University of California Press, 2014, 288 pages.
Exploring the political entailments of rehabilitating “victims of human trafficking” in Italy, Migrants in Translation speaks to the often puzzling disjuncture between recent anthropological and public discourses concerning migrant care and integration: while anthropology’s critiques have led, among social scientists, to a heightened analytic caution or else abandonment of “culture” for its potential to racialize, reify, and de-politicize experiences of suffering, “culture” has conversely found a flourishing after-life in various public domains (most visibly in sensitivity and competency frameworks, and in cultural diversity promotion policies, as well as the backlash against them). Charting new territory, Migrants in Translation critically engages with both the critique and the embrace of the “cultural” register by exploring how Italian ethno-psychiatrists in Turin’s Centro Fanon mediate between migrants, social institutions of rehabilitation, and Italy’s Turco-Napolitano Law which grants legal status to undocumented foreign sex workers as “victims” of global trafficking. Revealing how various social practices of translation make migrant sex workers intelligible to the state’s rehabilitation mission (or not), Giordano aims to interrogate what she terms a “politics of recognition” which reduces migrant difference and suffering to the diagnostic language of recovery. Drawing on Rancière, she sees in ethno-psychiatric practice a promising new modality of both politics and therapy—that of an “acknowledgment” which suspends diagnosis and “listens” to suffering.
Chapter 1 explores the translational work of ethno-psychiatry in the context of consultations between ethno-psychiatrists and three Nigerian patients at the Centro Fanon. In its various iterations, ethno-psychiatry is characterized by both a set of shared principles and local specificities. The first ethno-psychiatric clinic opened in 1979 in the outskirts of Paris under the direction of psychoanalyst Tobie Nathan who argued for the structuring, therapeutic, and womb-like significance of “culture” for migrant patients. In its broadest sense, ethno-psychiatry thus emphasizes the importance of encouraging migrant contact with “cultural material” (p.43) throughout the therapeutic process. In this vein, Centro Fanon ethno-psychiatrists could advise their Nigerian patients to practice devotion to the goddess Mami Wata, visit African art exhibitions, and engage with African literature as part of their therapy. While Giordano adeptly acknowledges current anthropological critiques of such culturalizing practices, she demonstrates how Italian ethno-psychiatrists worked to complicate Nathan’s original (and often-criticized) framework. While Giordano concedes that invoking “cultural material” risks reifying, stigmatizing, and exoticizing difference, diverting analysis from the political dimensions of migrant suffering, she makes a nuanced case for turning anthropological critiques of culture “upside down” (p.67). In her analysis, Italian ethno-psychiatrists treat culture as a “floating signifier” (p.68)—a “reification without mummification” which is essential to a dynamic framework of care. For Giordano, ethno-psychiatry’s invocation of “culture” enables a plurality of therapeutic strategies and invites rather than forecloses attention to the political aspects of suffering.
In Chapter 2, Giordano historicizes ethno-psychiatry’s framework of care. In Italy, this history includes the intellectual and clinical legacy of Franco Basaglia, leader of Italy’s democratic psychiatry movement, who actively critiqued the “institution” and its hegemonic practices of diagnosis. Religious historian, philosopher, and ethnographer, Ernesto de Martino is another guiding figure; his work validated religion and ritual practice as keys to the social re-integration of psychiatric patients. For Centro founder and clinician, Roberto Beneduce, Frantz Fanon—whose importance is foregrounded in the Centro’s name—remains a formative figure. Centro staff contextualize their practice within conditions of (post)coloniality, drawing direct parallels between the colonial situation and the lives of foreigners in present-day Italy, while striving to marry therapy with political engagement.
Chapter 3 describes the mediating and advisory role of ethno-psychiatrists vis-à-vis other agents of migrant rehabilitation—government officials, bureaucrats, Catholic nuns, and social workers. For Giordano, ethno-psychiatrists are “cultural experts” (p.106) often engaged in critically confronting the ambivalently inclusive residency regimes and rehabilitation practices of a “therapeutic state” which exchanges stories of victimhood for legal status. Citing the influence of international rights discourses which frame sex work according to narratives of human trafficking and modern slavery, Giordano reveals that ethno-psychiatry is often marginal in its radical critique of current psychiatric, legal, and moral regimes of national inclusion. With critical acuity, she discusses the limits of dichotomizing migrant sex workers as either trafficked “victims” or agents complicit in exploitation while addressing the often failed promise of a legal recognition which leaves women’s conditions of social and economic precarity unchanged.
Institutional practices of denuncia are explored in depth in Chapter 4. For the Nigerian and Eastern European sex workers which Giordano encounters, denuncia constitutes the first step in “rehabilitation.” It entails providing legal testimony against one’s traffickers by narrating one’s victimization. Giordano explores denuncia as a testimonial genre and translational regime through which migrant women are “verbalized” (p.138), their fragmented narratives rendered into stable institutional texts used to verify their victim status. Giordano underscores how institutional agents involved in crafting the denuncia as text—cultural mediators, the police, interpreters—must ventriloquize women’s accounts to produce stories which are intelligible to the state and its rehabilitating optic. In “distilling” the voice of the victim, this bureaucratic genre thus renders untranslatable notions of choice and agency in sex work. Giordano problematizes this paradoxical logic of what she terms “confessional recognition” (p.144) which makes residency conditional upon a limited (and limiting) genre of self-disclosure.
