’s closet-chemistry, to be sure.  But the craft doesn’t stop there.  In Managua’s Mercado Oriental, the stalls that sell household disinfectants stun you with a wash of color and aroma. At the market, the sights and smells of life—the greens of grass and leaves, the purples of ocean water (and, yes, many molds), the reds of blood, the yellows of flowers, and a crystal clear clearer than water itself, blend with the “natural” scents of lemon, pine, and fruit.  Bleaches, ammonias, peroxides—those veils of protection against microbial enemies—are themselves veiled in an artifactual, aesthetic lifeish-ness.  Bleaching is aromas amalgamating. Most good parents in Nicaragua wash the skins of their children’s fruits and vegetables in a light bleach solution.

Bleach is economy. | Down the road from Dr. Muñoz’s lab, Gertrudis cleans houses for a living.  She thinks through the presence and absence of dirt with her nose, her eyes, and her hands.  She calibrates the mix of water and cloro appropriate for scrubbing a tile floor to that which is appropriate for whitening socks and tee shirts.  Bleaching is about working the budget, and about being patient.  Shades of white matter. Not all cloros are created equal.  If you’ve got the money, Clorox is better than the kind they ladle into plastic bags. Bleach is artifice all the way down, from the electrolysis of salt and water, to application on floors and dishes to kill microbios, to dyeing school uniforms (stained whites are grounds for punishment).

Bleach is connection. |  Doña Feliciana is in charge of confirming the presence of cloro in her local water supply.  She sets out four times a year with litmus strips and a color scale to ensure that chlorine, released at pumping stations through old metal cylinders, has penetrated the far-reaches of the infrastructure and made the groundwater into agua potable. Feliciana dribbles water from faucets and hoses onto her strips and, squinting in the sunlight, holds them up to the color scale.

“Is this pink, or red?” she asks the ambulance driver who is chauffeuring us from test-site to test-site.

“For me, that’s red,” he says.  Cloro is present, but not in the right way.  We know there’s some in those pipes.  In accounting for it, aesthetics come before numbers.  What matters is the relationship between the strips and the water, rendered in pH, or “potential hydrogen.”  Yet that relationship can only be enumerated after it is rendered on a sensory scale.  Potential hydrogen thus comes to Doña Feliciana through diffraction: not a direct representation of difference, but a representation of the effects of difference.[iv]

The binary, digital truth of experiments and assays is everywhere underwritten by the analog craftwork of bleaching.  As a form of connection, bleaching is worlding.  This means that in our quest for sterility, we’re constantly looking for signals from microbes.  Care, as Frédéric Keck notes, is the result of interactions across biosecurity’s boundaries.[v]  The border between pink and red is the terrain of care. But wait a minute! Bleach creates boundaries, borders!  Bleach is a biosecurity intervention!  But what else—aside from blood and microbios themselves—connects the U.S. CDC to Nicaragua’s national disease diagnostic laboratory to the houses where Gertrudis calibrates smells and sights to the sink where she and her daughters soak school shirts and stockings?

Bleach is a gift. |  Dr. Muñoz  hands out little bags of his homemade cloro in exchange for cooperation: a blood sample for routine malaria testing, a dengue mosquito larval assay, or cooperation with a vaccination campaign.  Bleach is effective as a gift because it has volition.  Is its vibrancy, then, a material, chemical, contemporary “spirit”? Bleach helps us sleep at night—it is white noise. It stabilizes, equalizes, sterilizes.  It calms and reassures even as it marks, stains, and kills.  Yet above all, bleach is relation.  It provides the sense (and scent) that we care: about germs, about each other, about ourselves. Some people think that there can be too much of this kind of care.  Does over-sterilization weaken the body’s natural allergic defenses, for example?  Probably.  All the more reason to craft a good method for bleaching.

 

Alex Nading is an anthropologist of health, science, and environment.  He is a 2013-2014 Fernand Braudel Fellow at the Maison des Sciences de l’Homme in Paris, France and an Assistant Professor of Anthropology at Franklin & Marshall College in Lancaster, Pennsylvania.  His publications and ongoing projects examine participatory mosquito control programs for dengue fever prevention in low-income urban Nicaragua; the production and field-testing of genetically sterilized dengue mosquitoes and genetically engineered dengue vaccines; and the social production of the “human microbiome.”  His book, Mosquito Trails: Ecology, Health, and the Politics of Entanglement, is forthcoming from the University of California Press.

 

[i] Heather Paxson. The Life of Cheese: Crafting Food and Value in America. Berkeley: University of California Press, 2011.

[ii] Jane Bennett. Vibrant Matter: Towards a Political Ecology of Things. Durham: Duke University Press, 2010.

[iii] Karen Barad. “Posthumanist Performativity: Toward an Understanding of How Matter Comes to Matter.” Signs 28.3(2003): 801-831.

[iv] ibid

[v]Frédéric Keck. “Feeding sentinels. Logics of care and biosecurity in farms and labs.” Unpublished manuscript.

Image: “Bleaching Jakarta.” Flickr.

Plasticity and Pathology: A Workshop – UC Berkeley, Rhetoric Department – April 11 & 12, 2014 by Todd Meyers

4 Avril 2014 - 7:33pm

Plasticity and Pathology: History and Theory of Neural Subjects

Friday, April 11

1.00 pm Welcome from Workshop Organizers (David Bates and Nima Bassiri)

1.15 – 3.15 pm Session One

Laura Salisbury (English, Exeter)
TBA [On narrative and neural subjects in Luria]

Nima Bassiri (ACLS Fellow, Literature and Neuroscience, Duke)
“Epileptic Insanity and Personal Identity: Hughlings Jackson and the Formations of Neural Personhood”

3.15 – 3.30 pm Coffee Break

3.30 – 5.30 pm Session Two

Cathy Gere (History and STS, UC San Diego)
“Plasticity, Pathology and Pleasure in Cold War America”

Tobias Rees (Anthropology, McGill)
“Once Cell Death, now Cell Life”

5.30 – 6.30 pm Public Reception

Saturday, April 12

10.00 am – noon Session Three

Stefanos Geroulanos (History, NYU)
“Integrations, Vigilance, and Catastrophe: Henry Head and Kurt Goldstein” (paper co-written with Todd Meyers)

David Bates (Rhetoric and New Media, UC Berkeley)
“Automaticity and Plasticity: An Alternative History of Artificial Intelligence”

Noon – 1.00 pm Lunch Break

1.00 – 2.00 pm Session Four

Emily Martin (Anthropology, NYU)
Field Notes on Brain Study – a presentation (no pre-circulated paper)

2.15 – 4.15 pm Session Five

Joe Dumit (Anthropology and STS, UC Davis)
“Plastic Neuroscience: Studying What the Brain Cares About”

Katja Guenther (History, Princeton)
“Shaping the Body in the Brain: Mirrors and The Treatment of Phantom Limbs”

4.30 – 5.30 pm Session Six

Catherine Malabou (Philosophy, Kingston)
“From Sorrow to Indifference: Political Subjectivity and the Emotional Brain”

*** For access to precirculated papers (after April 1) please contact: David Bates (dwbates@berkeley.edu)

 

 

Image credit: Anonymous, Shiva Linga; Bikaner, Rajasthan, 2002 (Feature Inc., Gallery)

Elizabeth Roberts’ God’s Laboratory by Amy Cooper

3 Avril 2014 - 10:31pm

God’s Laboratory: Assisted Reproduction in the Andes

by Elizabeth F. S. Roberts

University of California Press, 2012, 273 pp.

 

In God’s Laboratory: Assisted Reproduction in the Andes, Elizabeth Roberts examines how science and spirituality are connected in the practice of in vitro fertilization (IVF) in Ecuador. This alone is a significant contribution to the anthropology of assisted reproduction, but in reading this book we come to understand how race, class, kinship, gender, and labor histories shape IVF in this setting as well. In this engaging ethnography, Roberts, shows us how Ecuadorians make up people, in both a literal sense—by means of IVF—and in a conceptual one.

Central to making up people in Ecuador are local understandings of the malleability of the body and the degree to which reproduction is perceived as always already “assisted” by others. Roberts shows how a long history of “Andean racial malleability” (p. 114) profoundly shapes reproductive practices, allowing some patients opportunities to “whiten” themselves and their families through donor eggs and sperm as well as through certain acts of care and cultivation. Roberts demonstrates that IVF does not pose the same conceptual problems that it does in a place like the United States because Ecuadorians do not view assisted reproduction as an artificial intrusion on a normatively bounded and dyadic experience of human reproduction. Instead, she notes, “it was assumed by Ecuadorians that relations between larger family groups, as well as relations between God and money, always assisted in producing children” (p. 6).

Roberts conducted ethnographic research between 1999 and 2007 in most of Ecuador’s nine IVF clinics and with people involved at all levels of IVF procedures: patients (most of whom self-identified as middle class), their families, doctors, biologists, other medical professionals, egg and sperm donors, and legal experts. The fact that her fieldwork spanned Quito and Guayaquil adds depth and nuance to the ethnographic story, since IVF is perceived and practiced differently in each region. The book’s vivid ethnographic narratives begin in the introduction with a description of how IVF practitioners make God “real” in their clinical practice. Each chapter is prefaced by a stand-alone narrative focusing on one patient’s or family’s experience of IVF, ethnographically anchoring the arguments that follow.

Chapter 1 explains how Catholic church doctrines and Ecuadorian state laws do not restrict IVF practices as much as we might expect. Practitioners and patients invoked God’s assistance constantly during IVF procedures, but disavowed official church sanctions against assisted reproduction, reasoning that God, not the church, was in charge of reproduction and that God not only supported IVF but was “the main actor in determining IVF outcomes” (p. 56). Also in this chapter Roberts explores the “gray areas of Ecuador’s legal landscape” (p. 49), in which a 2003 civil code theoretically limits IVF but in practice has no effect on what elite doctors and their patients do with eggs and embryos in private clinics.

The next two chapters explore how IVF practices are both shaped by and further entrench aspirational practices of whitening in Ecuador. In Chapter 2, Roberts shows how female patients, who often go into debt for expensive private medical treatments like IVF, are not merely accessing medical care but are obtaining care in the same way that wealthy, white women do. Thus, IVF in this setting is not only about assisted reproduction—it is also about “assisted whiteness” (p. 76). Roberts situates this claim in the history of race and racial malleability in the Andes, where a person’s perceived race can change depending on upbringing, use of language, education, and use of private health care. She argues that historically, public health services have been associated with the substandard treatment of poor people of color, while private health services were associated with highly valued, personalistic care practices of and for white elites.

Chapter 3 focuses on the cultivation of whiteness through anonymous egg and sperm donation. Ecuadorian IVF participants commonly associate whiteness with both beauty and better life chances in a racist society. Roberts shows how practitioners, anonymous donors, and patients navigate the racial politics of assisted reproduction in ways that reinforce older national projects of blancamiento (whitening) through mestizaje or racial mixture (e.g., by choosing eggs or sperm from a “whiter” donor than the prospective parent). Roberts brings nuance to this argument by showing how whitening does not just occur at the biological level but also gets cultivated by IVF patients in the ways they seek to raise their children.

The final chapters deal with the movements and meanings of eggs and embryos. In Chapter 4, Roberts explains how “egg economies” (p. 148) work in this setting. Women often choose female relatives as egg donors. This exchange of eggs between kin becomes part of ongoing exchange relationships between these women, while men are commonly on the sidelines, playing a minor role in egg economies. Unlike other settings where egg exchanges have been studied, these exchanges between female relatives did not usually bring about anxieties over the intertwining of love, blood, and money (p. 153). Chapter 5 explores how IVF participants deal with “extra embryos,” which are donated to other patients, placed in cryopreservation for different periods of time, or discarded. What people do with extra embryos is a matter of debate and anxiety and varies regionally. Participants in Guayaquil often embraced anonymous embryo donation, whereas Quiteños would rather eggs were wasted than circulate outside the family. Roberts argues that these divergent views are shaped by differing conceptions of kinship, individual autonomy, and the sanctity of life (p. 208).

Roberts provides excellent concrete examples to explain how assisted reproduction in Ecuador is always in dialog with regional forms of race, class, religion, gender, labor, and kinship. In addition, many readers will appreciate that Roberts’s analysis is explicitly comparative, outlining the similarities and differences between IVF in Ecuador and in other settings (particularly in the United States, where Roberts has also done fieldwork). The book is an important contribution to the anthropology of reproduction and Latin American studies, among other fields. With its skillful integration of ethnographic narratives and theoretical arguments, her book would be a thought-provoking and lively addition to both undergraduate and graduate courses in medical anthropology, science studies, and Latin American studies.

 

Amy Cooper is an Assistant Professor of Anthropology at Muhlenberg College. Her research interests include medicine, the body, mental health and psychiatry, homelessness, and aging; the anthropological study of citizenship and political activism; and Latin American and Caribbean studies. Her research focuses on the relationships between political ideologies, public health systems, and local formulations of bodies, medicine, and subjectivity. She has conducted ethnographic research on these topics in urban Venezuela, Cuba, and the United States. Amy received her Ph.D. from the University of Chicago’s Department of Comparative Human Development in 2012.

Petri Dish by Elizabeth F.S. Roberts

1 Avril 2014 - 4:34am

The petri dish was made for separation.  It was developed for culturing microorganisms while separating them from airborne contaminates.  As part of its ability to make separations between the contaminated world outside and the uncontaminated world inside, the dish also assisted in separating individuals from disease.  These days, it’s getting harder for petri dishes to maintain these separations.

Julius Richard Petri (1852-1921) worked as an assistant for Robert Koch in Berlin at the Imperial Health office.  Koch, who identified the microorganisms responsible for cholera, anthrax and tuberculosis, was, along with Pasteur and Lister, one of the late nineteenth century’s “fathers of microbiology,” aka the “fathers of germ theory.” When Petri arrived in Koch’s lab in 1877, lab assistants were using flat glass plates to grow bacteria colonies.  They would pour the bacteria along with a gelatin cultivation medium on top of the glass, layer the plates, cover them with a large glass bell jar, and then heat the whole thing to cultivate the colony.[i]  This was a cumbersome process, and it made counting bacteria difficult under a microscope, an essential tool for making microorganisms visible. Petri improved the technique: He developed a smaller, round, flat-bottomed double dish with sides. One dish was slightly larger, serving as a lid and a shield.  As Petri explained, in his short 1887 paper, “A minor modification of the plating technique of Koch,” “under these conditions, contamination from airborne germs rarely occurs.[ii] Key to this modification was how Petri made his dish fit under a microscope.

It’s not clear how or with whose help Petri manufactured the dish.  But we do know another crucial co-innovation – replacing gelatin with agar as a culture medium in the petri dish – came through the help of fellow lab assistant Walter Hesse, and his wife Angelina.  Angelina Hesse, who often assisted Walter in the Koch lab, learned about agar (the Malay word for a polysaccharide derived from red algae seaweed) from her Dutch neighbor in New York, who had migrated from Java.  Unlike gelatin, agar is heat stable and was able to keep Angelina’s summer jellies stiff.[iii]  Part of a larger story about science, domesticity, colonialism and gender too long to tell here, the combination of the dish and the agar made it possible to purify and clone bacterial colonies derived from single cells with the right heat conditions. This, in turn allowed scientists to identify bacteria responsible for disease, under a microscope.

Lilly_M, Glass Petri dish, Wikimedia Commons

The petri dish helped the laboratory scientists see and count something that was new: microorganisms.  It was only a few decades earlier that scientists had begun to identify diseases as entities on their own, separated from idiosyncratic environments and human bodies.[iv]  The petri dish helped grow microbiology and the relatively new “germ theory” of disease.

Petri dishes are also called cell-culture dishes.  This use of “culture” harkens back to the cultivation of agriculture and animal husbandry of the 16th century, which was extended to the process of human development and eventually linked by philosophers, like Johann Gottfried Herder, to people marinating in particular conditions of place, language, spirit and tradition.  This culture was not opposed to nature, as it came to be later on, but rather was part of the material processes of an organism’s development. The petri dish’s ability to culture bacteria and keep out contaminates was thus both old and new: Old because culturing bacteria developed organisms shaped by the entangled conditions of the culture medium surrounding them; new because the promise of the demarcated boundaries of a controlled experiment using a petri dish posited a world where separation between organisms and environment was possible.

Arguably, this new ability to separate organism and environment within germ theory and petri dishes came bundled with new kinds of persons – individuals who became stable, separate entities, bounded and impervious to the outside world.  In other words, within the late nineteenth century, new kinds of inviolable and discrete entities were born: both the individuated microorganisms of the germ theory of disease, and autonomous, individual people.

The processes involved in generating those individuals were undergoing related transformations as well.  The germ line of the late nineteenth century, like genes that came later, formed the basis for a “particulate theory of inheritance.” This theory was understood as the generational passing of discrete particles which were not affected by life circumstances.[v]  Germ plasm became part of emergent models that placed reproductive processes solely inside the body, instead of an older Lamarkian generation concerned with how acquired characteristics could be passed generationally and how “maternal impressions” coming from outside a mother’s womb could affect the conceptus within.  The germ line limited the number of “actors” involved to the germ plasm of an individual man and an individual woman.  The womb was rendered superfluous to how children turned out, and women became passive vessels of the future.  With the later development of assisted reproduction, petri dishes were also assumed to be inert; holding, but not shaping their reproductive contents.

In-vitro fertilization (IVF) brought us the ubiquitous image of the “test tube baby,” but as anyone with a passing familiarity with techniques of assisted reproduction knows, the more accurate image would be a “petri dish baby.”  When IVF was first developed, both process and petri dish exemplified particulate inheritance.  Reproductive cells were taken from individual women and men’s bodies, and were placed in a petri dish with cultivation mediums in the hopes of making an embryo.  The cells were then transferred back into a woman’s body. Any resulting child was a combination of only these particulate gametes.  The petri dish, like a woman’s womb, did nothing.

Today, petri dishes and wombs are having trouble staying inert or capable of maintaining a separation between their contents and the surrounding world.  For the last fifty years the majority of petri dishes have been made of disposable plastic, most commonly transparent polystyrene, often containing BPA.  These petri dishes were assumed to be “bio-durable,” meaning the dishes themselves would not affect their biological contents.  However, recently there have been a range of findings about how the petrochemicals of plastic petri dishes interact with cultivation mediums to affect fertilization, implantation, pregnancy and even children born through these procedures.[vi]  There is a now a call for attention to the “nano-environment” of the petri dish.[vii]

This is partly a story of chemical materials.  Glass or plastic?  Petri’s actual dishes were made out of glass, which is less permeable than plastic.  After each use they were washed sterilized and reused. Glass was what was available and labor to make it was cheaper.  Thus originally, the petri dish’s ability to separate organism from environment was stronger.  Petri and Koch were, in fact, keeping more of the world out. But in-vitro fertilization – which literally means “in glass” fertilization – has almost always occurred in plastic.

Plastic’s promise – derived from the bio-industrial processes that offered manipulability, separation, and disposability, world without end …Amen – might be waning.  Findings about plastic’s permeability inhabit a contemporary world also preoccupied with concerns about the permeability of the “maternal environment” on the developing fetus and the effects of plastics on organisms.  Within reproductive processes, plastic petri dishes and wombs no longer passively contain the eggs and sperm while they engage in their dyadic, particulate combining.  Instead, gametes are mingled within everything that contains and constitutes them.

These concerns about plastic petri dishes and permeable wombs relate again to the broader constitution of persons who are becoming less and less particulate.  Witness the fraying of the industrialized, first-world sense of the impervious individual gene, germ and person of the late 19th and 20th centuries.  Individual genes no longer determine us.  Complex and variable epigenetic mechanisms trigged by external conditions shape us.  We are awash in microbes.[viii]  Guts are us.[ix]  Nature and culture contaminate each other.  Nature and culture dissolve into each other.  We exist through environments that seem to be crumbling as forms of social welfare like education, health care, social security and public works are undercut and privatized.  I think of those entities as part of the “infrastructures of individualism,” the unseen endoskeleton of support that allows first-worlders a feeling of independence from the other people, germs and chemicals around them.[x]  That was a world where petrochemical plastics made sense.

Petri dishes have been a useful way to keep a few things in and most things out.  They still are, but not to the same degree as it becomes increasingly evident that separations are hard to make.  The black box of the petri dish is opening…. but to what?   Maybe to an expanded sense of contaminates, where contamination prevention is impossible, since entanglement is existence.  Isolating entities and controlling for all variables might no longer be the goal, as both the biological and social sciences model a more Lamarkian, dare we say Herderian world, where “to be is to be related.”[xi] Instead, we might need processes that ask: How and when do things relate? To what degree?  And to what effect?  Surely, petri dishes, with their chemical composition now noted, will be part of that work.

 

Elizabeth F.S. Roberts is an ethnographer of science, medicine and technology who teaches anthropology at the University of Michigan.  Her comparative research on environmental health, epigenetics, assisted reproduction, reproductive governance and nature in Latin America and the United States, traces how bio-scientific practice shapes bodies and relatedness. She is the author of God’s Laboratory: Assisted Reproduction in the Andes (University of California Press, 2012).

[i] Christopher Intagliata. “Science Diction: The Origin of the Petri Dish, Science Friday.”  http://www.sciencefriday.com/segment/12/16/2011/science-diction-the-origin-of-the-petri-dish.html.

[ii] p.219, Julius Richard Petri. “A minor modification of the plating technique of Koch,” 1887. http://202.114.65.51/fzjx/wsw/newindex/wswfzjs/pdf/1887p218.pdf.

[iii]  Timothy Paustian. “Through the Miscroscope: A Look at All Things Small.” In The Microbial World, 2014.

[iv] Charles E. Rosenberg. “The Therapeutic Revolution: Medicine, meaning, and social change in nineteenth-century America.” In M.J. Vogel and C.E. Rosenberg, eds. The Therapeutic Revolution: Essays in the Social History of American Medicine. Pp. 3-25. Philadelphia: University of Pennsylvania Press, 1979.