Giordano sustains an engagement with paradox in Chapter 5, which addresses the contradictions of migrant rehabilitation in a women’s shelter operated by Catholic nuns. As with practices of denuncia, the conditions of shelter-life place migrant women on an idealized trajectory of escape from exploitation, re-socialization, and social re-integration. Giordano illustrates how shelters constitute transitional and liminal sites of pedagogy where sex workers undergo transformation from “victims” into socially acceptable subjects according to both religious and secular logics of redemption and purification. A key insight of the chapter is that the Catholic logics of shelter-life are consonant with the state’s criteria for successful migrant integration—both render difference into the redemptive imperative of recovery. Nuns working with foreign women are thus engaged in translating their own religious mission, and its universalist logics of conversion, into a secular politics which must relativize alternative “spiritualities.” In foregrounding this contradiction, Giordano demonstrates how Catholic nuns ultimately reproduce Italy’s mainstream politics of recognition through the hierarchical ordering of spiritual practices: while nuns characterize African spirituality as “fertile terrain” (p.194) for its linkages, through missionization, to Christianity (where even “magical” beliefs provide a translational entryway for the Catholic ethos), they characterize Eastern European women as less spiritually malleable, proof of communism’s ostensible legacy of “amorality.”
In a final chapter, Giordano highlights the often irrevocable consequences of migrant translation through the case of Afërdita, an Albanian shelter-resident whose children are placed in foster care after she is hospitalized following a diagnosis of depressive “acute psychosis.” Giordano centers on Afërdita’s struggle to maneuver the various institutional and bureaucratic translations which evaluate her fitness to mother and thus condition her relationship to her children. The social workers, nuns, doctors, and child psychologists overseeing her rehabilitation translate her suffering according to the urgent and diagnostic temporality of finding a “cure”—the imperative that Afërdita quickly re-establish autonomy and regularize her employment and residency. Giordano contrasts “curing” with ethno-psychiatry’s quite opposite temporality of “caring.” “Caring” not only suspends diagnosis, but aims to acknowledge suffering through a “listening” which enables multiple and often disruptive temporalities to co-exist—that of dreams, mourning, melancholia, and repetition. While the ethno-psychiatric mediation of Afërdita’s case provides a potentially radical critique of the state and its unrelenting trajectories of recovery, this chapter reflects on the marginality of “care” within current regimes of migrant translation, and the ultimately tragic consequences for those caught in the state’s bureaucratic webs of meaning.
As a timely and thematically rich reflection on the constraints and possibilities of a culturally sensitive therapeutic practice, Migrants in Translation adeptly explores how a constellation of scenes and sites converge upon a shared state project of migrant integration, and how ethno-psychiatry attempts—in its own translations—to mediate these. With nuance and appreciation for the dilemmas of socially engaged clinical work, Giordano positions ethno-psychiatry as both a key node inside this constellation of care, as well as a site of critical engagement within it. While this text might still further elucidate some of the internal differences between the Centro’s various ethno-psychiatrists (who often followed quite different professional trajectories) and thus complexify what it means to practice “ethno-psychiatry” itself, Giordano’s multi-sited account ultimately incites a series of important reflections. While questioning the distinction between religious and secular logics of migrant rehabilitation, she offers new and valuable insight into how “cultural expertise” not only confronts (inter)national regimes of immigration and mobility, but how it hits the ground in situated and everyday practices of mediation. Perhaps most essentially, Migrants in Translation clears new terrain for understanding how talk of “cultural” difference—rightly the site of caution—might actually destabilize a dominant politics of recognition, both within and beyond the consultation room.
Shirley Yeung is a PhD Candidate in Anthropology at the University of Chicago. Her current research is exploring policies, practices, and ideologies of migrant social integration at various sites of adult education in Geneva, Switzerland.
For those of you who think that time is moving too quickly this holiday season, welcome back to November! Here is the belated second “In the Journals” post for November 2014. Enjoy!
This article considers how anthropologists and other social scientists examine biosecurity as an object in the making. It suggests that scholars encountered this object in research projects concerned with questions of global health, capitalism, neoliberalism, humanitarianism, citizenship, science, medicine, technology, ecology, surveillance, and risk. This growing body of work explores emerging modes of government that are characteristic for the post–Cold War period of global capitalism. Ethnographic accounts demonstrate how actors and institutions located in the Global North and the Global South perceive the spread of dangerous biological things as a threat to the health of individuals and populations. This article aims to review this literature and supplement the current approach with a theory of security performativity.
This review examines the emerging concept of “Native American DNA” utilized by genetic scientists and anthropologists to denote a connection via nucleotide bases between ancient and contemporary peoples of the Americas. This concept is problematic on conceptual and practical levels; this review highlights its use in various disciplines, focusing on ongoing disputes about its meaning and applicability and concluding with a call to attention for all who utilize such concepts. The ethical, legal, and social implications of Native American DNA have to be taken into account because the label itself is still under construction: Contemporary Native American peoples should not be confounded with the past or ancestral remains, but instead must actively be brought into research conversations at all stages.