[v] Evelyn Fox Keller. The mirage of a space between nature and nurture. Durham, NC: Duke University Press, 2010.

[vi] Sare Ashourzadeh, Azam Agha-Rahimi, and Mohammadali Khalili. “Quality Control of Disposable Object in ART Laboratories Performing Human Sperm Motility Assays.” Journal of Reproductive Infertility 12.2(2011):101-108. M. Nijs, K. Franssen, A. Cox, D. Wissmann, H. Ruis, & W. Ombelet. “Reprotoxicity of intrauterine insemination and in vitro fertilization-embryo transfer disposables and products: a 4-year survey.” Fertility and Sterility 92.2(2009):527–35.

[vii] Belle Dumé. Nanodiamond coating for a better Petri dish. In Nanotechweb.org, 2012.

[viii] Heather Paxson and Stefan Helmreich. “The Perils and Promises of Microbial Abundance: Novel Natures and Model Ecosystems, from Artisanal Cheese to Alien Seas.” Social Studies of Science 44.2 (2014):165-193.

[ix] Hannah Landecker, “Food as exposure: Nutritional epigenetics and the new metabolism.” BioSocieties 6 (2011):167–194.

[x] Elizabeth F.S. Roberts. “Assisted Existence: An Ethnography of Being in Ecuador.” Journal of the Royal Anthropolgical Institute 19.3(2013):562-580.

[xi] Annemarie Mol. The body multiple: ontology in medical practice. Durham, NC: Duke University Press, 2002.

Image: “Milkshake toppings.” Wikimedia Commons.

Web Roundup: The Gut Microbiome and our Bacterial Selves by Sara M Bergstresser

31 Mars 2014 - 3:02pm

Attempts at understanding the true nature our innermost selves has long been a human preoccupation. Are our inner worlds populated with repressed memories and persistent neuroses? Or perhaps our genes direct and define us even as they hide in the interior spaces of our interior spaces? Well, now there is a new contender in the hidden constitution of human selfhood: the gut microbiome. And these microbes even like chocolate!

Our innermost microbial identities are gaining a lot of attention on the world-wide-web (technically an antiseptic space, but nevertheless susceptible to “viral” transmissions – why not bacterial as well?). Now, we discover that our bodies are mostly microbes, with a ratio of about 90% microbial cells to a mere 10% of cells that are human. The accompanying picture of some actual gut microbes at first looks like a haphazardly decorated cupcake surface, swirled in leftover rainbow sprinkles and maybe some various nut dregs and old crumbs (see more of it here).

A great deal of interest was sparked by Michael Pollan’s New York Times article last year, “Some of My Best Friends Are Germs.” Pollan re-defines himself as a “superorganism,” a human body that is a community or an ecosystem for microbes. This view could lead us to a new means of understanding health and illness, or, as Anne Buchanan suggests, it could just be the latest form of “science marketing.”

The microbiome is cropping up in a variety of other ways: as a promising arena of cross-cultural comparison, as a means to track historical human migrations, or as a means of better understanding the inner worlds of our ancient ancestors. The NIH is already investing in a “Human Microbiome Project,” including support for research on the Ethical, Legal, and Social Implications.

If I had an extra $99, perhaps I would also send a sample of my personal bacterial ecosystem to the “American Gut Project,” where it would be analyzed and the results sent to me; the data is also aggregated into the “Earth Microbiome Project.” Of course, there are other means of exploring alterntive micro-personhoods, including the analysis of plain old DNA. After reading this article on commerical DNA testing meant to identify susceptibility to various diseases, I have my doubts, but there can still be an appeal in the discovery of possible Neanderthal-inflected selves. One fifth of Neanderthals’ genetic code lives on in modern humans, and some of us are up to 3% Neanderthal, depending on geographic ancestry! (There’s an at-home DNA test for this too! Only $199.95) So, if the 3% Neanderthal self is added to the 90% bacterial self, that leaves only 7% for our human selves.

Further reading:

  • The fecal transplant is a therapy that can be used as a treatment for individuals with intestinal illnesses. If by now you are feeling that your gut microbiome/bacterial selfhood is inadequate, and you are also very brave, an at-home fecal transplant may be the solution! (Or maybe not.)
  • Forget the refrigerator mother – the new way to blame the mother is for her tendency to transmit her stressed-out vaginal bacteria to the fetus!
  • If you want to explore your (possible) Neanderthal ancestry, there are many options available today: may as well start here.

 

In the Journals, March 2014 — Part II by Aaron Seaman

27 Mars 2014 - 12:18pm

And here is the second part of the March journal roundup!

Once again, there are several special issues, which have been detailed elsewhere on Somatosphere:

Critique of Anthropology, “Critical Perspectives on Multispecies Ethnography”

Theory, Culture and Society, “Social Theory after Strathern”

Global Public Health, “HIV Scale-Up and the Politics of Global Health”

Science, Technology, & Human Values, “The Conceptual and the Empirical: Expanding STS”

Medical Anthropology Quarterly has a new issue filled with several interesting articles:

Critical Anthropology of Global Health “Takes a Stand” Statement: A Critical Medical Anthropological Approach to the U.S.’s Affordable Care Act
Sarah Horton, Cesar Abadía, Jessica Mulligan, and Jennifer Jo Thompson

The Affordable Care Act (ACA) of 2010—the U.S.’s first major health care reform in over half a century—has sparked new debates in the United States about individual responsibility, the collective good, and the social contract. Although the ACA aims to reduce the number of the uninsured through the simultaneous expansion of the private insurance industry and government-funded Medicaid, critics charge it merely expands rather than reforms the existing fragmented and costly employer-based health care system. Focusing in particular on the ACA’s individual mandate and its planned Medicaid expansion, this statement charts a course for ethnographic contributions to the on-the-ground impact of the ACA while showcasing ways critical medical anthropologists can join the debate. We conclude with ways that anthropologists may use critiques of the ACA as a platform from which to denaturalize assumptions of “cost” and “profit” that underpin the global spread of market-based medicine more broadly.

Navigating and Circumventing a Fragmented Health System: The Patient’s Pathway in the Sierra Madre Region of Chiapas, Mexico
Rose Leonard Molina and Daniel Palazuelos

Mexico has implemented several important reforms in how health care for its poorest is financed and delivered. Seguro Popular, in particular, a recently implemented social insurance program, aims to provide new funds for a previously underfunded state-based safety net system. Through in-depth ethnographic structured interviews with impoverished farmers in the state of Chiapas, this article presents an analysis of Seguro Popular from the perspective of a highly underserved beneficiary group. Specific points of tension among the various stakeholders—the government system (including public clinics, hospitals, and vertical programs), community members, private doctors, and pharmacies—are highlighted and discussed. Ethnographic data presented in this article expose distinct gaps between national health policy rhetoric and the reality of access to health services at the community level in a highly marginalized municipality in one of Mexico’s poorest states. These insights have important implications for the structure and implementation of on-going reforms.

Framework Negotiations: Diagnostic Insights among Alternative Medical Practitioners Participating in Integrative Medicine Case Conferences
Ellen J. Salkeld

Medical anthropology concerns itself with cultural interpretations of health and illness in complex pluralistic societies whose members incorporate multiple strategies to address health issues. This research explored the variety of complementary and alternative medicine (CAM) topics introduced into biomedically structured clinical evaluation. A field study of routine case conferences held within a clinical fellowship program in integrative medicine (IM) provided the ideal setting to explore contrasting conceptualizations of disease. Study results yielded five core sources of information sought by CAM practitioners, typically not addressed in biomedicine: social relations history within family of origin, emotional health, energetic health, spiritual health, and in-depth nutritional evaluation.

For the Sake of Others: Reciprocal Webs of Obligation and the Pursuit of Transplantation as a Caring Act
Laura Lynn Heinemann

This article highlights reciprocal webs of care and moral obligations toward kin during transplantation, using an expansive notion of “care” to include both its obvious and more hidden forms. Evidence from 24 months of ethnographic fieldwork among transplant patients, their loved ones, and clinical personnel in the U.S. Midwest suggests that patients are simultaneously caregivers to others and are considered vital members of reciprocal webs of care without whom their kin networks could not effectively operate. Transplantation can become a person’s main, perhaps only hope of fulfilling ongoing obligations to others, so pursuing a transplant becomes not a matter of choice, but rather a moral orientation. A potential implication of these findings is that rather quotidian and conventional (even if contested) notions of what kin ought to do and be for each other may be among the underpinnings of high-tech biomedical practices like transplantation.

Nobody’s Child: The Role of Trauma and Interpersonal Violence in Women’s Pathways to Incarceration and Resultant Service Needs
Catherine Mitchell Fuentes

With the rate of women’s incarceration significantly outpacing that of men’s, combined with the fact that the United States has the highest incarceration rate in the world, there is an urgent need to delineate incarcerated women’s pathways to crime and subsequent service needs. This article reports findings of modified participant observation and qualitative research conducted from 2008 to 2010 with women incarcerated in a large, county jail in North Carolina addressing these issues. Thirty life history interviews, nine focus groups, and 60 questionnaires reveal the centrality of trauma, particularly in the form of interpersonal violence (i.e., sexual, physical, and/or emotional abuse in adulthood and/or childhood), in incarcerated women’s lives. In the absence of positive resources (e.g., counseling, family/friend support), women’s attempts to cope with trauma increase their risks for incarceration as well as further trauma. In addition to providing trauma-based treatment, decreasing women’s recidivism requires macro-level examinations of policies that marginalize women economically and socially.

Fallen Uterus: Social Suffering, Bodily Vigor, and Social Support among Women in Rural Mexico
Vania Smith-Oka

This article focuses on rural indigenous Mexican women’s experiences with uterine prolapse, particularly the illness’s expression of social suffering. Drawing on ethnographic research conducted during 2004–2005 and 2007 in a Nahua village in the state of Veracruz, the article analyzes the multifactorial nature of women’s social suffering. Results show that the roots of uterine displacement for the women lie in lack of social relations and in perceptions of bodily vigor. Additionally, inequality present in the women’s interactions with mainstream Mexico brings into focus the larger structural factors that shape their reproductive health. The implications of research on the effect of social support on women’s embodiment of social suffering can extend beyond one illness, linking it to broader issues shaping the health of marginalized populations.

Definitions and the Experience of Fertility Problems: Infertile and Sub-fertile Women, Childless Mothers, and Honorary Mothers in Two Southern Nigerian Communities
Bruce Whitehouse and Marida Hollos

Although infertility causes women considerable grief, social stigma, and economic deprivation, scholars have paid little attention to infertility’s definitions that may depart from the standard Western usage and how such definitions influence the way women experience the condition. This article, by listening to individual women’s experiences of infertility in two Nigerian communities, examines these definitions and differentiates between culturally salient categories of infertility. In distinguishing between different kinds of childless women and those with low fertility, we intend to enhance understandings of infertility by considering women’s subjective understandings of the condition and thus moving beyond the current medical definition. By comparing women’s experiences in two different ethnic groups in Nigeria, we show how distinct forms of kinship structures and social organizations shape the ways low fertility is defined, managed, and experienced.

The journal New Genetics and Society has five new articles to peruse, as well:

“It’s a risk that requires evaluation and rational appraisal”: emotion and infectious risk in xenotransplantation
Peta S. Cook

Xenotransplantation (XTP) is a potential solution to a variety of human health problems. While immunological disparities between source animals and humans remain significant hurdles to successful XTP, serious concerns have been raised with regard to cross-species viral transfer (zoonosis). This article explores how six male Australian scientists and clinicians working, or with collaborative roles, in the field of XTP construct infectious risk. These negotiations reveal that they primarily focus on known, measured risks, namely that of porcine endogenous retroviruses. This is used to prove zoonotic safety, which marginalizes broader zoonotic concerns. Such assessments heavily rely upon technical, cultural and emotional evaluations to provide an impression of certainty when faced with the potential problematic and uncertain outcomes. The combination of the technical and emotional, or what I call techniemotion, exposes the emotion that is invested in science and integral to science, and operates as part of XTP science.

Prospecting the past: genetic perspectives on the extinction and survival of indigenous peoples of the Caribbean
Jada Benn Torres

In this paper, I examine discourses of survival and extinction regarding the fates of indigenous Caribbean peoples and the manner in which genetic ancestry data influences these discourses. I argue that ideas of extinction and survival are intricately tied in places where a hybrid national identity is generally accepted, thus making the incorporation of genetic data into these debates more malleable. Meanwhile, other Caribbean contexts present the possibility for genetic data to significantly affect people’s conception of how indigenous people should fit within contemporary conceptualizations of the nation. Secondly, I explore the incongruities between folk and scientific understandings of ancestry as well as how ideologies of race, histories of colonialism, and political economy affect the manner in which researchers present genetic ancestry. Finally, I call for genetic anthropologists to “look beyond the laboratory” and to be prepared and willing to engage in the repercussions of their research. Such an engagement would involve the repudiation of racist applications of genetic ancestry data and making meaningful attempts to include and collaborate with members of the studied communities.

Streitkultur and the governance of genetic testing and insurance in Germany
Jonas Lander and Ine Van Hoyweghen

Rapid developments in genetic testing have given rise to fundamental ethical, legal, and social questions that need to be dealt with in society. Results of genetic tests may be of interest to third parties such as private insurance companies, leading to fears of genetic discrimination. In Germany, the Government adopted the Genetic Diagnosis Act (Gendiagnostikgesetz, GenDG) in 2009 to protect people from, inter alia, genetic discrimination in obtaining life or health insurance. Given the sensitivity of the topic, this legislation was continually revised between 2001 and 2009. In this article, we reconstruct the process of formulating the GenDG with regard to genetics and insurance. The article begins with the parliamentary Enquete Commission in 2000 to develop a strategy and recommendations for the governance of genetic diagnostics, and analyzes how these recommendations were applied during the legislative process. We demonstrate that the legislative process of GenDG was largely determined by conventional methods of governance, rather than Streitkultur called for by the Enquete Commission in 2002. We conclude that though Streitkultur was defined as a mechanism to develop a robust approach to the governance of genetic diagnostics, it failed to influence a crucial element in genetic testing and insurance; namely, to fully protect insurees from genetic discrimination.

Autobiologies on YouTube: narratives of direct-to-consumer genetic testing
Anna Harris, Susan E. Kelly, and Sally Wyatt

Despite a growing personal genomics market, little is known about how people engage with the possibilities offered by direct-to-consumer (DTC) genetic testing. In order to help address this gap, this study deploys narrative analysis of YouTube videos posted by individuals who have purchased DTC genetic testing for disease. Genetic testing is said to be contributing to new states of illness, where individuals may become “patients-in-waiting.” In the videos analyzed, we found a new form of storytelling about this ambiguous state of illness, which we refer to as autobiology. Autobiology – the study of, and story about, one’s own biology – concerns narratives of sense-making through forms of biological practice, as well as wayfaring narratives which interweave genetic markers and family histories of disease. These autobiologies – part of a broader shift toward public stories about genetics and other healthcare technologies – exhibit playfulness, as well as being bound with consumerist practices.

Implicit and explicit notions of valorization in genomics research
Dirk Stemerding and Roel Nahuis

Valorization of knowledge has been defined as a major challenge in the context of genomics as an emerging strategic research field. Valorization is a Dutch science-policy concept for what is elsewhere called science impact or the third mission of universities. This article describes the institutionalization of valorization policy in the Dutch genomics research system as a specific manifestation of a changing social contract between science and society, which mainly targets economic value creation and the stimulation of entrepreneurship. A societal debate has emerged in which this focus on economic aspects has been strongly criticized as one-sided. In response, policy-makers are willing to adopt a broader definition of valorization. On the basis of an analysis of valorization policies and practices in Dutch medical genomics, this article draws attention to two myths in this valorization debate.

Philosophy, Ethics, and Humanities in Medicine has posted a new article online this month:

The epistemological role of empathy in psychopathological diagnosis: a contemporary reassessment of Karl Jaspers’ account
Panagiotis Oulis

Introduction:
In his classic essay “The phenomenological approach to psychopathology”, Karl Jaspers defended the irreducible reality of the “subjective” mental symptoms and stressed the pivotal role of empathy in their diagnostic assessment. However, Jaspers’ account of the epistemological role of empathy in psychopathological diagnosis was far from clear: whereas at several places Jaspers claimed that empathy provides a direct access to patients’ abnormal mental experiences, at other places he stressed that it did so only indirectly, through a whole battery of their observable clinical indicators. The aim of this paper is to reassess Jaspers’ account of the epistemological role of empathy in psychopathological diagnosis.

Methods:
I examine thoroughly Jaspers’ assertions on in the role of empathy in the diagnosis of “subjective” symptoms. Moreover, I explicate briefly the epistemological status of psychopathological diagnostic examination with the aid of the distinction between direct and indirect observation.

Results:
Diagnostic assessment of “subjective” mental symptoms involves necessarily indirect psychopathological observation. Jaspers’ ambiguity is traced to his failure to distinguish clearly between direct and indirect psychopathological observation along with his excessive reliance on empathy. Relatedly, Jaspers’ ambiguity is also traced to his conflation of the semantics with the epistemology of psychopathological concepts representing patients’ “subjective” mental symptoms. These results apply also to contemporary phenomenological approaches to psychopathological diagnostic examination which maintain that patients’ abnormal mental experiences are invariably expressed in their overt behavior.

Conclusions:
Jaspers was right in stressing that psychopathological concepts of subjective mental symptoms represent patients’ genuine abnormal experiences irreducible to concepts representing their associated behavioral manifestations. Moreover, he was right in stressing the importance of the empathic ‘second person’ approach to patients’ mental experiences. However, he failed to recognize unambiguously that the epistemological access to patients’ mental symptoms, though enormously aided by empathy, remains mainly indirect and thus requires also a ‘third person’ approach to them. Overall then, clinical psychopathological examination requires both a ‘second’ and a ‘third’ person approach, as well as their judicious alternation during the diagnostic interview. Although focused on Jaspers’ essay, my critical analysis is also highly relevant to contemporary psychopathological approaches aiming to overcome the serious limitations of currently prevailing systems of diagnostic criteria of mental disorders.

Science as Culture

Bioethics in the Making: “Ideal Patients” and the Beginnings of Face Transplant Surgery in Mexico
Samuel Taylor-Alexander

Medical teams around the world are increasingly gaining ethical clearance to utilise face transplant surgery as a reconstructive surgical procedure. Analysis of the beginnings of the operation in Mexico vis-à-vis the early uptake of the procedure in France reveals that this controversial experimental medical field has become loaded with national significance. The primary issue of dispute has been the dependence on life-threatening immunosuppressant therapy in a procedure that treats otherwise biologically healthy people. Attempts to resolve related debate has resulted in the emergence of what my interlocutors refer to as an “ideal patient”, a person whose particular state of health and suffering render them operable within the current biomedical constraints. Drawing together the idiom of coproduction with the concept of sociotechnical imaginaries shows how this imagined patient category was refracted and stabilised as it entered into the Mexican context whilst producing patients and surgical experts as particular types of bioethical subjects. The flexibility and normative value of the “ideal patient” mobilises and is mobilised by surgeons, who themselves emerge as national bioethical subjects responsible for saving the face of nations in the midst of broader changes surrounding how State’s should respond to medical advancement.

Science in Context

The Endurance of Uncertainty: Antisociality and Ontological Anarchy in British Psychiatry, 1950–2010
Martyn Pickersgill

Research into the biological markers of pathology has long been a feature of British psychiatry. Such somatic indicators and associated features of mental disorder often intertwine with discourse on psychological and behavioral correlates and causes of mental ill-health. Disorders of sociality – particularly psychopathy and antisocial personality disorder – are important instances where the search for markers of pathology has a long history; research in this area has played an important role in shaping how mental health professionals understand the conditions. Here, I characterize the multiplicity of psychiatric praxis that has sought to define the mark of antisociality as a form of “ontological anarchy.” I regard this as an essential feature of the search for biological and other markers of an unstable referent, positing that uncertainties endure – in part – precisely because of attempts to build consensus regarding the ontology of antisociality through biomedical means. Such an account is suggestive of the co-production of biomarkers, mental disorder, and psychiatric institutions.

And, finally, a selection of the articles from the two issues (here and here) of Social Science & Medicine.

“I didn’t think I could get out of the fucking park.” Gay men’s retrospective accounts of neighborhood space, emerging sexuality and migrations
Victoria Frye, James E. Egan, Hong Van Tieu, Magdalena Cerdá, Danielle Ompad, and Beryl A. Koblin

Young, African American and Latino gay, bisexual and other men who have sex with men (MSM) are disproportionately represented among new HIV cases according to the most recent national surveillance statistics. Analysts have noted that these racial/ethnic disparities in HIV among MSM exist within the wider context of sexual, mental and physical health disparities between MSM and heterosexuals. The intercorrelation of these adverse health outcomes among MSM, termed syndemics, has been theorized to be socially produced by a heterosexist social system that marginalizes lesbian, gay, bisexual, MSM and other sexual minorities. African American and Latino MSM experience overlapping systems of oppression that may increase their risk of experiencing syndemic health outcomes. In this paper, using data from twenty in-depth qualitative interviews with MSM living in four New York City (NYC) neighborhoods, we present accounts of neighborhood space, examining how space can both physically constitute and reinforce social systems of stratification and oppression, which in turn produce social disparities in sexual health outcomes. By analyzing accounts of emerging sexuality in neighborhood space, i.e. across time and space, we identify pathways to risk and contribute to our understanding of how neighborhood space is experienced by gay men, adding to our ability to support young men as they emerge in place and to shape the social topography of urban areas.

Fast, cheap, and out of control? Speculations and ethical concerns in the conduct of outsourced clinical trials in India
Vinay R. Kamat

The globalization of biopharmaceutical clinical trials and their offshore outsourcing, from the West to low and middle-income countries, has come under increasing scrutiny from academic scholars, practitioners, regulatory agencies and the media. This article reports the results of a study conducted in Bangalore and Hyderabad between 2007 and 2009, to elicit the perspectives of stakeholders, concerning media representations of their work and the ethical issues that emanate from their engagement in the clinical trials enterprise. In acknowledging the inherently problematic nature of the outsourcing of clinical trials to low income countries, I argue that the practice of not prioritizing research on diseases that are most prevalent among communities, from which subjects are recruited, demands a coordinated and sustained critique. I propose that the critical discourse on the outsourcing of clinical trials should not only emphasize the perils of this practice, but also address some broader issues of equity and distributive justice that determine people’s access to basic health care in low income countries. Close attention to the specific context of clinical trials in an increasingly neoliberal medical and health environment in emerging economies such as India can provide critical insights into the on-the-ground complexities and challenges of outsourced global clinical trials.

Choose and Book: A sociological analysis of ‘resistance’ to an expert system
Trisha Greenhalgh, Rob Stones, and Deborah Swinglehurst

In 2004, the English Department of Health introduced a technology (Choose and Book) designed to help general practitioners and patients book hospital outpatient appointments. It was anticipated that remote booking would become standard practice once technical challenges were overcome. But despite political pressure and financial incentives, Choose and Book remained unpopular and was generally used reluctantly if at all. Policymakers framed this as a problem of ‘clinician resistance’. We considered Choose and Book from a sociological perspective. Our dataset, drawn from a qualitative study of computer use in general practice, comprised background documents, field notes, interviews, clinical consultations (directly observed and videotaped) and naturally occurring talk relating to referral to hospital in four general practices. We used strong structuration theory, Giddens’ conceptualisation of expert systems, and sensitivity to other sociological perspectives on technology, institutions and professional values to examine the relationship between the external environment, the evolving technology and actions of human agents (GPs, administrators, managers and patients). Choose and Book had the characteristics of an expert system. It served to ‘empty out’ the content of the consultation as the abstract knowledge it contained was assumed to have universal validity and to over-ride the clinician’s application of local knowledge and practical wisdom. Sick patients were incorrectly assumed to behave as rational choosers, able and willing to decide between potential options using abstracted codified information. Our analysis revealed four foci of resistance: to the policy of choice that Choose and Book symbolised and purported to deliver; to accommodating the technology’s socio-material constraints; to interference with doctors’ contextual judgements; and to adjusting to the altered social relations consequent on its use. We conclude that ‘resistance’ is a complex phenomenon with socio-material and normative components; it is unlikely to be overcome using the behaviourist techniques recommended in some health informatics and policy literature.

Institutional ethical review and ethnographic research involving injection drug users: A case study
Will Small, Lisa Maher, and Thomas Kerr

Ethnographic research among people who inject drugs (PWID) involves complex ethical issues. While ethical review frameworks have been critiqued by social scientists, there is a lack of social science research examining institutional ethical review processes, particularly in relation to ethnographic work. This case study describes the institutional ethical review of an ethnographic research project using observational fieldwork and in-depth interviews to examine injection drug use. The review process and the salient concerns of the review committee are recounted, and the investigators’ responses to the committee’s concerns and requests are described to illustrate how key issues were resolved. The review committee expressed concerns regarding researcher safety when conducting fieldwork, and the investigators were asked to liaise with the police regarding the proposed research. An ongoing dialogue with the institutional review committee regarding researcher safety and autonomy from police involvement, as well as formal consultation with a local drug user group and solicitation of opinions from external experts, helped to resolve these issues. This case study suggests that ethical review processes can be particularly challenging for ethnographic projects focused on illegal behaviours, and that while some challenges could be mediated by modifying existing ethical review procedures, there is a need for legislation that provides legal protection of research data and participant confidentiality.

Hospitals as a ‘risk environment’: An ethno-epidemiological study of voluntary and involuntary discharge from hospital against medical advice among people who inject drugs
Ryan McNeil, Will Small, Evan Wood, and Thomas Kerr

People who inject drugs (PWID) experience high levels of HIV/AIDS and hepatitis C (HCV) infection that, together with injection-related complications such as non-fatal overdose and injection-related infections, lead to frequent hospitalizations. However, injection drug-using populations are among those most likely to be discharged from hospital against medical advice, which significantly increases their likelihood of hospital readmission, longer overall hospital stays, and death. In spite of this, little research has been undertaken examining how social–structural forces operating within hospital settings shape the experiences of PWID in receiving care in hospitals and contribute to discharges against medical advice. This ethno-epidemiological study was undertaken in Vancouver, Canada to explore how the social–structural dynamics within hospitals function to produce discharges against medical advice among PWID. In-depth interviews were conducted with thirty PWID recruited from among participants in ongoing observational cohort studies of people who inject drugs who reported that they had been discharged from hospital against medical advice within the previous two years. Data were analyzed thematically, and by drawing on the ‘risk environment’ framework and concepts of social violence. Our findings illustrate how intersecting social and structural factors led to inadequate pain and withdrawal management, which led to continued drug use in hospital settings. In turn, diverse forms of social control operating to regulate and prevent drug use in hospital settings amplified drug-related risks and increased the likelihood of discharge against medical advice. Given the significant morbidity and health care costs associated with discharge against medical advice among drug-using populations, there is an urgent need to reshape the social–structural contexts of hospital care for PWID by shifting emphasis toward evidence-based pain and drug treatment augmented by harm reduction supports, including supervised drug consumption services.

“But we’re not hypochondriacs”: The changing shape of gluten-free dieting and the contested illness experience
Lauren Renée Moore

“Gluten free” exploded onto the American foodscape in recent years: as of January 2013, 30 percent of U.S. adults reported reducing or eliminating gluten in their diets. How do individuals participate in the expansion of gluten-free dieting, and what are the implications of that expansion? This article is based on 31 in-depth, semi-structured interviews conducted between May and October 2012 with gluten-free and -restricted persons. I identify three interrelated factors contributing to the expansion of gluten-free dieting among non-celiacs. Participants broaden the lay understanding of gluten-related disorders, undermine biomedical authority, and diagnose others. Such participant-driven change, termed self-ascriptive looping, is one factor in the diet’s rapid popularization. I show how participants question the doctor–patient relationship and increase social contestability for other dieters. My findings challenge previous work on contested illness and suggest food intolerances may require a reconceptualization of contested illness experience.

The Conceptual and the Empirical: Expanding STS — A Special Issue of Science, Technology, & Human Values by Aaron Seaman

27 Mars 2014 - 11:10am

The journal Science, Technology, & Human Values has a special issue currently, entitled, “The Conceptual and the Empirical – Expanding STS.” The details of the six articles composing the issue follow below:

The Conceptual and the Empirical in Science and Technology Studies
Christopher Gad and David Ribes

It is the purpose of this special issue to acknowledge the shifting definitions and uses of the conceptual and empirical in the field of Science and Technology Studies (STS), and to explore the constructive potential of this condition. In this introductory essay we point to four formulations in STS for the relation between the conceptual and the empirical which do not figure them as binaries or opposites: (1) the empirical as a path to the conceptual, (2) the conceptual as practical and empirical, (3) the empirical as an instantiation of the conceptual (and the dangers of that view), and (4) a conceptual minimalism. We then point to some inspirations in contemporary thought for engaging creatively with the conceptual and empirical, and conclude by summarizing the contributions to this issue.

Continuous Variations: The Conceptual and the Empirical in STS
Casper Bruun Jensen

The dichotomy between the conceptual and the empirical is part of common sense, yet its organizing force also extends to intellectual life more generally, including the disciplinary life of science and technology studies (STS). This article problematizes this dichotomy as it operates in contemporary STS discussions, arguing instead that the conceptual and the empirical form unstable hybrids. Beginning with a discussion of the “discontents” with which the dominant theory methods packages in STS are viewed, it is suggested that STS has entered a phase resembling Kuhnian normal science. Based on a discussion of the making of cognitive dissonance theory, it is then argued conceptual–empirical mixtures are unavoidable in actual research practice. This situation can be taken as an encouragement for more sustained exploration of conceptual–empirical relations and their inventive potentials. Invoking Deleuze and Guattari’s notion of “continuous variation,” the article concludes that STS as a discipline is well served by promoting an ethos of empirical and conceptual experimentation.

The Ethnographic Machine: Experimenting with Context and Comparison in Strathernian Ethnography
Atsuro Morita

Context holds a significant place mediating the conceptual and the empirical in ethnography. This modality of knowledge has also become a significant part of science and technology studies since the rise of laboratory studies. However, conventional modes of contextualization that locate the object of study within a whole—such as within a society or culture—have become a target of suspicion and criticism since the 1980s. This led to the radical alteration of the contextualizing strategies of actor–network theory (ANT) and multisited ethnography. Anthropologist Marilyn Strathern is also responding to this crisis by renovating the practice of ethnography in a way significantly different from both strategies. Since contextualization occupies a significant place in the formation of ethnography as a representation of a larger “out there” reality, her alternative contextualization requires a new characterization of ethnography other than representation. This article tries to expound the complicated, and often perplexing, ethnography of Strathern by making an analogy with objects familiar to most science, technology, and society scholars, namely, machines. By doing so, this article argues that Strathern is opening up a new way of dealing with context that is radically different both from ANT and from multisited ethnography.

The Empirical as Conceptual: Transdisciplinary Engagements with an “Experiential Medicine”
Mei Zhan

Traditional Chinese Medicine (TCM) is often considered an “experiential medicine.” As such, it is seen as in need of conceptual elevation by scientific experiments and theorization, which actualize and undermine scientized forms of TCM. This essay argues that the predicaments of TCM are thoroughly modern and must be understood within the “Modern Constitution” in which the production and proliferation of asymmetries are both constitutive of and obscured by modern knowledge production. This essay dislodges these asymmetries through transdisciplinary engagements with TCM. This transdisciplinary approach, as I will show, allows us to animate the experiential in order to unsettle the relations between the empirical and the conceptual, the concrete and the abstract, and the contingent and the universal. Most importantly, it enables reconsiderations of the experiential and the empirical as conditions for thinking, doing, and being that insist on immanence, move analogously, and travel sideways. Thus, rather than wanting conceptual uplifting, TCM as an experiential medicine could not only work as a critique of the Modern Constitution but also force a conceptual disruption from within by insisting on the empirical as conceptual.

Seamful Spaces: Heterogeneous Infrastructures in Interaction
Janet Vertesi

Understanding contemporary environments in the laboratory and elsewhere requires grappling conceptually with multiple, coexisting, nonconforming infrastructures which actors engage at the same time. In this article, I develop the analytical vocabulary of “seams” for studying heterogeneous, multi-infrastructural environments. Drawing upon six years of ethnographic fieldwork with two distributed science teams, as well as studies in Ubiquitous Computing, I examine overlaps among infrastructures and how actors work creatively with and across their seams. Rather than suggesting that actors are hemmed in or incapacitated by multiple infrastructural commitments, inclusions, and exclusions, I show instead how they work artfully to align them in ways concordant with membership and how this produces both consequences for their work and opportunities for analysis.

Who Killed WATERS? Mess, Method, and Forensic Explanation in the Making and Unmaking of Large-scale Science Networks
Steven J. Jackson and Ayse Buyuktur

Science studies has long been concerned with the theoretical and methodological challenge of mess—the inevitable tendency of technoscientific objects and practices to spill beyond the neat analytic categories we (or their actors) construct for them. Nowhere is this challenge greater than in the messy world of large-scale collaborative science projects, particularly though not exclusively in their start-up phases. This article examines the complicated life and death of the WATERS Network, an ambitious and ultimately abandoned effort at collaborative infrastructure development among hydrologists, engineers, and social scientists studying water. We argue in particular against the “forensic imagination,” a particular style of accounting for failure in the messy world of large-scale network development, and against two common conceptual and empirical pitfalls that it gives rise to: defaults to formalism and defaults to the future. We argue that alternative postforensic approaches to “failures” like the WATERS Network can support forms of learning and accountability better attuned to the complexities of practice and policy in the real world of scientific collaboration and network formation.

Top of the heap: Sherine Hamdy by Maria Cecilia Dedios

26 Mars 2014 - 4:33pm

This week Sherine Hamdy, Assistant Professor of Anthropology at Brown University, takes “Top of the heap” readers into the field of “graphic medicine.”

 

Sherine Hamdy

I’ve only recently come to learn about the growing field of “graphic medicine” – graphic novels and comics that explore medicine from a personal perspective. There are a few annual conferences, and a website devoted to it here.

Clinicians have found them eye-opening for the unflinching explorations of disease and treatment from the perspectives of patients and their family members; readers gain insight into medical processes and experiences that others have lived to tell. The use of image provides another way to bring the (perhaps textually oversaturated) reader in, offering ways to visualize strange processes (like seizures, pain, auditory hallucinations, or the darkness of depression).

This has led me to ask: Might there be a space for a ‘graphic medical anthropology’ that could bring medical anthropological and bioethical insights into more public engagement?

I’ve been interested in how such books could serve as resources and even models for medical anthropologists, both in our teaching and in our own publications.

 

Brian Fies, Mom’s Cancer (Abrams Comicarts, 2006).

Initially published as an online series, Fies offers a visual-memoir about his own family’s (white, American middle-class) experience with his mom’s terminal cancer and treatment regimen. Fies uses appealing line-sketches, and also draws on comics’ use of color, charts, and graphs to narrate a family’s harrowing journey through confused medical diagnosis, radiation, surgery options, chemotherapy and the management of side effects. One would think there would be no room here for humor, but there is. One of my favorite scenes depicts how each of the three adult siblings bears the stress of their mother’s suffering and intensive treatment schedule. Fies’ wife tells him that under stress, each person becomes more of herself; and Fies depicts each of the siblings taking on exaggerated super-human characteristics, drawing on the superhero imagery of the genre that he is simultaneously re-fashioning into a more realistic, personal, and intimate form. The story raises important ethical questions about the meaning, for example, of individual consent when more people than the decision-maker will be significantly impacted by the decision, and when the decision-maker cannot fully understand the repercussions. I could imagine pairing this work, in class, with Sharon Kaufman’s ethnography And A Time To Die to think about how end of life care is managed medically in the U.S., or with Julie Livingston’s Improvising Medicine to raise questions about medical intervention and aggressive cancers in radically different settings. How can it be that the radically different use of resources in an “impressive” U.S. research hospital vs. in Botswana’s only cancer ward can yield similarly grim outcomes?

 

Phoebe Potts, Good Eggs (HarperCollins, 2010).

This book is a much longer memoir, and grapples with two medical themes: depression and infertility, with an emphasis on the latter. The author-illustrator, a college-educated white American woman, chronicles her quest to conceive a child and the financial, bodily, emotional, and social stresses that the battery of infertility tests poses on her and her husband. Her pursuit to become a mother is part of a larger story of coming to terms with who she is as a person as she navigates her revolutionary political views, her mother’s emotional unavailability, her increasing preoccupation with her Jewish identity, and her yet-to-be fulfilled desire to be an artist. The sections dealing with high-intervention and high-cost fertility treatments raise a number of ethical questions about the production of desires and hopes that are ramified in consumer-oriented medicine and its uneven effects on people. I thought this might be paired in a class with Gay Becker’s The Elusive Embryo, or Elizabeth Roberts’ God’s Laboratory.

 

David Small, Stitches (Norton, 2009).

This one blew me away. It is more images than dialogue, and feels more cinematic than drawn. The medical themes it touches on include: psychiatry, radiation, and cancer. It is written from the perspective of a young (white, middle-class American) child; from six to fifteen years old. I’m afraid to say more because I don’t want to give anything away. It is a gripping, disturbing, and ultimately triumphant story.

 

Lesley Fairfield, Tyranny (Tundra Books, 2009).

A slim comic about a young (white, middle-class American) woman’s struggle with an eating disorder; she illustrates the voice telling her not to eat as a scribbled-skeletal image named “Tyranny” and her struggle to overcome Tyranny’s hold over her.

 

Frederik Peeters, Blue Pills (Houghton Mifflin, 2008).

Originally in French, in this English translation by Anjali Singh, Peeters tells his story of living in Geneva as a comic artist and falling in love with a woman, and mother of a young boy, both of whom have HIV. It raises questions about trust, blame, intimacy, and pathologization among a sero-“discordant” (white, middle-class European) couple.  It stresses how, even with ready access to anti-retroviral therapy, living with HIV is an uphill battle.

 

These I haven’t started yet:

Jeffrey Brown, Funny Misshapen Boy (Touchstone, 2009).

Memoir of a (white, middle-class American school-aged boy). Medical themes explored: use of alcohol, drugs, Crohn’s disease.

 

David B., Epileptic (Pantheon Books, 2005).

Originally in French, this English translation by Kim Thompson compiles six volumes of David B.’s work which details the difficulties that his brother’s severe epilepsy poses on the entire (white, middle-class, French) family.

 

All of these take the form of memoirs, written from the perspective of either the person with an illness or a family member. They all include the perspectives of highly-educated, middle class white Europeans or Americans. There is so much room for this field to grow!

What would it look like to depict a wider swath of experiences and voices?

These two, final ones, give us some inclination of what a more social-science oriented visual work might look like:

 

Derrick Jensen and Stephanie McMillan, As the World Burns: 50 Simple Things You Can Do to Stay in Denial (Seven Stories Press, 2007)

A comic satire about our present ecological troubles and the ridiculous consumer-oriented simplistic “solutions” posed as “environmental consciousness.” There is a lot of information packed in here, and the picture moves skillfully from micro to macro-processes of consumption and ecological implications. The use of line drawings is not, however, as visually powerful as the others.

 

Lauren Redniss, Radioactive (HarperCollins, 2010).

This book is of an entirely new genre, unlike any other I have seen before. It tells the story of Marie and Pierre Curie, about the struggles of a female scientist in the Sorbonne and the strange and powerful effects of radiation – as a weapon, as a treatment, as a space tool. The book does not follow a story line, but mixes media, images, and texts and incorporates information from the Curie archives and the author’s interviews with the Curies’ granddaughter, Hiroshima survivors, radiation and space scientists, and oncological specialists. The artist, Lauren Redniss, relies on a process called cyanotype, mixing photography, paintings, drawings, and amazing color – including the use of a compound used in medicine to treat radiation sickness that produces an eerie and potent indigo-blue. Also, the cover glows in the dark! You can see some pages here.

 

Sherine Hamdy is an Assistant Professor of Anthropology at Brown University. Her book Our Bodies Belong to God: Organ Transplants, Islam, and the Struggle for Human Dignity in Egypt was published by the University of California in 2012. She is currently working on a book on the role of doctors in Egypt’s political uprisings with Professor Soha Bayoumi. She has also recently completed the text of a graphic novel called “Hijabville.”

Image: Page from Radioactive, Lauren Redniss.

In the Journals, March 2014 – Part I by Elizabeth Lewis

25 Mars 2014 - 3:39pm

BioSocieties

Beyond the “Therapeutic Misconceptions”: Research, Care and Moral Friction
Sarah Wadmann and Klaus Hoeyer

In research ethics regulation, health care and research are depicted as serving distinct goals, and policies are in place to prevent what is seen as patients’ misconceived understanding of research as health care. On the basis of ethnographic research in four Danish hospitals in conjunction with a cardiovascular drug trial in patients with chronic disease, we argue that the objectives of health care and research often merge in mutually constitutive practices. We build on observations of trial activities, interviews with physician-investigators, research nurses, patient-participants and trial sponsors and a survey of the patient-participants. We found an organization of clinical drug trials allowing extraordinary care relationships to form, which makes trial participation attractive for patients and allows information to flow more freely. However, the research-care intermingling generates moral concerns for those involved. We conceptualize these concerns as a productive moral friction resulting from research staff caring too much for patients. We identify four situations in which friction arises: when care-giving comes to replace specialist contact, when caring for individuals appears unfair for the collective, when care motives may be doubted and when patients invent their own ways of helping staff in order to reciprocate their care. We conclude that the presentation of the research-care tension as an ethical dilemma is misleading and even part of the problem that must be dealt with by those involved.

Patients’ Attitudes Towards Animal Testing: “To conduct research on animals is, I suppose, a necessary evil”
Malin Masterston, Tobias Renberg, and Sofia Kälvemark Sporrong

A strong argument for the practice of animal testing in medical research is the potential benefit to patients in getting improved pain relief, minimising morbidity and mortality. However, patients’ opinions on the ethics of animal testing are seldom sought, despite their role as principal stakeholders. This study compared the attitudes of patients and researchers on animal testing. Focus-group interviews were held with patients suffering from chronic inflammatory diseases, resulting in a questionnaire that was distributed January–May 2011. The questionnaire was posted to patient members of the Swedish Rheumatism Association (n=1195) and to all scientific experts serving on Ethical Review Boards in Sweden (n=364), with response rates of 65 per cent and 60 per cent, respectively. Results show that patients hold a positive stance towards animal testing, but with many caveats, and the level of support is comparable to those held by the general public found in national surveys. A clear majority of researchers were positive towards animal testing, and large statistical differences between patients and researchers were found regarding their attitudes towards testing animals commonly held as pets (P<0.001). Women were more critical than men regarding which species are used for what purposes (P<0.001). Researchers need to be aware that their more positive attitude towards animal testing is not shared to an equal degree with patients, who are the intended end-users and beneficiaries of medical research. The moral basis for using animals in research needs to be further discussed by all stakeholders.

 Sharing Motherhood in Lesbian Reproductive Practices
Rosana Machin

 This article explores the experience of lesbians seeking gestation by means of reproductive technologies involving donor insemination and two biological mothers: one who provides the eggs and the other who carries the embryo in her womb. This model is called Reception of Oocytes from Partner (ROPA). This article considers the processes that are required for this procedure in Brazil. It is a study carried out from in-depth, semi-structured interviews with five lesbian couples in Sao Paulo, in 2011. Cultural changes in the paths to the construction of a family by means of biomedicine can be characterized by the formulation of a reflective style of project that repeatedly reconsiders the data in search of its ultimate feasibility. The study reveals the desire to involve both partners, the importance of donor health history and the connection to the families of origin.

Early Prevention of Antisocial Behavior (ASB): A Comparative Ethical Analysis of Psychosocial and Biomedical Approaches
Dorothee Horstkötter, Ron Berghmans, and Guido de Wert

Scientific research regarding juvenile delinquency increasingly emphasizes the importance of early identification of at-risk children and early preventive interventions. Recent developments in the life sciences give a special boost to this development. The corresponding ethical discussion, however, seems to be characterized by a remarkable discrepancy. Life science approaches toward antisocial behavior (ASB) are frequently confronted by controversial discussions as to their ethical, social and legal implications. By contrast, ethics hardly takes notice of currently existing early ASB prevention practices that largely result from social sciences. This article investigates whether biomedical approaches are indeed ethically more problematic or whether instead this gap in the ethical debate manifests undue “bio-exceptionalism”. To this end, existing ASB prevention practices and potential biomedically informed future developments are presented and discussed. A series of potential drawbacks, as highlighted in bioethics, are reviewed; and whether, when and how far these might also apply to established psychosocial practices will be explored. We conclude that negative ethical implications might result from all kinds of early screening and prevention practices irrespective of their disciplinary origin. Therefore, it is a moral imperative to include not only future biomedical developments in ethical research, but to critically investigate current psychosocial practices as well.

“The Risk of Bioweapons Use: Considering the Evidence Base”
Filippa Lentzos

There are some weapons deemed so abhorrent that the international community has agreed to eliminate them completely. The first of these was biological weapons. Their use was banned in 1925; their development, production and stockpiling in 1972. Yet concerns about these weapons have not gone away. Indeed, post 9/11 and the anthrax letters, the political attention to them has increased despite what seems to be a very weak evidence base. This roundtable asks four leading biological disarmament and non-proliferation experts their views on the risk of bioweapons proliferation and use, the strength of the taboo and prohibition against the use of biology to sicken and kill people, and the responsibility of life scientists in this regard.

Body & Society

Having an Anthropocene Body: Hydrocarbons, Biofuels and Metabolism
Adrian Mackenzie

What does it mean to have an Anthropocene body? The Anthropocene period is putatively defined by flows of hydrocarbons and hydrocarbon derivatives (fuels, plastics, fertilizers, etc.), and the very term ‘Anthropocene’ suggests an increasing awareness of the finitude and contingency of contemporary corporealities. This article explores the idea of modelling an Anthropocene body as a living/non-living metabolic process. While identifying bodies with molecules raises a host of problems, metabolism and hydrocarbon biomolecules display a gamut of forms of possession and ways of having a body. Conversion between living and non-living forms of possession can be traced in contemporary genomic science and particularly in synthetic biology as they engineer microbes to produce next-generation biofuels. In contrast to fossil fuels, these fuels derive from genomically re-engineered microbes that digest biomass or photosynthesize to produce hydrocarbons. The problematic contemporary production of these fuels might help us to articulate what it means to have a body as a metabolic manifold of living and non-living forms of possession.

Where Bodies End and Artefacts Begin: Tools, Machines and Interfaces
Daniel Black

Our use of artefacts has at different moments been characterised as either replacing or impoverishing our natural human capacities, or a key part of our humanity. This article critically evaluates the conception of the natural invoked by both accounts, and highlights the degree to which engagement with material features of the environment is fundamental to all living things, the closeness of this engagement making any account that seeks to draw a clear boundary between body and artefact problematic. By doing this I seek to clarify the nature of our embodied relationship with various kinds of artefacts; moving from tools to machines to digital interfaces, I consider their differing potentials to be gathered into the body schema, and thus change our embodied horizons of perception and action. While much research currently seeks to facilitate a more ‘natural’ mode of interacting with technology, I argue that such a mode of interaction does not exist outside the particularity of our relationships with specific objects. As a result, rather than trying to cater to supposedly more natural modes of action and perception, future technologies should aim to enrich our experience with new modes, inviting novel relationships that produce new kinds of sensory and other experience.

Making Sense of Domestic Warmth: Affect, Involvement, and Thermoception in Off-grid Homes
Phillip Vannini and Jonathan Taggart

Drawing from ethnographic research conducted in Alberta, as well as across multiple sites in Canada, this article describes and discusses the practices and experiences of heating off the grid with renewable resources (i.e. passive solar and wood). Heating with renewable resources is herein examined in order to apprehend the cultural significance of dynamics of corporeal involvement in the process of creating indoor warmth. A distinction between energy for which corporeal involvement is relatively high (hot energy) and relatively low (cool energy) is then made. Off-grid indoor warmth is therefore understood as a hot energy requiring intense involvement. The authors argue that thermoception is a type of affect with catalytic properties.

Consuming the Lama: Transformations of Tibetan Buddhist Bodies
Tanya Maria Zivkovic

Tibetan understandings about the bodies of spiritual teachers or lamas challenge the idea of a singular and bounded form. Tibetan Buddhists believe that the presence of the lama does not depend on their skin-encapsulated temporal body, or a singular lifespan. After death, it is not uncommon for a lama to materialize in other appearances or to become incorporated into the bodies of others through devotees’ consumption of their bodily remains. In this article, I discuss how the European ingestion of the holy bodies of Tibetan lamas creates new possibilities for embodied intersubjectivity, and also how this practice repositions bodily substance in cannibal discourse.

Culture, Medicine and Psychiatry

Social Vulnerability in Paediatric Dentistry: An Overview of Ethical Considerations of Therapeutic Patient Education
Thomas Trentesaux, Caroline Delfosse, Monique Marie Rousset, Christian Hervê, and Olivier Hamel

Dental caries is a multifactorial condition that remains a major public health issue in high income countries. The prevalence of dental caries in children has markedly declined in most countries over the past 30 years. However, the disease continues to affect a vulnerable population defined as a high-risk group. As many public health policies are inefficient in dealing with this underprivileged group, it is necessary to find other strategies to decrease the incidence and the burden of dental caries. Defining dental caries as a chronic disease enables us to develop the concept of ‘therapeutic patient education.’ It is meant to train patients to self-manage or adapt treatment to their particular chronic disease and to cope with new processes and skills. The purpose of this paper is to propose a new approach to dental caries, in particular to early childhood caries. That should decrease the gravity and prevalence of the disease in this specific population. As a result, this new approach could increase the quality of life of many children both in terms of function and aesthetics.

Parenthood in Migration: How to Face Vulnerability
Marie Rose Moro

Whether they are African or Asian, the children of immigrant families live in situations in which they may be exposed to serious trauma. Immigrant families themselves often live in extreme conditions. Although research has described these conditions, intervention is still inadequate. These families need not only medical or psychological treatment but also basic needs for survival such as food, shelter, a place to sleep, a place to bury their dead. However, the psychological care of immigrant children and their families has much to teach us. We set out here to share what we have learned about immigrant families with infants.

Some General Considerations of a Human-Based Medicine’s Palliative Approach to the Vulnerability of the Multiply Disabled Child Before the End of Life
M.L. Viallard

Specificities of situation of individuals with multiple disabilities and pediatric neurological pathologies call for specialized and multi-field competences that are commonly allowed and disallowed in contemporary clinical contexts. However what must be questioned in this matter is not only the meaning of the clinical, social, and human approach that is implemented, but also its spirit. The aim of medicine is double: to offer a technoscientific capacity (to cure as much as it is possible and always relieve suffering) and guarantee the meaning and value of the child’s human and social capacities. We suggest the importance of a medicine always as care-giving whose aim(s) can be either curative or palliative, or even both at the same time with possibilities for moving back and forth between each one, is easily understandable by all professional groups and patients. It is not at the time of the death, at the last moments, that we will be able to introduce what could have given meaning, spirit and comfort in life. It is very early in the life, in the approach of care, to precisely preserve a meaning of life and to take adapted and shared care as a precious tool that we will propose to the patients, to the parents, and to the professionals. Palliative medicine can support a caring and human approach that takes account of the handicapped child’s vulnerabilities not only at the end of his life, but throughout his/her life. The palliative approach and reasoning approach requires a specific, adapted training and the development of shared knowledge. Without giving up the indisputable contributions of the Evidence-Based Medicine (EBM), it is necessary to develop, in a scientific way, what we could call Human-Based Medicine (HBM).

Considering Ethics, Aesthetics and the Dignity of the Individual
Aline Strebler and Claude Valentin

There are variations on vulnerability that are often based on opposing authorities. In his book Parcours de la reconnaissance, Paul Ricœur offers a reflection grounded in a survey from Aristotle to Levinas, with way stations in phenomenology, from Hegel to Husserl. He sketches the silhouette of capable man. In a reversal of thinking and positioning, weakness, which could be considered the hallmark of disability in all its forms, becomes a source of mutual wealth and an argument in favour of reciprocity and dialogue. Relying on clinical examples, we propose art as a mediator of the doctor–patient relationship, which in its present unique form forces us to question the dynamics of empathy.

The Aphasic Patient: Vulnerability and/or Exclusion
Armelle Jacquet-Andrieu

The aim of this article is to account for the vulnerability of the patient/subject affected by aphasia, the loss of acquired language in adults. In the case of a sudden onset of aphasia, the patient is often aware of his/her disorder from the very onset of the impairment. Vulnerability also affects patients suffering from progressive aphasia, mainly due to a collapse of the various components of memory. After describing the main types of aphasia in broad outline, the study focuses on the isolation and exclusion that they generate, starting from a brief study of the emotional impact of the impairment on the language-deprived subject. This will be related to the patient’s awareness of the disorder and the notion of awareness in structuring and using language, considered as the expression of thought. Finally, given that aphasia leads to the loss of employment, patients enter a phase of social vulnerability. Their speech is perceived as strange or even “foreign” by others in ordinary communicative contexts. What solutions can be proposed to overcome this state of vulnerability and exclusion, which is often felt to be insoluble by the patients themselves?

The Poetics of Therapeutic Practice: Motivational Interviewing and the Powers of Pause
E. Summerson Carr and Yvonne Smith

Motivational interviewing (MI) is an increasingly prominent behavioral therapy that draws from and claims to synthesize two American therapeutic traditions long thought to be antithetical—“client-centered” and “directive” approaches. This paper proposes that MI achieves its hallmark “client-centered directiveness” through the aesthetic management of the therapeutic encounter, and more particularly, through MI practitioners’ marked use of silence. Drawing on data collected during the ethnographic study of MI trainings and the formal analysis of video-recorded MI sessions that are commonly used as models in such trainings, we identify three patterns of pause that regularly fall at specific grammatical junctures within seasoned MI practitioners’ turns-at-talk. We demonstrate how these pauses allow MI practitioners to subtly direct the conversation while simultaneously displaying unequivocal signs of client-centeredness. In other words, we show how and explain why the poetics of pause matter to MI. In presenting this case, we more generally highlight practice poetics—that is, the aesthetic management of the style and delivery of a professional message with a particular practical aim in mind—suggesting that this is a central if under-appreciated aspect of therapeutic practices.

Micro-blogs, Online Forums, and the Birth-Control Policy: Social Media and the Politics of Reproduction in China
Lihong Shi

In June 2012, the news of a Chinese woman’s forced late-term abortion quickly spread across the internet in China. Graphic photos of the woman with the aborted fetus provoked public outrage and widespread condemnation on social media sites. In the aftermath, local authorities apologized, seven officials were given demerits, and the couple received monetary compensation. This case was put under the spotlight mainly because of the exposure of the story by family members of the woman through social media and the resulting public outcry in cyberspace. Following the disclosure of this story and public reactions online, this article explores the complex interplays among different layers of state power, the individual, and the public in reproductive politics, and discusses the ways in which social media has been utilized to resist state control of reproduction. By delving into the nuanced interactions among layers of state authorities, this article sheds light on the study of state–society relations in reproductive politics. It also calls attention to the role that social media plays in reproductive issues.

Translating Disability in a Muslim Community: A Case of Modular Translation
Nissim Mizrachi

This study examines how Muslim religious leaders (imams) introduce the liberal notion of disability to their communities in Israel. The project described, initiated and supported by an American NGO, provides a case for exploring how the secular notion of disability rights is cast and recast in a Muslim world of meaning. It focuses on the mediation strategy that I call modular translation, employed by imams in sermons delivered for the purpose of altering or improving the status and conditions of people with disabilities. This strategy, as it emerged from the analysis, entails decoupling norms of conduct from their underlying justifications. It thus suggests that norms of conduct are open to change so long as the believers’ cosmology remains intact. As such, this turn may offer new avenues of thinking and acting about globalizing human rights within the arena of health and disability.

East Asian Science, Technology, & Society

Reading Hands: Pulse Qualities and the Specificity of the Clinical
Judith Farquhar

Opening with a contrast between the pulse-reading practices of traditional Chinese medicine doctors in clinics and the objective data on pulses provided by the electronic pulsometer, this discussion analyzes the qualitative judgments involved in medical diagnosis and therapy. Working clinicians who discern and classify pathological processes employ a semiotics of qualities to establish the value, or practical and ethical significance, of bodily signs. The embodied perceptiveness of pulse reading in Chinese medicine is thus understood as an engagement with qualities. As such, it narrows the field of qualities available to the touch in conventional and historically authorized ways, while still relying on a qualitative excess. In spite of a widespread interest in providing objectively proven, evidence-based medicine both in China and in North America, this article suggests that it is in the nature of clinical work everywhere ultimately to prefer a qualitative semiotics that exceeds standardized classification and quantification.

Standardization and Its Discontents: Translation, Tension, and the Life of Language in Contemporary Chinese Medicine
Sonya Pritzker

Various attempts at language standardization have been central in efforts to integrate Chinese medicine into a global, mainstream medical framework. At the same time, language has also proven critical in efforts to integrate Chinese medicine into personal frameworks of meaning as students around the globe grapple with multiple translations. In an effort to convey some of these diverse experiences of standardization and plurality of translations, this article offers four “snapshots” in the life of language standardization in Chinese medicine. These snapshots are derived from extensive, multisited ethnographic research conducted over four years in diverse settings in both China and the United States. The article thus offers an appreciation of standardization as an ongoing series of human encounters, a complex web of human networks shaping the always changing answers to seemingly simple questions about the motivations behind standardization, the methods used to create standards, and the implications of standards in an increasingly “global” Chinese medicine. As such, it contributes to an emerging “anthropology of translation” that underscores the role of human relationships, power, understanding, and interaction in translation.

Herbs, Laboratories, and Revolution: On the Making of a National Medicine in Vietnam
Ayo Wahlberg

This article examines the making of a national medicine in Vietnam. How can it be that the medical traditions in Vietnam came to be described as Vietnamese during the course of the twentieth century? In this article, I suggest that historical contingencies in Vietnam have facilitated what might be thought of as a “doctrine of combination,” somewhat in contrast to the institutionalized and contentious separation of, for example, Chinese and Korean medicine from modern medicine. In particular, I show how when it came to traditional medicine, Hồ Chí Minh and the people around him responsible for health-care-related issues were on the “offensive” from the very outset of their nation-building efforts.

 The Reformulation Regime in Drug Discovery: Revising Polyherbals and Property Rights in the Ayurvedic Industry
Laurent Pordié and Jean-Paul Gaudillière

 In so-called traditional medicine in South Asia, substances have not ordinarily been prescribed or consumed in isolation, yet the transformations of compound formulations have been comparatively little studied from any position within anthropology or history. Since the early twentieth century, ayurvedic formulations have often been redesigned to address the biomedical disorders of a new global clientele. This has involved overlapping medical cultures and the creation of heterodox epistemologies, which have then allowed the creation of new “traditional” products that suit the demands of the market. In India, these new formulations fall under the category of “Ayurvedic Proprietary Medicines,” which are distinct from classical, textual (shastric) formulations already in the public domain. Proprietary medicines are the object of specific systems of appropriation and protection, which have not only gained central stage in the country but also influenced international regulatory bodies. This article seeks to explore the way in which the “reformulation regime” has fostered the emergence of alternative models of property rights, and their global acceptance, as well as how, in turn, these new forms of property have today come to drive pharmaceutical innovation itself. By analyzing this “looping effect,” this article sets out prospective avenues to study the industrialization of traditional medicine and the complex interface between regulatory systems, innovation processes, and the market.

Colonizing Safety: Creating Risk through the Enforcement of Biomedical Constructions of Safety
Paul Kadetz

In the normative health care discourse, safety is represented as a concept that is at once universal, irrefutable, and inherently beneficent. Yet, research at local levels in the Philippines challenges these assumptions embedded in the biomedical construction of safety. This article examines how the imposition of a biomedical construction of safety onto a given local group, which does not share this construction of safety, can affect the local group. Specifically, this article examines the application of the biomedical construction of safety to the regulation and control of local nonbiomedical practices and practitioners in the rural Philippines. This twenty-two-month field research was carried out through interviews, focus groups, and participant observation within communities of four rural municipalities in the Philippines and with stakeholders at state and multilateral levels. The case study of the implementation of safe delivery through the insistence on in-facility birthing with “skilled birth attendants” and the cessation of training for traditional birth attendants provides an illustrative example of the need for more nuanced and complex understandings of safety and risk within any given context. This research identifies that the enforcement of an etic conception of safety onto any given group can, ultimately, compromise the safety of that group.

Convergent Lines of Descent: Symptoms, Patterns, Constellations, and the Emergent Interface of Systems Biology and Chinese Medicine
Volker Scheid

During the first decade of the twenty-first century, a network composed of politicians, regulators, bioscientists, clinical researchers, and Chinese medicine specialists has emerged that seeks to bridge an imagined gulf between the modern West and ancient China in order to create a new type of personalized medicine. The central building block of this bridge is the Chinese medical concept of zheng 證/証, variously translated into English as syndrome, pattern, or type. My paper places side by side two different genealogies of how zheng assumed this central role. The first genealogy examines the process by means of which zheng came to be considered as something shared by both ancient China and cutting-edge biological science and, by extension, how it manages to hold together the entire institutional, political, and economic framework into which this bridge is embedded and which it co-creates. The second genealogy shows zheng to be central to a much older series of redefinitions of Chinese medicine and Chinese medical practice that extend from the eleventh century to the present. Read together, these two genealogies—neither of which should be seen as exhaustive—raise three important issues that are further discussed in the conclusion of the paper. First, I explore how the concept of zheng has come to tie a medical tradition derided by its adversaries for being a pseudoscience to one of the most cutting-edge fields of bioscience research. I ask what is at stake in this synthesis, for whom, and why, and how it transforms Chinese medicine and/or systems biology along the way. Second, I am interested in finding out how and why the very same concept can be at the heart of two apparently agonistic visions of Chinese medicine’s future as it is popularly imagined in China today. Finally, I insist that the medical humanities need to become actively involved in the construction of emergent articulations such as the ones I am exploring. Merely writing a history of the present will not be productive unless its critique can somehow be articulated into the very processes of emergence that historians or anthropologists seek to examine.

Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine

Differences by Degree: Fatness, Contagion and Pre-Emption
Tim Brown

Drawing on evidence from the Framingham Heart Study, Christakis and Fowler in their 2007 article published in the New England Journal of Medicine make the claim that obesity spreads in social networks. Whether they are correct in this assertion is neither the concern nor focus of this article. Rather, what is of interest is the subsequent mobilisation of ‘contagion’ to describe this spread and to account for the emergence of an ‘obesity epidemic’ in contemporary society. Contrary to the argument that there is less stigma attached to obesity, the reporting of the Christakis and Fowler article suggests that being ‘fat’ remains a signifier of moral and physical decay; if we add to this the suggestion that obesity is spread within social networks, it is possible that the stigma associated with body size will begin to mirror that which is attached to other infectious bodies. In order to consider the potential implications of this, the article develops in three directions: it explores the application of contagion as a metaphor for understanding the spread of obesity; it sets this understanding within the context of scholarship on contagion and it draws on critical obesity studies literature to call for a more cautionary approach to be taken when deploying a term that when combined with pre-emptive public health discourse would add significantly to the pathologising of the corpulent, fat or obese body.

The Management of Situated Risk: A Parental Perspective on Child Food Allergy
Marie-Louise Stjerna, Mirja Vetander, Magnus Wickman, and Sonja Olin Lauritzen

Food allergy is an illness that requires constant risk management in everyday life. To date, there is no cure or preventive treatment, and the only way to manage the condition is therefore careful avoidance of the offending foodstuff and treatment of reactions when they occur. This article draws on a socio-cultural approach to explore parents’ understandings and management of child food allergy in the context of everyday life, as ‘situated’ risk. A focus group study was carried out with 31 parents of children diagnosed with food allergy at two children’s hospitals. The analysis of the focus group material reveals how the management of allergy risk seems to permeate most aspects of everyday life as well as how the parents draw on a dominant norm of risk avoidance as well as a counter-discourse of calculated risk taking. The patterns of risk management found in this study are discussed in terms of how risk avoidance and risk taking are intertwined and balanced in the context of moral parenthood.

“Men give in to chips and beer too easily”: How Working-Class Men Make Sense of Gender Differences in Health
Alan Dolan

This article, based on qualitative research with working-class men, explores men’s perceptions and experiences regarding gender differences in health. It demonstrates how men put forward a range of behavioural/cultural, materialist/structural and psychosocial factors, which were believed to differently impact men’s health compared to women. A common theme underpinning their explanations was the ways in which men and women were located within two distinct gender categories. These characterisations were used to explain why health-damaging beliefs and behaviours were more prevalent among men and also why men were better suited for certain kinds of jobs, albeit with potential costs to their health. Men also believed that women were protected from the damaging physical and emotional impact of manual employment because of their primary role within the home and because they were less emotionally robust, which required men to shield women from the stresses they experienced. However, men’s emotional withdrawal can also be viewed as another example of how men use whatever resources are available to achieve and maintain dominance over women. Finally, the article demonstrates how a gender- and class-based approach can capture the impact of men’s health-related practices alongside the broader cultural and structural influences on men’s health.

Time and the Psychiatric Interview: The Negotiation of Temporal Criteria of the Depressive Disorder
Justyna Ziólkowska

In this article, I am concerned with doctors’ negotiations of the temporal dimension of the diagnostic criteria of depressive disorders during the first psychiatric interview. The data come from 16 initial psychiatric interviews recorded by doctors in three psychiatric hospitals in Poland. Taking a constructionist view of discourse and psychiatric practices, I shall argue that the discursive practice related to temporal information about patients’ illnesses serves in gaining information, which is useful in the medical model of psychiatric diagnosis. The doctors positioned the patients’ experiences on the timeline when the illness history was taken and temporal information authenticated the information. Conversely, the patients’ current conditions were constructed in a limitless present, which allowed the psychiatrists to remove the relativity.

“DSM-V is taking away our identity”: The Reaction of the Online Community to the Proposed Changes in the Diagnosis of Asperger’s Disorder
David Giles

This article considers the fate of Asperger’s disorder in the light of proposals for the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) to collapse Asperger’s disorder along with other pervasive developmental disorders into a general spectrum of autism. It is argued that a powerful lay and scientific culture has evolved around the concept of Asperger’s disorder, which has found a particularly compelling voice over the last decade in the online Asperger community, with websites such as Wrong Planet recruiting tens of thousands of members. In order to assess the impact of these proposed changes on the online Asperger community, 19 threads on the topic of Diagnostic and Statistical Manual of Mental Disorders (5th ed.) are analysed according to the arguments that community members put forward in favour of, or in opposition to, the proposals. Many members embrace the notion of the spectrum and have already coined a new identity – ‘spectrumite’ – to adapt to the diagnostic shift. Others, however, are suspicious of the motives behind the absorption of Asperger’s disorder, and potential threats to the provision of services as well as the strong ‘aspie’ identity that reflects the large literature and the online public sphere around Asperger’s disorder. To what extent this culture poses a challenge to the authority of the Diagnostic and Statistical Manual of Mental Disorders is uncertain at present.

Engineering the Fitness of Older Patients for Chemotherapy: An Exploration of Comprehensive Geriatric Assessment in Practice
Alexandra McCarthy, Peta Cook, and Patsy Yates

Clinicians often report that currently available methods to assess older patients, including standard clinical consultations, do not elicit the information necessary to make an appropriate cancer treatment recommendation for older cancer patients. An increasingly popular way of assessing the potential of older patients to cope with chemotherapy is a Comprehensive Geriatric Assessment. What constitutes Comprehensive Geriatric Assessment, however, is open to interpretation and varies from one setting to another. Furthermore, Comprehensive Geriatric Assessment’s usefulness as a predictor of fitness for chemotherapy and as a determinant of actual treatment is not well understood. In this article, we analyse how Comprehensive Geriatric Assessment was developed for use in a large cancer service in an Australian capital city. Drawing upon Actor–Network Theory, our findings reveal how, during its development, Comprehensive Geriatric Assessment was made both a tool and a science. Furthermore, we briefly explore the tensions that we experienced as scholars who analyse medico-scientific practices and as practitioner–designers charged with improving the very tools we critique. Our study contributes towards geriatric oncology by scrutinising the medicalisation of ageing, unravelling the practices of standardisation and illuminating the multiplicity of ‘fitness for chemotherapy’.

Health and Place

Hot Spots in Mortality from Drug Poisoning in the United States, 2007-2009
Lauren Rossen, Diba Khan, and Margaret Warner

Over the past several years, the death rate associated with drug poisoning has increased by over 300% in the U.S. Drug poisoning mortality varies widely by state, but geographic variation at the substate level has largely not been explored. National mortality data (2007–2009) and small area estimation methods were used to predict age-adjusted death rates due to drug poisoning at the county level, which were then mapped in order to explore: whether drug poisoning mortality clusters by county, and where hot and cold spots occur (i.e., groups of counties that evidence extremely high or low age-adjusted death rates due to drug poisoning). Results highlight several regions of the U.S. where the burden of drug poisoning mortality is especially high. Findings may help inform efforts to address the growing problem of drug poisoning mortality by indicating where the epidemic is concentrated geographically.

Blood, Sex and Trust: The Limits of the Population-Based Risk Management Paradigm
Mike Kesby and Matt Sothern

Blood screening is imperfect so Donor Health Check questionnaires (DHC) are used to defer those whose ‘behaviour’ suggests disproportionate risk of Blood Borne Infection (BBI). Taking the UK case, we compare deferment of three sub-populations with different HIV prevalence; Men-who-have-Sex-with-Men (4.7%), black-Africans (3.7%) and ‘the-general-(heterosexual)-population’ (c.0.09%) arguing that, with respect to STIs, DHC assesses risk based on broad population-level risk-groups not behaviour. This approach relies on an imaginative geography that distances heterosexual risk from the domestic population. Most DHCs knowingly commit the ecological fallacy allowing population-level statistics to obscure within-group diversity, inadequately identifying the risk posed by ‘low-risk-groups’. The disjuncture between ontological risk phenomenon (diverse sexual practice) and the epistemological grid used to map risk (homogenised risk-groups) needs examination. Unpacking the category ‘heterosexual’ would both better differentiate risk within this group and change the relative-risk calculated for ‘high-risk groups’. We call for piloting of practice-based questions and a mixed-method approach to DHCs to more accurately assess all potential donors.

Whose Place is it Anyway? Representational Politics in a Place-Based Health Initiative
Carole Rushton

The association between place and poor health, such as chronic disease, is well documented and in recent years has given rise to public health strategies such as place-based initiatives (PBIs). This article reports on the emergence of one such initiative in Australia, in regions identified as culturally diverse and socially disadvantaged. The study draws on the intellectual resources provided by governmentality and actor-network theory to provide insights into the reasons why community actors were excluded from a new governance body established to represent their interests. Risk-thinking and representational politics determined who represented whom in the PBI partnership. Paradoxically, actors representing ‘community’, identified as being ‘at risk’, were excluded from the partnership during its translation because they were also identified as being ‘a risk’. As a consequence, contrary to federal government health and social policy in Australia, it was state government interests rather than the interests of community actors that influenced decisions made in relation to local health planning and the allocation of resources.

Online Social Networking Sites – A Novel Setting for Health Promotion?
Julika Loss, Verena Lindacher, and Janina Curbach

Among adolescents, online social networking sites (SNS) such as Facebook are popular platforms for social interaction and may therefore be considered as ‘novel settings’ that could be exploited for health promotion. In this article, we examine the relevant definitions in health promotion and literature in order to analyze whether key characteristics of ‘settings for health promotion’ and the socio-ecological settings approach can be transferred to SNS. As many of our daily activities have shifted to cyberspace, we argue that online social interaction may gain more importance than geographic closeness for defining a ‘setting’. While exposition to positive references to risk behavior by peers may render the SNS environment detrimental to health, SNS may allow people to create their own content and therefore foster participation. However, those health promotion projects delivered on SNS up until today solely relied on health education directed at end users. It remains unclear how health promotion on SNS can meet other requirements of the settings approach (e.g. building partnerships, changing the environment). As yet, one should be cautious in terming SNS a ‘setting’.

Health, Risk & Society

“I can choose”: The Reflected Prominence of Personal Control in Representations of Health Risk in Canada
Jennifer Lee, Christine Dallaire, Marie-Pierre Markon, Louise Lemyre, Daniel Krewski, and Michelle Turner

Multidisciplinary research has contributed to a better understanding of the personal and societal correlates of risk perception. However, representations of ‘health risk’ remain to be characterised more fully. Drawing on a Canadian study conducted in 2004, an analysis was conducted to develop better characterisations of individual representations of health risk. The study involved a national telephone survey (N = 1503) and face-to-face semi-structured interviews with individuals across Canada (N = 73) in which participants’ representations of health, risk and health risk were elicited using a word association technique. In the telephone survey, it was found that representations of health risk were most frequently negative, with many participants referring to disease and illness. The concept of health risk was also associated with lifestyle, individual control and personal agency, suggesting that individual health behaviour and personal responsibility for health were prominent features of public discourse on health risk in Canada. However, subtle variations in representations of health risk were observed in analyses of semi-structured interviews, pointing to important differences according to age and gender in this specific discourse. There was agreement among participants that health risks were associated with individual vulnerability and menace to life or health, and that such vulnerability increased with age. However, women were less likely to focus on the idea of actively making choices to control health risks and less frequently made references to the positive aspects of health risks.

One-Week Recall of Health Risk Information and Individual Differences in Attention to Bar Charts
Dan Mason, Sue Boase, Theresa Marteau, Ann Louise Kinmouth, Theresa Dahm, Nami Minorikawa, and Stephen Sutton

Presenting personalised health risk information can support lifestyle decisions and help patients make informed choices about treatments. The way such information is presented can influence how well it is understood, and supplementary graphical representations have been shown to be helpful. However, there are little data on longer term recall of risk-related messages presented graphically and on the attention paid to graphics by those trying to interpret risk-related messages. This article draws on two studies in the United Kingdom of risk information recall. In study 1, participants aged 40–65 (N = 570) were given hypothetical personal cardiac risk information via a website, either numerically or supplemented with different types of bar chart. Participants’ recall of the key messages of the communication was assessed 1 week later. Bar charts led to greater recall of a key risk message only among the most numerate participants. Study 2 examined the extent to which participants made use of the graphics in interpreting the numerical information using concurrent verbal protocols. Expert (N = 16 practice nurses) and non-expert (N = 16 general public) participants who read numerical information from the graphics were also more likely to make direct interpretations of the numerical information. The 1-week recall findings from study 1 contrasted with recent empirical findings that graphics aid understanding in lesser numerate individuals. The observational data from study 2 indicated the presence of individual differences in the ways people used graphics to interpret risk information. A closer examination is required of the ways people use descriptive graphical tools when interpreting risk information, and the effect this has on recall of key messages.

Science, Policy and the Rise of “Thirdhand Smoke” as a Public Health Issue
Kirsten Bell

‘Thirdhand smoke’, the designated term for the cigarette smoke toxicants that linger on room and car surfaces long after the smoke itself dissipates, is a concept that has gained increasing prominence in tobacco control policy and research over the past six years. In this paper, I track the emergence of thirdhand smoke as a social and scientific concept, conducting a critical analysis of newspaper reports and references to the term in the academic and policy literature. Demonstrating that claims about the health effects of thirdhand smoke occurred in the absence of evidence of harm, I examine the broader sociopolitical conditions that enabled the concept to become meaningful (and useful). I show that some of the concept’s legitimacy came from its presentation as a natural extension of secondhand smoke, and its framing as a particular threat to babies and children. However, I argue that the experiential, embodied dimension of thirdhand smoke itself was crucial to its success.

Counselling Uncertainty: Genetics Professionals’ Accounts of (Non)Directiveness and Trust/Distrust 
Michael Arribas-Ayllon and Srikant Sarangi

In genetic counselling, uncertainty is central to the client–professional relationship where decisions are made on the basis of risk information/assessment. For various historical reasons, genetic counsellors adopt an ethos of ‘nondirectiveness’ to communicate risk and offer support without advising their clients on what decisions to reach. However, nondirectiveness remains an ambiguous and contested concept that has acquired a negative meaning of ‘not influencing clients’ or ‘adopting an indifferent stance’. We argue that nondirectiveness also implies a positive sense of acknowledging genetic counselling as a process of influence. Drawing on interview data (n = 25) involving professionals from England and South Wales (UK), accounts of genetic testing indicate a dynamic relationship between managing uncertainty on the one hand and negotiating trust and distrust on the other. In the counselling process, trusting and distrusting are coexisting techniques of assessing clients’ motivations, expectations and reasons for genetic testing. Using rhetorical discourse analysis as our analytical approach, we identify a pattern of accounting whereby professionals justify a directive stance when they are not confident whether clients have considered the uncertainty of the situation. More than a veneer of neutrality and indifference, we argue that nondirectiveness is a technique by which genetics professionals explore whether clients can be trusted to make autonomous decisions within a climate of uncertainty. Eliciting confidence and establishing trust within the context of genetic counselling are enabling, pastoral strategies for configuring risk and emotion.

Australian Mothers’ Notions of Risk and Uncertainty in Relation to Their Pre-Teen Children
Jan Wright, Christine Halse, Gary Levi, Catherine Hartung

In this article we examine the ways discourses of risk manifested and played out within and across two groups of Australian mothers living in two large urban centres in Australia: the first comprised of mothers who had a pre-teen child diagnosed with an eating disorder (n = 13); the second of mothers who had a pre-teen child without the symptoms or diagnosis of an eating disorder (n = 13). In 2011 and 2012, we conducted in-depth interviews with the mothers in their homes on their ideas about health and their relationships with their children. An analysis of the data collected from these interviews indicated that having a pre-teen child diagnosed with an eating disorder had a decisive impact on how the mothers constituted and responded to risk. For mothers, who had a pre-teen child with an eating disorder, risk was intensified by bio-medical discourses. The particular intensifications of risk limited the ways in which mothers could act and often threatened to undermine their abilities as competent carers. By contrast, the mothers who did not have a pre-teen child with an eating disorder spoke about risk less directly, and with less sense of immediacy. Where these mothers acknowledged risk discourses particularly in regard to health, they were in a stronger position to negotiate them. Our analysis indicates that the ways in which mothers responded to risk is contingent on circumstances and contexts. Mothers’ responses to risk were related to the calculability of the risk and their perceived capacity to manage it.

 

Table by Emily Martin

25 Mars 2014 - 3:32am

 

Early anthropological experiments depended on tables to hold their equipment steady, at eye level, and off the ground. Photographs from the Cambridge Anthropological Expedition to the Torres Straits in 1898 make it clear that tables played an important role in the psychological experiments conducted by the anthropologists.

WHR Rivers and Torres Strait Islander with the color wheel. In Richards, G. (1998). Getting a result: The Expedition's psychological research 1898-1913. Cambridge and the Torres Strait: centenary essays on the 1898 anthropological expedition. A. Herle and S. Rouse. Cambridge, Cambridge University Press: 136-157.

A table is a technology that stabilizes people and things in space for a time. The table, with its chair, enforces a posture of attention to what is on it.  It permits display and use of other tools, and enables precise recording on paper. It also allows the display of disparate materials on the same plane in space. Bruno Latour explained the effect of this, as he watched botanists in the field arranging soil and plant samples on tables: “specimens from different locations and times become contemporaries of one another on the flat table, all visible under the same unifying gaze.”[i] The flat plane provided by the table enables the abstraction of dissimilar specimens into categories.

Infrastructures like the table are not necessarily passive. Perhaps the table is even a kind of trap. Open and inviting a table might seem, but once you are sitting at it, certain forms of courtesy might serve to hold you there. Alfred Gell famously described a hunting trap as a device that embodies ideas and conveys meanings because it is a “transformed representation of its maker, the hunter, and the prey animal, its victim, and of their mutual relationship, which . . . is a complex, quintessentially social one. . . traps communicate the idea of a nexus of intentionalities between hunters and prey animals via material forms and mechanisms.”[ii]  If the table can be thought of as a kind of trap to capture and contain a subject, it is a disarming one—it looks so placid and innocent, for something that has the potential for intrusion and control. Perhaps this is one reason it has largely gone without notice. Nor need the table, or any technology, only have one use. Think about dinner tables, seminar tables, and of course medical examination tables. Nor are such tools neutral in the play of gender dynamics: think of the “head” of the table, or “high” table, both of which provide a stage for social hierarchies.

Now, at the table: How can we best understand the deep assumptions that govern the scientific method, particularly when it is applied to the human sciences? In particular, how can we identify epistemological assumptions that enable historically specific understandings of such concepts as number, measurement, conservation, time, space, or mass?

I am beginning a new project on the history of the “subject” in experimental psychology. How was (and still is) a living human being held constant in time and space so that comparable data can be extracted from him or her? My participation as a subject in psychology experiments leads me to propose a modest candidate for a scientific technology central to the psychological experiment: the table. Obvious and overlooked, the table is nonetheless an essential accompaniment of civilized living: the first thing Robinson Crusoe did after being shipwrecked on his island was build a table. As he put it, “I could not write or eat, or do several things, with so much comfort, without a table.”[iii]

Down through the ages, anthropologists have had their tables, once used to create an island of French culinary civilization in the Brazilian rain forest. The photograph chosen to represent the ethnographic work of Claude Lévi-Strauss in his obituary showed him in a Brazilian rain forest standing by a table made of sticks lashed together. Laura Bohannan says that among the limited bits of advice given to her about how to do fieldwork in Africa, was this: “You’ll need more tables than you think,” a remark attributed to Evans-Pritchard.

Claude Lévi-Strauss, Amazon rain forest ~ 1936. Edward Rothstein, "Claude Lévi-Strauss, 100, Dies; Altered Western Views of the ‘Primitive’." New York Times, November 4, 2009.

Tables have also been used to corral thought, guide the reader’s mind along a certain course, as in the classic and often quoted examples from Plato and Marx. As usual, such tools do not determine their own use. “Table” is also a verb, as in “table it” in which the “table” holds items of business steady and unchanged in time. There are a myriad practices in meetings involving tables of all kinds, which exert a certain force in governing how matters proceed. Think of referring to “what is on the table,” “setting an agenda,” “laying a question on the table,” “taking a motion from the table,” and so on.

By now you might be wondering why the graphic form drawn on paper, displaying data enclosed in columns and rows is also called a “table”! It might have something to do with early scientific collections, arranged in flat boxes divided up into little square compartments.  Or perhaps the table as a graphic form derives from the medieval practices of counting money on tables marked with squares.  The table — as a piece of furniture with a flat surface and legs — and the table — as a display of facts in columns and rows — might both trace their genealogies to the Latin tabula rasa, literally ‘scraped tablet.’ The tablet was wax, and it could be heated and smoothed (scraped) to yield the literal origin of the epistemological “blank slate.” Whatever the historical link between the two kinds of tables, they both remain intriguing forms of everyday technology, which guide and form our posture and attention so that we can become, instead of blank slates, stable human subjects in psychology experiments, in the classroom, or at dinner.

In my current project tables are ubiquitous. Tables, with their chairs, keep one’s body in place.  In all the experiments I participated in, the experimenter made frequent and repeated requests concerning tables: sit here at the table, pull your chair closer to the table, put your hand on the table, rest your hand flat on the table, arrange the keyboard conveniently on the table.  And of course tables hold computers, monitors, keyboards, and recording equipment steady.  In the contemporary lab, the place of the psychological subject in relation to the equipment is not open for debate. The subject sits at a table and yields data to the machines.

Experimental table. Photo by Emily Martin.

The table is so embedded in the experimental context that it escapes notice, even though without it the stability of the subject in space and over time would be difficult if not impossible to achieve. Once it becomes evident that the table is an active artifact in the production of knowledge, new possibilities for opening up the nature of the experimental space in psychology abound. Latour was right to say that “Laboratories are excellent sites in which to understand the production of certainty, [but] . . . they have the major disadvantage of relying on the indefinite sedimentation of other disciplines, instruments, languages, and practices. One no longer sees science stammer, making its debut, creating itself from nothing in direct confrontation with the world. In the laboratory there is always a pre-constructed universe that is miraculously similar to that of the sciences.”[iv]   After a discussion of the table’s role in experiments, one of my researcher interlocutors began puzzling about what it would take to conduct an experiment about – say – memory in a crowded coffee shop instead of an experimental setting. This was disconcerting to him because leaving the laboratory would mean leaving a world of tables, flat, one dimensional, and still. But anthropologists should take note: even the busiest coffee shop has its tables too.

 

Emily Martin teaches anthropology at New York University. She is the author of The Woman in the Body: A Cultural Analysis of Reproduction (Beacon Press, 1987); Flexible Bodies: Tracking Immunity in American Culture From the Days of Polio to the Age of AIDS (Beacon Press, 1994); and Bipolar Expeditions: Mania and Depression in American Culture (Princeton University Press, 2007). She is the founding editor of the public interest magazine Anthropology Now.

[i] Bruno Latour, “Circulating reference: Sampling the soil in the Amazon forest.” In Pandora’s hope: Essays on the reality of science studies. Cambridge: Harvard University Press, 1999, p. 24-79

[ii] Alfred Gell, “Vogel’s Net: Traps as Artworks and Artworks as Traps.” Journal of Material Culture 1:1, 1996, p. 29.

[iii] Daniel Defoe, Robinson Crusoe. London: Wordsworth, 2005, p. 36

[iv] Latour, ibid.

Image: “Day 51: Division Board.” Flickr.

HIV Scale-Up and the Politics of Global Health — A Special Issue of Global Public Health by Aaron Seaman

22 Mars 2014 - 3:54pm

A recent issue of the journal Global Public Health was a notable double special issue on “HIV Scale-Up and the Politics of Global Health,” edited by Nora J. Kenworthy and Richard Parker. As the editors write in their introduction:

[W]e embark on this special issue at a particular disjuncture in the history of the epidemic. Just over 10 years ago, the President’s Emergency Plan for AIDS Relief (PEPFAR) was launched, shortly after the introduction of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). What followed was a race to treat and prevent HIV in resource-poor contexts – a global ‘scale-up’ that set the stage for many subsequent global health initiatives. For many, scale-up represented a primarily technocratic and infrastructural challenge: a focus on how donors, agencies, NGOs and community-based organisations (CBOs) could develop the kinds of health system capacities necessary for the large-scale implementation of treatment regimens. Now, however, we appear to be at the twilight of this acute period of scale-up: many perceive the long-awaited expansion of treatment as unfinished, cut short by the global financial crisis. Many now speak of ‘scale-down’ as an inevitability, rather than the potential consequence of shifting funding priorities. Other global health concerns seem well-poised to eclipse the once exceptional focus on HIV/AIDS.

The fourteen articles that compose the issue work across a range of disciplines, geographic foci, and particular questions to flesh out a portrait of the global ‘scale-up’ response and where it has left those funding, fighting, and living with HIV. The details of the articles are as follows:

‘All they do is pray’: Community labour and the narrowing of ‘care’ during Mozambique’s HIV scale-up
Ippolytos Kalofonos

This paper tracks the intertwined biographies of a community home-based care (CHBC) volunteer, Arminda, the community-based organisation she worked for, Mufudzi, and the HIV scale-up in Mozambique. The focus is on Arminda – the experiences, aspirations, skills, and values she brought to her work as a volunteer, and the ways her own life converged with the rise and fall of the organisation that pioneered CHBC in this region. CHBC began in Mozambique in the mid-1990s as a community-level response to the AIDS epidemic at a time when there were few such organised efforts. The rapid pace and technical orientation of the scale-up as well as the influx of funding altered the practice of CHBC by expanding the scope of the work to become more technically comprehensive, but at the same time more narrowly defining ‘care’ as clinically-oriented work. Over the course of the scale-up, Arminda and her colleagues felt exploited and ultimately abandoned, despite their work having served as the vanguard and national model for CHBC. This paper considers how this happened and raises questions about the communities constituted by global health interventions and about the role of and the voice of community health workers in large-scale interventions such as the HIV scale-up.

Participation, decentralisation and déjà vu: Remaking democracy in response to AIDS?
Nora J. Kenworthy

Participation, decentralisation and community partnership have served as prominent motifs and driving philosophies in the global scale-up of HIV programming. Given the fraught histories of these ideas in development studies, it is surprising to encounter their broad appeal as benchmarks and moral practices in global health work. This paper examines three intertwined, government-endorsed projects to deepen democratic processes of HIV policy-making in Lesotho: (1) the ‘Gateway Approach’ for decentralising and coordinating local HIV responses; (2) the implementation of a community council-driven priority-setting process; and (3) the establishment of community AIDS councils. Taken together, these efforts are striking and well intentioned, but nonetheless struggle in the face of powerful global agendas to establish meaningful practices of participation and decentralisation. Examining these efforts shows that HIV scale-up conveys formidable lessons for citizens about the politics of global health and their place in the world. As global health initiatives continue to remake important dimensions of political functioning, practitioners, agencies and governments implementing similar democratising projects may find the warnings of earlier development critics both useful and necessary.

Elusive accountabilities in the HIV scale-up: ‘Ownership’ as a functional tautology
Daniel E. Esser

Mounting concerns over aid effectiveness have rendered ‘ownership’ a central concept in the vocabulary of development assistance for health (DAH). The article investigates the application of both ‘national ownership’ and ‘country ownership’ in the broader development discourse as well as more specifically in the context of internationally funded HIV/AIDS interventions. Based on comprehensive literature reviews, the research uncovers a multiplicity of definitions, most of which either divert from or plainly contradict the concept’s original meaning and intent. During the last 10 years in particular, it appears that both public and private donors have advocated for greater ‘ownership’ by recipient governments and countries to hedge their own political risk rather than to work towards greater inclusion of the latter in agenda-setting and programming. Such politically driven semantic dynamics suggest that the concept’s salience is not merely a discursive reflection of globally skewed power relations in DAH but a deliberate exercise in limiting donors’ accountabilities. At the same time, the research also finds evidence that this conceptual contortion frames current global public health scholarship, thus adding further urgency to the need to critically re-evaluate the international political economy of global public health from a discursive perspective.

Evidence and AIDS activism: HIV scale-up and the contemporary politics of knowledge in global public health
Christopher J. Colvin

The HIV epidemic is widely recognised as having prompted one of the most remarkable intersections ever of illness, science and activism. The production, circulation, use and evaluation of empirical scientific ‘evidence’ played a central part in activists’ engagement with AIDS science. Previous activist engagement with evidence focused on the social and biomedical responses to HIV in the global North as well as challenges around ensuring antiretroviral treatment (ART) was available in the global South. More recently, however, with the roll-out and scale-up of large public-sector ART programmes and new multi-dimensional prevention efforts, the relationships between evidence and activism have been changing. Scale-up of these large-scale treatment and prevention programmes represents an exciting new opportunity while bringing with it a host of new challenges. This paper examines what new forms of evidence and activism will be required to address the challenges of the scaling-up era of HIV treatment and prevention. It reviews some recent controversies around evidence and HIV scale-up and describes the different forms of evidence and activist strategies that will be necessary for a robust response to these new challenges.

Up-scaling expectations among Pakistan’s HIV bureaucrats: Entrepreneurs of the self and job precariousness post-scale-up
Ayaz Qureshi

Existing research has documented how the expansion of HIV programming has produced new subjectivities among the recipients of interventions. However, this paper contends that changes in politics, power and subjectivities may also be seen among the HIV bureaucracy in the decade of scale-up. One year’s ethnographic fieldwork was conducted among AIDS control officials in Pakistan at a moment of rolling back a World Bank-financed Enhanced Programme. In 2003, the World Bank convinced the Musharraf regime to scale up the HIV response, offering a multimillion dollar soft loan package. I explore how the Enhanced Programme initiated government employees into a new transient work culture and turned the AIDS control programmes into a hybrid bureaucracy. However, the donor money did not last long and individuals’ entrepreneurial abilities were tested in a time of crisis engendered by dependence on aid, leaving them precariously exposed to job insecurity, and undermining the continuity of AIDS prevention and treatment in the country. I do not offer a story of global ‘best practices’ thwarted by local ‘lack of capacity’, but an ethnographic critique of the transnational HIV apparatus and its neoliberal underpinning. I suggest that this Pakistan-derived analysis is more widely relevant in the post-scale-up decade.

HIV testing as prevention among MSM in China: The business of scaling-up
Elsa L. Fan

In this paper, I examine the emergence of goumai fuwu, or contracting with social organisations to provide social services, in the HIV/AIDS sector in China. In particular, I interrogate the outsourcing of HIV testing to community-based organisations (CBOs) serving men who have sex with men (MSM) as a means of scaling-up testing in this population, and how the commodification of testing enables new forms of surveillance and citizenship to emerge. In turn, I tie the scaling-up of testing and its commodification to the sustainability of CBOs as they struggle to survive. In recent years, the HIV/AIDS response in China has shifted to expanding testing among MSM in order to reduce new infections. This response has been catalysed by the transition to sexual contact as the primary transmission route for HIV and the rising rates of infection among MSM, leading government institutions and international donors to mobilise CBOs to expand testing. These efforts to scale-up are as much about testing as they are about making visible this hidden population. CBOs, in facilitating testing, come to rely on outsourcing as a long-term funding base and in doing so, unintentionally extend the reach of the state into the everyday lives of MSM.

Bringing the state back in: Understanding and validating measures of governments’ political commitment to HIV
Radhika J. Gore, Ashley M. Fox, Allison B. Goldberg, and Till Bärnighausen

Analysis of the politics of HIV programme scale-up requires critical attention to the role of the state, since the state formulates HIV policies, provides resources for the HIV response and negotiates donor involvement in HIV programmes. However, conceptual and methodological approaches to analysing states’ responses to HIV remain underdeveloped. Research suggests that differences in states’ successes in HIV programme scale-up reflect their levels of ‘political commitment’ to responding to HIV. Few empirical measures of political commitment exist, and those that do, notably the AIDS Program Effort Index (API), employ ad hoc scoring approaches to combine information from different variables into an index of commitment. The indices are thus difficult to interpret and may not have empirically useful meaning. In this paper, we apply exploratory factor analysis to examine whether, and how, selected variables that comprise the API score reflect previously theorised dimensions of political commitment. We investigate how variables associated with each of the factors identified in the analyses correspond to these theorised dimensions as well as to API categories. Finally, we discuss potential uses – such as political benchmarking and accountability – and challenges of factor analysis as a means to identify and measure states’ political commitment to respond to HIV.

‘Low-hanging fruit’: Counting and accounting for children in PEPFAR-funded HIV/AIDS programmes in South Africa
Lindsey J. Reynolds

The article traces the social life of a policy that aimed to define and circumscribe the ambiguous and contested category of ‘orphaned and vulnerable children’ (or OVC) in South Africa at the height of the ‘emergency response’ to HIV/AIDS. Drawing on several months of institutional ethnographic research conducted over the course of five years with South African organisations receiving funding from the US President’s Emergency Plan for AIDS Relief to provide services to ‘OVC’, the project interrogates the influence of governmental forms of counting and accounting on health policy and practice in South Africa. Focusing on the experiences of one organisation, the article describes a process of policy ‘translation’ typified by a series of disconnects between the intentions of a policy and the exigencies of implementation, structured by the ambiguous and flexible nature of the ‘OVC’ category. In this context, the article argues that the uncertainty produced by the implementation of the guidelines was not simply an artefact of a poorly designed policy, but rather signals an underlying epistemological tension in the practice of ‘global health’, in which quantitative metrics designed for monitoring and evaluation are often incapable of approximating the complexities of everyday life.

Towards the embodiment of biosocial resistance? How to account for the unexpected effects of antiretroviral scale-up in the Central African Republic
Pierre-Marie David

At the fringes of the unprecedented medication scale-up in the treatment of HIV, many African countries have experienced dramatic antiretroviral drug stock-outs. Usually considered the result of irrational decisions on behalf of local politicians, programme managers and even patients (who are stigmatised as immoral), these problems seem not to be so exceptional. However, ethnographic attention to the social consequences of the presence and absence of antiretroviral drugs in the Central African Republic (CAR) suggests that these stock-outs entail far more than logistical failures. In 2010 and 2011 in the CAR, major antiretroviral treatment (ARV) stock-outs resulted in the renewal of ‘therapeutic’ social ties and also significant social resistance and defiance. While this paper explores reasons for the shortage, its focus is on subsequent popular reactions to it, particularly among people who are HIV-positive and dependent on ARVs. The exceptional and ambiguous consequences of these drug stock-outs raise new concerns relevant to the politics of global public health.

Meaningful change or more of the same? The Global Fund’s new funding model and the politics of HIV scale-up
Anuj Kapilashrami and Johanna Hanefeld

As we enter the fourth decade of HIV and AIDS, sustainability of treatment and prevention programmes is a growing concern in an environment of shrinking resources. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) will be critical to maintaining current trajectories of scale-up and ultimately, ensuring access to HIV treatment and prevention for people in low/middle-income countries. The authors’ prior research in India, Zambia and South Africa contributed evidence on the politics and impact of new institutional and funding arrangements, revealing a ‘rhetoric-reality gap’ in their impact on health systems, civil society participation, and achievement of population health. With its new funding strategy and disbursement model, the Fund proposes dramatic changes to its approach, emphasising value for money, greater fund predictability and flexibility and more proactive engagement in recipient countries, while foregrounding a human rights approach. This paper reviews the Fund’s new strategy and examines its potential to respond to key criticisms concerning health systems impact, particularly the elite nature of this funding mechanism that generates competition between public and private sectors and marginalises local voices. The authors analyse strategy documents against their own research and published literature and reflect on whether the changes are likely to address challenges faced in bringing HIV programmes to scale and their likely effect on AIDS politics.

After the Global Fund: Who can sustain the HIV/AIDS response in Peru and how?
Ana B. Amaya, Carlos F. Caceres, Neil Spicer, and Dina Balabanova

Peru has received around $70 million from Global Fund to fight AIDS, Tuberculosis and Malaria (Global Fund). Recent economic growth resulted in grant ineligibility, enabling greater government funding, yet doubts remain concerning programme continuity. This study examines the transition from Global Fund support to increasing national HIV/AIDS funding in Peru (2004–2012) by analysing actor roles, motivations and effects on policies, identifying recommendations to inform decision-makers on priority areas. A conceptual framework, which informed data collection, was developed. Thirty-five in-depth interviews were conducted from October to December 2011 in Lima, Peru, among key stakeholders involved in HIV/AIDS work. Findings show that Global Fund involvement led to important breakthroughs in the HIV/AIDS response, primarily concerning treatment access, focus on vulnerable populations and development of a coordination body. Nevertheless, reliance on Global Fund financing for prevention activities via non-governmental organisations, compounded by lack of government direction and weak regional governance, diluted power and caused role uncertainty. Strengthening government and regional capacity and fostering accountability mechanisms will facilitate an effective transition to government-led financing. Only then can achievements gained from the Global Fund presence be maintained, providing lessons for countries seeking to sustain programmes following donor exit.

Confronting ‘scale-down’: Assessing Namibia’s human resource strategies in the context of decreased HIV/AIDS funding
Liita-Iyaloo Cairney and Anuj Kapilashrami

In Namibia, support through the Global Fund and President’s Emergency Plan for AIDS Relief has facilitated an increase in access to HIV and AIDS services over the past 10 years. In collaboration with the Namibian government, these institutions have enabled the rapid scale-up of prevention, treatment and care services. Inadequate human resources capacity in the public sector was cited as a key challenge to initial scale-up; and a substantial portion of donor funding has gone towards the recruitment of new health workers. However, a recent scale-down of donor funding to the Namibian health sector has taken place, despite the country’s high HIV and AIDS burden. With a specific focus on human resources, this paper examines the extent to which management processes that were adopted at scale-up have proven sustainable in the context of scale-down. Drawing on data from 43 semi-structured interviews, we argue that human resources planning and management decisions made at the onset of the country’s relationship with the two institutions appear to be primarily driven by the demands of rapid scale-up and counter-productive to the sustainability of interventions.

HIV scale-up in Mozambique: Exceptionalism, normalisation and global health
Erling Høg

The large-scale introduction of HIV and AIDS services in Mozambique from 2000 onwards occurred in the context of deep political commitment to sovereign nation-building and an important transition in the nation’s health system. Simultaneously, the international community encountered a willing state partner that recognised the need to take action against the HIV epidemic. This article examines two critical policy shifts: sustained international funding and public health system integration (the move from parallel to integrated HIV services). The Mozambican government struggles to support its national health system against privatisation, NGO competition and internal brain drain. This is a sovereignty issue. However, the dominant discourse on self-determination shows a contradictory twist: it is part of the political rhetoric to keep the sovereignty discourse alive, while the real challenge is coordination, not partnerships. Nevertheless, we need more anthropological studies to understand the political implications of global health funding and governance. Other studies need to examine the consequences of public health system integration for the quality of access to health care.

AIDS policy responsiveness in Africa: Evidence from opinion surveys
Ashley M. Fox

As a result of massive scale-up efforts in developing countries, millions of people living with HIV are now receiving antiretroviral therapy (ART). However, countries have been uneven in their scale-up efforts with ART coverage rates exceeding expectations in some places and lagging behind expectation in others. This paper develops a model that explains ART scale-up as a function of the responsiveness of political parties to their primary constituents. Specifically, the paper argues that, faced with a perilous ‘threat to the nation’, countries responded in one of two ways, both of which were designed to appeal to their primary constituents – either adopting a ‘Geneva Consensus’ response, or depicting the epidemic as a Western disease and adopting a ‘pan-African’ response. The article tests this theory using Afrobarometer data for eleven countries. The paper finds that HIV/AIDS is generally a non-partisan issue in most countries. However, the analysis does uncover some differences in partisan support for HIV/AIDS responses in both countries that have adopted Geneva Consensus and pan-African responses, though not in the direction hypothesised. The lack of congruence in policy preferences between the public and their governments suggests a democratic deficit in that these governments have acted independently of the preferences of core constituents.

Social Theory after Strathern — A Special Issue of Theory, Culture & Society by Aaron Seaman

21 Mars 2014 - 2:40pm

Theory, Culture & Society recently published a special issue, entitled “Social Theory after Strathern.” Along with a forward by Paul Rabinow, a wonderful introduction by co-editors Alice Street and Jacob Copeman, and an afterword by Nigel Thrift, the issue includes articles from a host of disciplines, as well as an interview with Strathern conducted by Janet Carsten. The details are below, but it promises for good reading….

Foreword to Social Theory After Strathern
Paul Rabinow

Today, somewhat counter-intuitively, we no longer have an obvious venue for thinking-in-the world about our actuality. Despite, or because of, the endless conferences, seminars, mobility, publication outlets, new media and the like in which it is easier and easier to be connected, it is increasingly difficult to avoid the diagnostic that it is harder and harder to relate. This Foreword to the special issue ‘Social Theory After Strathern’ considers the contemporary problem of the inversion of connectedness and relatedness in the light of Marilyn Strathern’s oeuvre. Proceeding from a discussion of the three kinds of friendship distinguished by Aristotle, Deleuze and Guattari’s notion of conceptual persona is invoked as a way of thinking through conceptual friendship and the forms of relationality that an engagement with Strathern’s work requires and sustains.

Social Theory after Strathern: An Introduction
Alice Street and Jacob Copeman

Taking its cue from the articles in this special issue, this introduction explores what value a critical engagement with Strathern’s work might have for the social sciences by setting such an engagement in motion. It argues that Strathern’s writings are a particularly fruitful starting point for reflecting on our assumptions about what exactly theory might be and how and where it may be made to travel. Through the juxtaposition of articles published in this special issue and Strathern’s writings on Melanesia it explores the theorization of power in the social sciences as one arena in which Strathernian strategies might be harnessed in order to reflect on and extend Euro-American concepts. It also takes Strathern’s own interest in gardening as a metaphoric base for generating novel topologies of subject and object, the particular and the general, and the concrete and the abstract. This introduction does not provide a primer for ‘Strathernian theory’. Instead it reviews some of the original strategies and techniques – differentiation, staging of analogy, surprise, bifurcation, the echo, and an unremitting focus on how we make our familiar categories of analysis known to ourselves – that Strathern has used to ‘garden’ her theory: it can be used, if you like, as a conceptual toolkit.

Melanesian Ethnography and the Comparative Project of Anthropology: Reflection on Strathern’s Analogical Approach
Eric Hirsch

Melanesian ethnography has been a substantial and enduring presence in Strathern’s comparative project of anthropology. The cornerstone of this project was The Gender of the Gift, where a model was established for demonstrating the analogies between Melanesian societies based on a system of common differences. The comparisons created in this work were centred on a real and radical divide between Melanesia and the West. Strathern’s subsequent comparative work has examined the debates surrounding new social and technological forms in the West (e.g. new genetic and reproductive technologies) through drawing analogies with Melanesian social forms; she has simultaneously highlighted the limits of these comparisons. Her intention in this comparative project has been to expand the range of concepts and language used to understand western social and technological innovations that potentially affect the world at large, so that debate is not simply circumscribed by western preoccupations and concerns. As mediated through the analysis of Strathern and the other Melanesian anthropologists she draws on, the voices and interests of non-westerners can potentially inform and even reform the grounds of such deliberations.

Plagiarism, Kinship and Slavery
Mario Biagioli

In conversation with Marilyn Strathern’s work on kinship and especially on metaphors of intellectual and reproductive creativity, this paper provides an analysis of plagiarism not as a violation of intellectual property but of the kinship relationships between author, work, and readers. It also analyzes the role of figures of kidnapped slaves and children in the genealogy of the modern concept of plagiarism.

Language Trails: ‘Lekker’ and Its Pleasures
Annemarie Mol

This is an article about bodily pleasures, words and some of the relations between them. It is a turn in a conversation between the author (‘me’) and Marilyn Strathern (‘Strathern’). It talks theory, but not in general. Instead, this theory gets situated in traditions; specified; in relation to concerns; and exemplified with stories to do with the term lekker. This article is in English, but lekker is not an English term. It is Dutch. The stories come from long-term field work in various sites and situations close to home for the author, who is also Dutch. They were driven by a concern with fostering bodily pleasures in contexts such as nursing homes and dieting practices where nutrients and calories are granted more importance. The difficulties of translating lekker (tasty? pleasant? delicious? fun? nice?) are used as a set of intellectual resources. In contrast to Strathern, the author insists on the fleshy particularities of the practices where lekker is spoken. Along with Strathern, the author seeks to escape nature/culture divides. Inspired by Strathern, the author follows lekker around merographically – that is, along iterative trails and between sites and situations that are connected, but only partially so. In homage to Strathern, finally, the author plays with the question of who the collective subject of anthropological theory – we – might be, and who belongs to the others that form its object – they.

The Coming of the Corporate Gift
Jamie Cross

Corporate gifts – from philanthropic donations to individual reward schemes – attract considerable attention from scholars for the kinds of moral, economic and political logics that motivate them. This article considers the gifts that transnational corporations give to producers and draws from Marilyn Strathern’s writings on exchange and personhood in order to reverse dominant analyses. Focused on the gifting of gold coins to industrial workers at a global manufacturing unit in India, it brings together field-based observations with a diverse field of literature on the gift in anthropology. Against an analysis that sees the corporate gift harnessed directly to a corporate bottom line, this article proposes an alternative accounting that uses Strathern’s notions of ‘elicitation’, ‘revelation’ and ‘detachment’ to explore the contours of knowledge, personhood and relationality in the transaction. If corporate gifts have powerful effects, the article argues, it is because they establish difference between the person of the giver and the person of the recipient and because they materialize actions, desires and capacities that accrue to and transform the recipients rather than simply because they are vessels for the interests of global capital. As social theory confronts the political economy of corporate giving, Strathern’s writings prompt provocative questions about agency and power that challenge the hegemonic status of the modern corporation.

Law after Anthropology: Object and Technique in Roman Law
Alain Pottage

Anthropological scholarship after Marilyn Strathern does something that might surprise lawyers schooled in the tradition of ‘law and society’, or ‘law in context’. Instead of construing law as an instrument of social forces, or as an expression of processes by which society maintains and reproduces itself, a new mode of anthropological enquiry focuses sharply on ‘law itself’, on what Annelise Riles calls the ‘technicalities’ of law. How might the legal scholar be inspired by this approach? In this article, I explore one possible way of approaching law after anthropology, which is to find within law’s own archive a set of resources for an analogous representation of law itself. Drawing on the historical scholarship of Yan Thomas, I suggest that the Roman conception of law as object offers an engaging counterpart to the anthropological take on law as a specific set of tools or, technicalities, or as a particular art of making relations.

Unexpected Properties: Strathern on the Relation of Law and Culture
Carol J. Greenhouse

This article takes up Marilyn Strathern’s formulation of a law/culture ‘duplex’ – her term for the complementarity of anthropology and law as means to each other’s ends. She draws attention to the limitations of the duplex, and urges us to consider ethnography as (in part) a project of unwinding its entwinement. As a step toward that end, the article returns to classic texts by Emile Durkheim and Bronislaw Malinowski – texts that were foundational to the emergence of anthropology, and to the establishment of law as an object of study for the social sciences. Re-read in light of Strathern’s insight, what has been widely taken as their relativism emerges instead as their defense of political community as a subject for ethnography, and (accordingly) the basis for a theoretical check on law conceived globally – within states or as colonial overrule. The article concludes with a discussion of the contemporary relevance of that position.

The Image after Strathern: Art and Persuasive Relationality in India’s Sanguinary Politics
Jacob Copeman and Alice Street

Publicly-enacted blood extractions (principally blood donation events and petitions or paintings in blood) in mass Indian political contexts (for instance, protest or political memorial events and election rallies) are a noteworthy present-day form of political enunciation in India, for such extractions – made to speak as and on behalf of political subject positions – are intensely communicative. Somewhat akin to the transformative fasts undertaken by Gandhi, such blood extractions seek to persuade from the moral high ground of political asceticism. This essay seeks to shed light on how and why these extractions have become such a means, with a particular focus on blood-based portraiture. What makes such portraits – chiefly of politicians and ‘freedom fighter’ martyrs – interesting from a Strathernian point of view is their immanent persuasive relationality. The insights of Strathern can help us to explicate these objects’ dynamic relational features, while reciprocally, the portraits may help us to illuminate and clarify the very particular and interesting nature of the way Strathern treats (and creates) images.

Strathern beyond the Human: Testimony of a Spore
Anna Lowenhaupt Tsing

How might Strathernian comparison extend anthropology beyond human exceptionalism? This essay explores how a fungal spore might guide attention to more-than-human nature. The exercise allows us to reflect on knowledge tools we use for understanding human as well as nonhuman social relations.

Analogic Return: The Reproductive Life of Conceptuality
Sarah Franklin

One of the most important lessons the work of Marilyn Strathern has taught us about knowledge practices is how they stand alone or intersect according to their context. In turn, this has helped us to develop a more dynamic account of knowledge formations as they both travel and stand still. Indeed it is the vacillation between movement and stasis that explains how essentialisms can either anchor cultural systems of thought or become unmoored – a process Strathern has tracked across both cultural and epistemological contexts. In this paper I use the biological sciences as a context in which to track the process by which analogies ‘travel back’ to remake both their object and its epistemology, or ‘habits of thought’. Indeed, context itself can change, and be changed by, what I am calling analogic return – something we might also consider in relation to scale or perception, or as one of the world-making practices out of which we constantly remake ourselves, now more literally than ever in the context of new genetic technologies and stem cell science.

An Interview with Marilyn Strathern: Kinship and Career
Janet Carsten

The interview was conducted in September 1996 in Cambridge. Marilyn Strathern (MS) and Janet Carsten (JC) had been colleagues at the University of Manchester’s Department of Social Anthropology until September 1993, when Marilyn Strathern left to take up the William Wyse Professorship at the University of Cambridge, where she remained until retirement in 2008. Janet Carsten joined Edinburgh in October of the same year, where she is presently Professor of Social and Cultural Anthropology. (Supplementary questions, reflecting back on the earlier interview, were put to Marilyn Strathern by the editors of the special issue in 2013.)

Afterword: Struck Dumb? Marilyn Strathern and Social Science
Nigel Thrift

Marilyn Strathern has produced a remarkable body of work that not only demonstrates range and tenacity but also has produced a host of inspirations that have made their way into the world. This Afterword to the special issue ‘Social Theory After Strathern’ dwells on the subject of the modesty of what Strathern is proposing and how it relates to space, noting that her work enables us to forge new practico-theoretical combinations and works of diplomacy between incompatibles which show up the limitations of each party even as they forge new understandings – an approach that chimes with a move towards a more spatial view of knowledge. Theory, to echo Strathern’s gardening metaphor, needs to leave room not just to prune but to grow, the two being inter-related, as she points out. This Afterword also proposes that the extraordinary ability of anthropology to be inside and outside at once might serve as a model for what the social sciences need to become if they are to stay relevant in a world which cannot be reduced to a cipher for theory but still needs to learn from theory – theory which is precarious but spreadable, theory which establishes a rapport, but a rapport with friction built into it.

Critical Perspectives on Multispecies Ethnography — A Special Issue of Critique of Anthropology by Aaron Seaman

21 Mars 2014 - 2:17pm

The most recent issue of Critique of Anthropology is a special issue, entitled “Critical Perspectives on Multispecies Ethnography.” The introduction, by Alan Smart, discusses the use of “multispecies ethnography” as the designation for their enterprise, working through the implications of both words of the phrase. Along with the introduction, the five articles detailed below round out the issue:

Ethnoprimatology: Critical interdisciplinarity and multispecies approaches in anthropology
Nicholas Malone, Alison H. Wade, Agustín Fuentes, Erin P. Riley, Melissa Remis, and Carolyn Jost Robinson

The emerging practice of ethnoprimatology creates an important venue for diverse epistemologies in anthropology and primatology to interact in an intellectually robust and engaged manner. At the same time that multispecies ethnographies are becoming more common in social anthropology, a subset of primatologists are immersing themselves in approaches that merge ethnographic engagement with primate studies. In these endeavors the distinction between “human worlds” and “nature” is discarded and multispecies entanglements become central aspects of anthropogenic ecologies. By drawing from ecological, biological, ethnographic and historical approaches, ethnoprimatology creates a more robust and accurate methodology for anthropologists and primatologists interested in understanding complex systems of human–alloprimate interface in the Anthropocene. In this essay, we outline what ethnoprimatology is, how it plays out in real-world contexts, and why it is a potentially powerful tool to move past historical rifts in anthropological practice and integrate perspectives in a successful and engaged manner. Finally, we address the practical and ethical considerations of human–alloprimate engagements in both conservation and scientific contexts.

Animal spirits and mimetic affinities: The semiotics of intimacy in African human/animal identities
John G. Galaty

Human identities are often conceived in counter-position to objects outside the individual or the collective self with which lines of affinity or opposition, or the blurring together of both, run. Selfhood itself is forged out of the experience of “alterity” through encounters with diverse “others” with whom we identify or differentiate ourselves. With reference to the experience of East African pastoralists, this paper examines the meshing of human and animal identities, where both wild and domestic animals represent human partners and counterparts. Semiotic theories propose that there are two opposed sign functions, based on relations of contiguity and similarity. Domestic animals are “part of,” but often serve as metaphors for, pastoralist societies. Both functions describe forms of human/animal “similitudes,” via large affinities as people are seen as like, as or together with domestic animals, or via small and intimate affinities, built up through sensual experience. Sacrifice creates the ultimate intimacy, as the sacrificed animal becomes a key signifier of personal and social identities. Here, the two semiotic functions are blended to form especially powerful semiotic objects, with metonymical sources elevated to analogies identities. Livestock, then, are human metonyms that serve as especially convincing metaphors and allegories for society and personal identity. It is through relations of intimate affinity between herding peoples and their stock that the sense of what an animal is and the qualities it sensually shares with people are built up through experience and affect into memories and anticipations. Then, the nature of the beast as a set of forms, properties, ideas, and associations is elevated into indexical images of special similitude that can assume the full weight of signifying people as individuals and collectivities and in so doing brings identities within society into being.

Hokkaido’s frontiers: Blurred embodiments, shared affects and the evolution of dairy farming’s animal-human-machine
Paul Hansen

Japan’s northernmost island of Hokkaido is popularly viewed as a frontier space. This stems from a pre-modern conceptualization of the island as barbaric, its contemporary image as pastoral, and the downplaying of its colonization in between. In Hokkaido, dairying is an occupation that is profoundly influenced by negotiations with modernity, regional identity and the “West”. Thus, the image of the dairy industry is usually promoted through two tropes; dairy as foreign and dairy as a modern health benefit coalescing with conceptualizations of idealized foreign physical and political bodies. These perceptions link the contemporary industry to idyllic Euro-American pastoral images and imaginations. However, as in much of the northern world, Hokkaido dairy farming has rapidly industrialized. Until the 1980s Hokkaido dairy farms rarely exceeded 50 head. The norm was that members of a single farm family would intimately know their livestock through the embodied sharing of space and interaction; especially in relation to the twice daily process of milking. But, over the last generation a shift to rotary parlor milking systems has occurred. This high-tech and high-cost equipment enables the “automated” and simultaneous milking of up to 60 cattle at any given moment presided over by only four human staff whose work involves attaching suction devices and observing readouts. Such unskilled dairy workers are often not from farm families. Increasingly they are transient urban youth remaining on the job for less than a year, or international migrants with little interest in farming. This paper is based on 19 months of ethnographic and archival fieldwork and examines how the boundaries between animal, human, and technology have shifted and may further shift in Hokkaido.

Revisiting distinctions between ranching and pastoralism: A matter of interspecies relations between livestock, people, and predators
Olivier LaRocque

North American ranching did not evolve as a solution to the ecological contradictions of pastoralism. This has been the conventional view from an institutional perspective, but from a perspective of interspecies relations, the reverse is more plausible. Rather than invest in careful husbandry, early colonists released livestock to fend for themselves and henceforth partook in the eradication of predators. This estrangement of livestock from the domestic sphere and the persecution of predators have lasted beyond the open range era and persist on private ranches. Range science tailored its prescriptions to the free-roaming livestock practices of ranching. But stocking rate guidelines are not sufficient to prevent the degradation of rangelands. Trophic cascade ecology has since demonstrated that the sound distribution of grazing activities takes place on a landscape of fear where nonlethal predation effects prevent the overutilization of key sites. In order to replicate these effects without undue losses, now that predators are protected, ranchers are compelled to reformulate their interspecies relations of estrangement and persecution. Technologies are a poor substitute for human presence, and ranchers are faced with adopting pastoralist practices of herding in order to improve rangelands and maintain surveillance to prevent predation. Thus by turning to pastoralist interspecies relations and practices, ranching might resolve its ecological contradictions.

Worldviews and human–animal relations: Critical perspectives on bison–human relations among the Euro-Canadians and Blackfoot
Gerald A. Oetelaar

Researchers generally study human–animal relations in terms of hunter–gatherers, pastoralists or urbanites but few have explored the relationship between humans and the same animal across cultures. In this paper, I examine the relationship between humans and bison in the world of Euro-Canadians and the cosmos of the Blackfoot. Although both groups perceived the bison as a valuable resource and implemented conservation strategies to ensure its survival, their respective attitudes toward this species reflected very different worldviews. To Euro-Canadians and western researchers, the bison are perceived as being a part of nature, and thus human–animal relations change in tandem with the changing perceptions of the natural environment. To the Blackfoot people, humans are part of nature as are bison, and therefore, human–animal relations involve direct interactions between sentient beings.

TB/HIV: Distinct Histories, Entangled Futures. Towards an Epistemology of Co-infection by Lukas Engelmann

20 Mars 2014 - 10:13pm

Communication never occurs without a transformation,
and indeed always involves a stylized remodelling,
which intracollectively achieves corroboration
and which intercollectively yields fundamental alteration.

(Fleck 1981, 111)

One office, two diseases, two disciplines. That’s where we started. And while sharing an office as post-doctoral researchers at the University of Zürich, that’s where we stumbled upon one of those “epistemological obstacles” – to use Gaston Bachelard’s famous expression – when we were trying to think about two distinct diseases, tuberculosis (TB) and HIV/AIDS, as an entangled object of co-infection, in short as TB/HIV. Dubbed as ‘double trouble’, ‘perfect storm’, ‘deadly duo’ or ‘deadly liaison’, TB/HIV is understood to be a blending of the two deadliest epidemics of the 20th century: “In 2007, 1.37 million people infected with HIV were estimated to be coinfected with TB, according to the World Health Organization, and 1 of 4 deaths from TB is now HIV related” (Mayer and Dukes Hamilton 2010) and “living with HIV, dying of TB” has become the morbid slogan to describe the often preventable outcome of this steadily emerging global health crisis.

In order to approach TB/HIV as an entangled object, we organized a Symposium called “TB/HIV: Distinct Histories, Entangled Futures. Towards an Epistemology of Co-infection,” which took place at the Fondation Brocher in Geneva in February 2014 and was generously funded by the Fondation Brocher as well as the Institute for the History of Medicine of the University of Zürich (programme below).  A group of engaged scholars from different disciplines, countries, and institutions shared their rich and inspiring thoughts to discuss this challenging topic. As for ourselves, each one of us brought a rather unusual disease perspective to this collective experiment: as an anthropologist of European biomedicine and public health with a research focus on France and Germany, Janina worked on a classical medical history object – tuberculosis – and as a historian of medicine Lukas engaged with HIV and AIDS, since the late 1990’s a paradigmatic research object for many medical anthropologists engaging with global infectious diseases.

Lukas followed the trail of visualizations of AIDS and HIV in medical atlases to interrogate the becoming of the disease entity of AIDS through clinical photographs, epidemiological mappings and virus models. Unfolding these visual archives within the framing of medical history revealed the many ways in which images merge symptoms of opportunistic diseases, geographical patterns and causal agents in order to reveal the entity of a chronic disease that inherited the former “epidemic of signification” (Treichler 1988). Lukas showed, that the growing specificity and uniqueness of AIDS, its ontologization, was as crucial in its normalization as was social activism, pharmaceutical intervention or global funding efforts.

Janina demonstrated how TB – the paradigmatic “white plague” of the past – is conceived of as a “disease without a future” in contemporary Western Europe today, regaining sense in France and Germany only as a disease of the Other (immigrants) and the Elsewhere (the Global South and the East). Yet she also described how TB – against common assumptions – has always persisted within European countries, and so has an important yet largely unrecognized biopolitical apparatus of disease control, set up in the early 20th century, spanning the laboratory, clinical medicine and public health. Through multi-sited fieldwork, Janina thereby showed TB to be an awkward spatio-temporal object for European medicine, public health and their societies in the present, whose being and problematization changes with each site, making it a disease multiple.

Despite obvious differences in the methodologies, disciplinary conventions and the objects of investigation, our research was nevertheless characterized by a common concern: to carve out the dynamics of stability and dissolution of diseases, of transformation and repetition of treatment and prevention, of inclusion and exclusion, of continuity and change – be it in the domain of disease ontology, clinical practice or the politics of public health. Thinking in terms of entanglements and collaboration while at the same time understanding the analytics of separation was thus the challenge we set out to confront when organizing the international symposium on TB/HIV.

Scholars from the humanities, social sciences and the field of public health came together to develop perspectives, discuss limits and engage in an interdisciplinary exchange of ideas around the topic of co-infection. The Symposium was clustered in three sections: Beginning with a number of historical perspectives, TB and HIV were approached as entangled and parallelly distinguished entities. “Beyond Separation and Integration” worked as a framing, to bring historians (Oppenheimer, Columbia University and Condrau, University of Zurich) in contact with policy makers and scientific advisors (Getahun, WHO and Godfrey-Faussett, LSHTM/UNAIDS). Different iconographies (Unger/Odukoya, LMU Munich), contrasting cultures of care (Daftary, Columbia University) and the difficult process of policy integration (Vidal, IRD Youndé) were topics in a series of discussions on the distinguishable nature of the diseases and their histories. How to think “Beyond Singularities” and beyond the binaries of TB and HIV was demonstrated in a session about localized examples of co-infection and their management. HIV and Hepatitis C co-infection (Chabrol, Université d’Aix-Marseille), the “trifecta” of HIV, TB and Cancer (Livingston, Rutgers University) or the entanglement of TB with other disease programs (Harper/Ecks) were conceptually theorized through ethnographic descriptions. Thinking multiple diseases, disease multiplicity, and patient complexity on an epistemological level was the scope of the last session “Towards Entanglements.” Following rhetorical figures across different disease campaigns (Patton, University of Vancouver), exemplifying the poisonous ingenuity of time at the example of a patient’s trajectory (Meyers, Wayne State University) and exploring the potentiality of multi-morbidity for novel collaborations (Rosengarten, Goldsmith College). Through fine-grained ethnographies that mingled with conceptual work, the symposium laid out the dense field of co-infection and opened up for debate how to think with and through them in the field of medicine and public health.

The symposium thereby brought together in one location different research communities of TB and HIV/Aids, much in the way that we have been brought together in one single office. It offered a space to jointly think (about) TB/HIV and other co-infections, through an encounter of thought collectives defined by single diseases. It thereby facilitated a scientific “contact zone” (Pratt 1991) so to speak, in which researchers, activists and policy makers from different disease contexts, countries, institutions, disciplines and academic backgrounds could encounter each other and work together, a “zone of awkward engagements”, to use a formulation by Ana Tsing,  “where different rationalities rub against each other, compete and become entangled in different ways” (Kontopodis et. al 2011). Through the institutional, disciplinary and geographic mélange of its participants, the symposium, taking place at the beautiful and remote location of the Fondation Brocher, was thus a unique opportunity to engage in a collective reflection beyond single disease histories and presents of TB/HIV.

One way to think further about this “engagement” and encounter of two diseases and their communities is to return to the seminal work of Ludwik Fleck, who followed the multiple biographies of syphilis. In his work, Fleck raised awareness about the troubled and troubling effects which occur when two thought collectives communicate and when their objects start to mingle. Much alike his quote above suggests, the emergence of a new entity through communication and mingling is not necessarily connected to the disappearance of the former distinguishable entities through which the thought collectives emerged in the first place.

TB/HIV serves as perfect example for this line of thought. TB/HIV raises a set of new problems and challenges in terms of care, treatment or prevention; just adding TB-practices to HIV-practices won’t solve the crisis that emerged with the linkage of the deadly double, nor will the thinking about TB/HIV as a simple addition of diseases show new ways to conceptualize co-infections. Here, Fleck reminds us that the communication between two thought collectives achieves fundamental alteration intercollectively, namely between the distinct communities and their way of thinking. In other words when thinking together about both diseases or in cross-referencing them through collective research, new epistemologies can emerge. But Fleck also insists on what he calls “intracollective corroboration”, pointing to the fact that the emergence of a new and fundamentally altered entity – TB/HIV – will at the same time strengthen and stabilize the “old” entities within their epistemological habitats. This parallel process of alteration and corroboration is not only at work in the case of TB/HIV. Rather, it can be understood as a fundamental principle of the emergence of all scientific knowledge and their objects of investigation, as Fleck reminds us.  AIDS and TB – as any other disease – were not born as natural entities, but merged at different points in history from fuzzy disease phenomena, only gradually morphing into specific and well defined disease entities. Thus engaging with TB/HIV from an epistemological and interdisciplinary as well as intercollective perspective might improve our understanding of the historical nature of disease entities as such, through the translational process that is communication.

To return to the concrete event of the symposium for a minute with Fleck in mind, we would like to stress that the participant’s communication throughout the two days of intense discussions, added up to something more than “just” new knowledge about the entanglement of distinct disease entities – even if this something has been difficult to pin down, name and process in our debates. Among the developing conversations and interventions was a shared agreement on the need to complexify disease biographies and shift them to an investigation of mingled disease histories and experiences. The cross-referencing of different diseases in documents, lives, and treatment approaches might be a starting point to go along this road, teasing out connections rather than obfuscating them through a categorical focus on single diseases. Another line of investigation focused on trajectories – be it the trajectories of patients navigating ward worlds, of researchers travelling between scientific funding opportunities and research fields, or between doctors, working in different countries and institutions from the hospital to the community clinic and the offices of the global fund. In line with much contemporary anthropological and historical scholarship, the focus on paradoxes, inconsistencies and failures proved to be another avenue of inquiry, opening up interesting perspectives on iatrogenicity, pharmaceuticalization, treatment possibilities and regimes of care, which go beyond problematizations that are possible in following single diseases. And lastly, infrastructures turned out to be essential to an epistemology of co-infection, be the infrastructures financial like the Global Fund, clinical like diagnostic tests, economic like scarcity approaches, or health systemic like access to and provision of care. Hybrid institutional forms of care and treatment provision and financing thereby indicate that not only the entanglement of diseases should be a starting point, but also the mélange of care provision and the functioning of health systems in global health.

We want to conclude by restating that Fleck’s epistemological insight became manifest in different ways during the symposium: firstly, disciplinary boundaries or thought communities – as between history, anthropology, and policy – stayed solid throughout the discussions, albeit not as unbridgeable contradictions or immutable epistemic lenses, but rather as productive tensions and epistemological liaisons, making new questions emerge, and thereby laying the basis for new ways of thinking. Secondly, the “epistemological obstacle” of TB/HIV was transformed in the process of joint investigation and discussion, multiplying what co-infection could and should be as a research object, yet solidifying single disease categories at the same time. Communication lead to the transformation of co-infection as an object of investigation, opening up the black box of the problem, thereby pointing to the many avenues of exploration and problematization instead of providing clear-cut solutions or definitions. As such, the symposium was the beginning of a conversation and of communication as translation, which is to be continued.

 

References

Fleck, L., 1981. Genesis and Development of a Scientific Fact. University of Chicago Press, Chicago.

Kontopodis, M., Niewöhner, J. and Beck, S., 2011. Investigating Emerging Biomedical Practices: Zones of Awkward Engagement on Different Scales. Science, Technology & Human Values 36(5):599 – 615.

Mayer, K.H., Dukes Hamilton, C., 2010. Synergistic Pandemics: Confronting the Global HIV and Tuberculosis Epidemics. Clinical Infectious Diseases 50:67– 70.

Pratt, Mary Louise. 1991. Arts of the Contact Zone. Profession 91: 33- 40.

Treichler, P.A., 1988. AIDS, Homophobia, and Biomedical Discourse: An Epidemic of Signification, in: Crimp, D. (Ed.), AIDS, Cultural Analysis, Cultural Activism. MIT-Press, Cambridge, Mass., 31–70.

 

Janina Kehr studied Anthropology and Political Sciences at the University of Göttingen and the University of California Santa Cruz. She received her PhD in Anthropology from the Ecole des Hautes Etudes en Sciences Sociales Paris and the Humboldt University of Berlin in 2012, with a dissertation entitled “A Disease Without a Future. An Anthropology of Tuberculosis in France and Germany” (2012)”. Since 2011, she works as researcher at the Institute of the History of Medicine in Zurich. Her new project looks at health affects and medical belonging in Europe, in investigating how two national public health systems, the UK in the North and Spain in the South of Europe, have progressively been interiorised by its population and are defended as a right by its citizens in times of crisis, being part of their social and political identity. 

Lukas Engelmann concluded his studies in History and Gender-Studies in Berlin in 2009. He received his PhD in History at the Humboldt University of Berlin in 2013, titled “AIDS as a clinical picture of disease. The normalization of an epidemic in the AIDS atlas” (2013). His dissertation engages with the visual history of AIDS/HIV, contributing to a broader perspective on visualizations in medial history and intervening with an interdisciplinary research design into the emerging field of the historiography of AIDS. From May 2014 on, Lukas Engelmann will be an appointed post-doc research associate at CRASSH, University of Cambridge, following the visual history of the Third Plague Pandemic in North and South America.

 

Image Credit: Cy Twombly UNTITLED II, 2005 (BACCHUS). ACRYLIC ON CANVAS, 317,5 X 468,6 CM

 

TB/HIV: Distinct Histories, Entangled Futures. Towards an Epistemology of Co-infection

A reader’s guide to the “ontological turn” – Part 4 by Annemarie Mol

19 Mars 2014 - 3:27pm

Editor’s note: In the wake of all the discussion about the ‘ontological turn’ at this year’s American Anthropological Association conference, we asked four scholars, “which texts or resources would you recommend to a student or colleague interested in the uses of ‘ontology’ as an analytical category in recent work in anthropology and science and technology studies?”  This was the answer we received from Annemarie Mol, professor of Anthropology of the Body at the University of Amsterdam.  Answers from Judith Farquhar, Javier Lezaun, and Morten Axel Pedersen appear as separate posts in the series.

 

The point of the use of the word ‘ontology’ in STS was that it allowed us not just to talk about the methods that were used in the sciences, but (in relation to these) also address what the sciences made of their object. E.g. rather than asking whether or not some branch of science knows ‘women’ correctly, or instead with some kind of bias, we wanted to shift to the question: what are the topics, the concerns and the questions that knowledge practices insist on; how do they interfere in practices; what do they do to/with women; etc. At first this was cast in constructivist terms as ‘what do various scientific provinces make of women’. But then we began to doubt whether ‘making’ was such a good metaphor, as it gives some ‘maker’ too much credit; as it suggests a time line with a before and an after; and materials out of which x or y might be made. So we shifted terminology and used words like perform, or do, or enact. Here we widened the idea of the staging of social realities (e.g. identities) to that of physical realities.

The idea was that there are not just many ways of knowing ‘an object’, but rather many ways of practising it. Each way of practising stages – performs, does, enacts – a different version of ‘the’ object. Hence, it is not ‘an object’, but more than one. An object multiple. That reality might be multiple goes head on against the Euroamerican tradition in which different people may each have their own perspective on reality, while there is only one reality – singular, coherent, elusive – to have ‘perspectives’ on.  To underline our break with this monorealist heritage of monotheism, we imported the old fashioned philosophical term of ontology and put it in the plural. Ontologies. That was – at the time – an unheard of oxymoron.

Crucial in all this was the work of Donna Haraway (even if she did not particularly use the word ontology). Read it all – or pick out what seems interesting to you. Here, now. But if you don’t quite know where to start, plunge into Primate Visions.

Crucial, too, was earlier STS work on methods that had recast these as techniques of staging a world (not just of objects, but also of tools, money, readers, investors, etc.). Here Bruno Latour, Michel Callon and John Law worked in ways that later fed into the ‘ontology’ stream. See for that particular history: Annemarie Mol, “Actor-Network Theory: Sensitive Terms and Enduring Tensions.”

The branches of STS from which studies into ontology grew, took themselves as shifting the anthropological gaze from ‘the others’ to the sciences, scienced that staged themselves as universal, but weren’t. They were variously situated techno-science practices and making them travel was hard work. “Show me a universal and I will ask how much it costs,” wrote Bruno Latour, (in Irréductions, the second part of The Pasteurisation of France) Hence, going out in the world to study ‘others’ while presuming ‘the West’ (or at least (its) science) was rational, coherent, naturalist, what have you – seemed a bad idea to us. The West could do with some thorough unmasking – and taking this to what many saw as pivotal to its alleged superiority, its truth machines, seemed a good idea (even if a lot later some of the techniques involved were highjacked by climate change deniers… ).

But there were also always specific relevant interventions to be made. For instance, if ontology is not singular and given, the question arises about which reality to ‘do’. Ontology does not precede or escape politics, but has a politics of its own. Not a politics of who (who gets to speak; act; etc.) but a politics of what (what is the reality that takes shape and that various people come to live with?) See: A. Mol, “Ontological politics. A word and some questions,” (in Law & Hassard, Actor Network Theory and After).

For a longer and more extensive opening up of ontologies / realities (in the plural), well, there is my book The body multiple: Ontology in medical practice (Duke University Press 2003) – that lays it all out step by step… Including the difficult aspect of ontological multiplicity that while there is more reality than one, its different versions are variously entangled with one another, so that there are less than many. (As Donna Haraway put it; and as explored by Marilyn Strathern in Partial Connections)

For an earlier use of the term ontological that makes its relevance clear and lays out how realities being done may change over time: Cussins, Charis. “Ontological choreography: Agency through objectification in infertility clinics.” Social studies of science 26, no. 3 (1996): 575-610. Later reworked in Thompson Charis, Making Parents: The Ontological Choreography of Reproductive Technologies.

For an early attempt to differentiate the semiotics involved from the symbolic interactionist tradition and its perspectives see: Mol, Annemarie, and Jessica Mesman. “Neonatal food and the politics of theory: some questions of method.” Social Studies of Science 26, no. 2 (1996): 419-444.

The politics at stake come out very well in Ingunn Moser: “Making Alzheimer’s disease matter. Enacting, interfering and doing politics of nature.” Geoforum 39, no. 1 (2008): 98-110.

And for the haunting question as to what/who acts and/or what/who is enacted, see: Mol, Annemarie, and John Law. “Embodied action, enacted bodies: the example of hypoglycaemia.” Body & Society 10, no. 2-3 (2004): 43-62.

If you like realities as they get tied up with techniques, this is an exciting one, as it multiplies what it is to give birth: Akrich, Madeleine, and Bernike Pasveer. “Multiplying obstetrics: techniques of surveillance and forms of coordination.” Theoretical medicine and bioethics 21, no. 1 (2000): 63-83.

Remember, the multiplicity of reality does not imply its plurality. Here is a great example of that, a study that traces the task of coordinating between different versions of reality in the course of an operation: Moreira, Tiago. “Heterogeneity and coordination of blood pressure in neurosurgery.” Social Studies of Science 36, no. 1 (2006): 69-97.

But if different versions of ‘an object’ may be enacted in practice, this is not to say that they are always fused at some point into ‘an object’ – they may never quite get to hang together. For a good case of that, see: Law, John, and Vicky Singleton. “Object lessons.” Organization 12, no. 3 (2005): 331-355.

And here an obligatory one for anthropologists, as the ‘object’ being studied – and multiplied – is a ‘population’ as defined by genetics in practice: M’charek, Amâde. “Technologies of population: Forensic DNA testing practices and the making of differences and similarities.” Configurations 8, no. 1 (2000): 121-158.

Oh, and I should not forget this troubling of ‘perspectives’ that went beyond realities to also include appreciations: Pols, Jeannette. “Enacting appreciations: beyond the patient perspective.” Health Care Analysis 13, no. 3 (2005): 203-221.

More recently, there was a special issue of Social Studies of Science to do with ontologies. It has a good introduction: Woolgar, Steve, and Javier Lezaun. “The wrong bin bag: A turn to ontology in science and technology studies?.” Social Studies of Science 43, no. 3 (2013): 321-340. In it, you may want to read: Law, John, and Marianne Elisabeth Lien. “Slippery: Field notes in empirical ontology.” Social Studies of Science 43, no. 3 (2013): 363-378.

And if you are still hungry for ontologies, then there is (with the example of eating and with norms explicitly added to ‘onto’): Mol, Annemarie. “Mind your plate! The ontonorms of Dutch dieting.” Social Studies of Science 43, no. 3 (2013): 379-396.

All of which is not to say that I would want to argue for such a thing as a ‘turn to ontology’ in anthropology or anywhere else. In the branch of the social studies of science, technology and medicine that I come from this term, ontology, has served quite specific purposes. It has helped to put some issues and questions on the agenda. But of course, like all terms, it has its limits. For it evokes ‘reality’ better than other things deserving our attention – norms, processes, spatialities, dangers, pleasures: what have you…

 

Annemarie Mol is professor of Anthropology of the Body at the University of Amsterdam. In her work she combines the ethnographic study of practices with the task of shifting our theoretical repertoires. She is author of  The body multiple: Ontology in medical practice and The Logic of Care: Health and the Problem of Patient Choice.

Brain by Nima Bassiri

18 Mars 2014 - 2:00pm

The brain speaks the truth of the self. I imagine it would not be controversial by now to suggest that this general formulation indexes a set of implicit constraints that have to some significant degree underwritten and informed the historical ontology of the modern self since the nineteenth century.

But let me be clear: to assert that the brain speaks the truth of the self is neither to endorse that we really are our brains (that we ever have been, or that we ever will be), nor is it to accept that the neurosciences either already or will at some point access a transcendental reality with regards to who or what we are. It is instead to suggest that the conditions of acceptability have long been met for neurological discourse to function as a system of knowledge capable of possessing a veridical hold on the question of selfhood, on what will comprise the intelligibility of the self, on what will count as true or false in relation to it.

Such an assessment has admittedly come into focus as a consequence of contemporary disputes about the role the brain and the neurosciences can or should play in the determination of personhood. But to say that the brain speaks the truth of the self is not some sort of conciliation for the present. Today’s disputes around the viability of describing personhood in thoroughly neural terms are grounded on a discursive possibility, the medical and epistemological acceptability of which was formalized over a century ago. It has, in other words, once again become necessary to resolve some problem of the self through neuroscientific discourse.

This is, admittedly, not a commonly held position (culturally or academically), and it is often overshadowed by a different sort of inquiry: How do we reckon with a growing tendency that suggests that scientific claims — especially those drawn out of the neurosciences — do a better job than other kinds of claims of telling us who and what we are? This question is indicative of the concern with (or, conversely the affirmation of) the scientistic attitude towards brain research, one that has emerged as neuroscientific claims have been increasingly translated into the terms of cultural value. It is to the rise of this neuro-scientism that much recent scholarship has responded, in the form of a twisting progression of critiques, appropriations, and, eventually, negotiations — a kind of “neurohelix,” as Joseph Dumit has called it.[1] It isn’t necessary to provide a systematic account of these various twists and turns.[2] What even a small sample of them shows is that the relationship between personhood and neuroscience remains an open question, and one that does not amount to a debate on the merits or drawback of neurological reductionism.[3]

What appears so striking is that much of this scholarship finds itself situated somewhere along a continuum of acceptable positions and reactions to the issue of personhood and the brain.[4] At one end of this discursive spectrum, there lies contestation, rejection, or critique, typically directed at the supposed belief (illegitimate for many) that, through the brain, the self is entirely accounted for and elucidated.[5] And at the other end, there lies affirmation or, merely, acquiescence: either a cautious concession that neuroscientific knowledge ultimately has real effects on processes of self-identification and recognition or, on the other hand, a full embrace of the so-called “neuro-turn.” In many instances authors variously deploy both ends of this spectrum at once. What emerges here is the trend towards a renovated materialism or more judicious neo-naturalism. Otherwise we encounter harsh appraisals of the epistemological groundlessness of a set of effects that scholars concede are nevertheless quite real, from an anthropological point of view.

More noteworthy, however, than any possible position one might take is the apparent acceptability of the debate itself. It has become appropriate, even necessary (once again, I will propose) to wonder whether and how neurological discourse can, as a system of knowledge, encapsulate the truth of self and others. The possibility of being a “neural person” is, first and foremost, a discursive possibility. Precisely in the extent to which we feel incited to respond, one way or another (either through rejection or affirmation) to this state of the present, the brain speaks a certain truth of the self.

But in order to understand why such a possibility has come to pass, it is not enough to trace its inevitability across the epistemological and institutional advances of brain research over the past thirty or so years. That is because, despite the fundamental metaphysical (to say nothing of medical) privilege attributed to the brain since the seventeenth-century anatomies of Descartes and Thomas Willis, it would be some time historically before it would become necessary to speak in a certain way, in a way where brain and self could resonate synonymously. It would be some time before neurological knowledge could discursively animate personhood through and through. The question to ask is: why might such a development have occurred, when it might not have otherwise? What, in other words, might have incited a neurologist, a physiologist, or a clinician, to speak in such a way when the need to do so was neither inevitable nor “inscribed in any a priori”?[6]

Let us, for instance, shift our gaze back to the late nineteenth century, the period when brain research came to be organized according to concepts, methodologies, and institutional formations that are still familiar to us today. Beginning in the late 1880s, John Hughlings Jackson, the so-called “father” of clinical neurology and neurophysiology, inaugurated a very peculiar and surprising resolution to the problem of personhood and neuropathology. Rather than correlating mental derangements caused by neurological disease to the various lacunae of personal identity — a decision that would have linked Jackson to a centuries-old view of personhood instituted by another English physician, John Locke — Jackson instead proposed that neuropathological disruptions were the introduction of another, “new” person, which he understood in a legitimately epistemological and forensic sense.[7] A disordered brain was the instantiation of another brain, which, while certainly debilitated, nevertheless retained some semblance of physiological normality; another brain, therefore, meant another self. What would have compelled Jackson to describe the relationship between the brain and self in this way? In other words, why would he have deployed such a level of formalized synonymy that speaking about a brain (normal or pathological) was, in effect, always to speak about some person (whether it be myself or another)?

To begin with, consider the context in which Jackson is writing, in terms of developments within psychiatric and neurological medicine from the 1860s to 1890s. Within the growing interest and discussion of behavioral abnormalities, there was a greater willingness to view the dangers and precariousness of pathology not in the extent to which it opposed normality, but in the extent to which disorders could so easily and in such unsettling ways intersect, overlap, and coincide with normal neural conditions and states of mind. There emerged a prevalent view of the ordinariness and regularity of being reduced to states of automatism, somnambulism, and other “masked” pathological states, where a person would be said to be simultaneously unconscious while acting in ways that appeared entirely rational and socially intelligible. It was not always easy to ascertain according to what mental process or neurological function a person was really herself, and therefore who she might be in a state of derangement. The emergence and apparent intelligibility, not to mention seriousness, of a disorder like double consciousness suggests that medical professionals felt a certain obligation not only to consider the medico-legal significance of these normal abnormalities, but to address, if only implicitly, the more underlying forensic conundrum related to the very status of “personal identity, and its morbid modifications” — to quote the title of a 1862 article by psychiatrist James Crichton-Browne (who was, along with Jackson, one of the founding editors of the journal Brain).

In the late nineteenth century, the very category of personal identity found itself in a state of medical reconsideration, something tantamount to a sort of crisis of the self, at least for anyone committed to a Lockean view of personhood. And this was a crisis indeed. Mary Douglas has argued that Western industrialized-capitalist societies, with their respective “enterprise cultures,” have come to rely on a conception of a singular self, whose claims to unity and self-accountability are, in Lockean fashion, usually tested against forensic standards and juridical constraints.[8] Furthermore, during the historical materializations of fin-de-siècle industrial and modernized life, certain neuropathologies (e.g., neurasthenia, railway spine) were profoundly coupled with the emerging civilizational imperatives of labor power, technological development, and the new political economies and legal demands that came with them.[9]

During the same period, when a unified sense of self was becoming an increasing economic, political, and legal obligation, behavioral medicine witnessed disorders related to personal identity itself – an unhealthy, yet dangerously normal disposition of becoming disunified. As Georg Simmel warned, “The metropolis extracts from man as a discriminating creature a different amount of consciousness than rural life….”[10] Perhaps the extractions of mind are as much a cost as they are, in concert with the knowledge systems that classify and diagnose them, a requisite for entry into the political economies of industrial modernity.

Yet in Jackson’s case, thanks to the language of neurophysiology, illness was not the strict absence of personhood, but its dramatic retention, albeit in the form of the transformation of self. Through Jackson, neurological discourse justified, explained, and provided an entirely new neural architecture to rationalize the dangerously normal disposition of the illness of personal identity. And yet, by rationalizing the disunity of personhood, neurological discourse successfully enshrined the very framework of the modern self, as a classificatory limit that could be expanded and multiplied but not ruptured or undone. In its rationalization, neurological discourse itself became the unity, the singular system of knowledge (or power-knowledge, if you like) that could newly encapsulate and circumscribe selfhood and its possible diffusions.

By the end of the nineteenth century, selfhood became a problem that neurological discourse could frame, stabilize, and resolve, by establishing itself as the knowledge system that could successfully imbue meaning and coherency into the frequent incoherencies of personal identity. The language of brain research established a new truth of the self wherein the presence of personhood would be guaranteed, even in its absence – or, rather, guaranteed because the self could never be neurologically absent as such. The modern self, with its numerous political, economic, and legal imperatives, was always able to fall ill; but now, thanks to neurological discourse, the illness of one self was tantamount to the recuperation of another. Where there is brain, there will always (some) person be.

The work of a robust genealogical reappraisal of “neural personhood” (which this short entry cannot possibly accomplish) would ideally propose that the historical neurologization of self was neither inevitable nor necessary, having had less to do with neurological scientism than with a need to attend to anxieties about personhood. With that in mind, perhaps our concern in the present should not be directed towards the specter of the “neuro.” It might instead be directed at how selfhood is being problematized today, implicitly or otherwise, such that it has become necessary and acceptable (once again) to deploy the discourse of the brain.

 

Nima Bassiri is an ACLS New Faculty Fellow at Duke University and a postdoctoral affiliate of the Duke Center for Interdisciplinary Studies in Science and Cultural Theory. He teaches in the Duke Institute for Brain Sciences, the Program in Literature, and the Department of Philosophy.

[1] Joseph Dumit, “Afterword: Twisting the Neurhelix,” in The Neuroscientific Turn: Transdisciplinarity in the Age of the Brain, eds. Melissa M. Littlefield and Jenell M. Johnson (Ann Arbor, Mich., 2012).

[2] For a discussion of some aspects of these debates, see, Etienne Pelaprat and Valerie Hartouni, “The Neural Subject in Popular Culture and the End of Life,” Configurations 19 (2011): 385–406; see also Neuroscientific Turn and also Victoria Pitts-Taylor, “The Plastic Brain: Neoliberalism and the Neuronal Self,” Health 14, no. 6 (2010): 635-52.

[3] Some examples include: Fernando Vidal, “Brainhood, Anthropological Figure of Modernity,” History of the Human Sciences 22, no. 1 (2009): 5-36. Nikolas Rose and Joelle M. Abi-Rached, Neuro: The New Brain Sciences and the Management of the Mind (Princeton: Princeton University Press, 2013); Nikolas Rose, “Neurochemical Selves” in The Politics of Life Itself (Princeton: Princeton University Press, 2007). Elizabeth Wilson, “Melancholic Biology: Prozac, Freud, and Neurological Determinism,” Configurations 7, no. 3 (1999): 403-19. William E. Connolly, Neuropolitics: Thinking, Culture, Speed (University of Minnesota Press, 2002). Emily Martin, “Self-making and the Brain,” Subjectivity 3, no. 4 (2010): 366-381; Rayna Rapp, “A Child Surrounds this Brain: The Future of Neurological Difference According to Scientists, Parents and Diagnosed Adults,” in Sociological Reflections on the Neurosciences, eds. Martyn Pickersgill and Ira Van Keulen (Emerald, 2012). Margaret Lock, The Alzheimer’s Conundrum: Entanglements of Dementia and Aging (Princeton University Press, 2013). Catherine Malabou, The New Wounded: From Neurosis to Brain Damage, trans. Steven Miller (New York: Fordham University Press, 2012); and Adrian Johnston and Catherine Malabou, Self and Emotional Life: Philosophy, Psychoanalysis, and Neuroscience (New York: Columbia University Press, 2013). Malabou presents a philosophical orientation towards neuroscience that can be contrasted with the sort presented, for example, by Patricia Churchland, most recently in Touching a Nerve: The Self as Brain (New York: Norton, 2013).

[4] It will become clear in the remainder of this essay why I am using “person” and “self” interchangeably, that is, according to a Lockean tradition. For more on Locke’s conception of self/person and the role Locke plays in the development of the notion of the “subject” as we come to understand it after Kant, see Etienne Balibar, Identity and Difference: John Locke and the Invention of Consciousness, trans. Warren Montag (New York: Verso, 2013).

[5] See for example, Critical Neuroscience: A Handbook of the Social and Cultural Contexts of Neuroscience, ed. Suparna Choudhury and Jan Slaby (Oxford, 2012).

[6] Michel Foucault, “What is Critique?” in The Politics of Truth, ed. Sylvère Lotringer (Los Angeles: Semiotext(e), 2007), 62.

[7] See, for example, John Hughlings Jackson, “On Post-Epileptic States” and “The Factors of Insanities,” in Selected Writings of John Hughlings Jackson, 2 vols., ed. James Taylor (London, 1958).

[8] Mary Douglas, “The person in an enterprise culture,” in Understanding the Enterprise Culture: Themes in the Work of Mary Douglas, eds. Shaun Hargreaves Heap and Angus Ross (Edinburgh University Press, 1992).

[9] Anson Rabinbach, Human Motor: Energy Fatigue, and the Origins of Modernity (University of California Press, 1992), chapter 6; Wolfgang Schivelbusch, The Railway Journey: The Industrialization of Time and Space in the 19th Century (University of California Press, 1987).

[10] Georg Simmel, “The Metropolis and Mental Life,” in The Sociology of Georg Simmel, ed. Kurt H. Wolff (London: Free Press, 1950). Quoted in Human Motor, 154.

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