Tine M. Gammeltoft and Ayo Walberg
From a historical perspective, selective reproduction is nothing new. Infanticide, abandonment, and selective neglect of children have a long history, and the widespread deployment of sterilization and forced abortion in the twentieth century has been well documented. Yet in recent decades selective reproduction has been placed under the aegis of science and expertise in novel ways. New laboratory and clinical techniques allow for the selective fertilization of gametes, implantation of embryos, or abortion of fetuses. Although they will often overlap with assisted reproductive technologies (ARTs), what we term selective reproductive technologies (SRTs) are of a more specific nature: Rather than aiming to overcome infertility, they are used to prevent or allow the birth of certain kinds of children. This review highlights anthropological research into SRTs in different parts of the world, discussing how selective reproduction engages with issues of long-standing theoretical concern in anthropology, such as politics, kinship, gender, religion, globalization, and inequality.
This review traces anthropological studies of humanitarianism starting in the late 1980s, when humanitarianism began to take shape as a particular moral and political project through the formation of transnational nongovernmental organizations (NGOs). It follows both the evolving relationship of anthropologists to humanitarianism—initially as allies, then as critics, alternately embracing and challenging their conjoined humanist legacy—and the growing field of the anthropology of humanitarianism.
Risk and resilience research articulates major explanatory frameworks regarding the persistence of health disparities. Specifically, scholars have advocated a sophisticated knowledge of risk, a more grounded understanding of resilience, and comprehensive and meaningful measurements of risk and resilience pathways across cultures. The goal is to operationalize research issues into sustainable health practice and equity-focused policy. This article synthesizes current understandings on risk and resilience from the lens of medical anthropology: It reviews key insights gained from the standpoint of cultural narratives, political economy, and life history theory, as well as current shortcomings. The emergent literature on health-related risk and resilience is breathing new life into collaboration and dialogue across diverse fields of research and policy.
Note the special section on global mental health, edited by Laurence J. Kirmayer and Duncan Pederson. For a Somatosphere post on the special section, see http://somatosphere.net/?p=9539.
The iconography of the African AIDS orphan, captured in National Geographic– style images of half-starved toddlers with distended bellies, inspires humanitarian aid for the continent. In Botswana, stereotypes underlying both foreign-funded and governmental programs for orphaned children—which imply that orphans are underfed and underloved—initially resonated with Tswana people’s anxieties that neglect by overburdened kin results in parentless children going hungry. However, during the past decade international feeding projects began to evolve into elaborate day-care complexes in which village orphans gained exclusive access to swimming pools, DVDs, trendy clothing, and daily meat rations. This article traces the shifting moral semiotics of orphans‘ fat and skinny bodies, explaining why new discourses protesting the over-fattening of orphans arose in a southeastern village. Metaphors of fat and feeding have become a scale on which the excesses of humanitarian aid and the perceived shortcomings of local kinship practices are weighed. A new kind of “politics of the belly“ calls into question relations of patronage around metaphors of fleshiness and dependence on foreign support. In the process, contestations over children’s skinny and fat bodies lead to reconfigurations of the idea of orphanhood.
Claudia Marcela Vargas-Peláez, Marina Rajiche Mattozo Rover, Silvana Nair Leite, Francisco Rossi Buenaventura, Mareni Rocha Farias
Despite countries’ efforts to ensure access to essential medicines, some people do not have their needs met, and often resort to the Judiciary to get access to the medicines they need. This phenomenon, known as “judicialization of access to medicines”, has aroused the academia’s interest in law, health and social fields. In this context, this scoping study investigates, through qualitative thematic analysis, the approach to judicialization of access to medicines (normative or social) and its possible impacts (positive or negative) described in articles published in scientific journals indexed in the main health databases prior to July 2012. 65 of 384 papers met the inclusion criteria of focusing on lawsuits for access to medicines or judicialization of access to medicines as a phenomenon; empiric studies, review articles or theoretical discussions, written in English, Portuguese or Spanish; most of them were about Brazil, Colombia and England. Results show that judicialization is a complex phenomenon that involves technical-scientific, legal and social aspects. The judicialization impacts mentioned have changed over time. In the late 1990s and early 2000s the emphasis of positive impacts predominated both on the normative and social approaches, having as main reference the movements that claimed from the States the guarantee of access to HIV/AIDS treatment. In the mid-2000s, however, there was an emphasis of the negative effects of judicial intervention, when lawsuits for access to medicines became a problem in some countries. Few studies used the social approach to judicialization. For this reason, there is not enough information about whether lawsuits for access to medicines are related to a real recognition of the right to health as an exercise of citizenship. Such aspects need to be further studied.
Femke Verduin, Geert E. Smid, Tim R. Wind, and Willem F. Scholte
To date, reviews show inconclusive results on the association between social capital and mental health. Evidence that social capital can intentionally be promoted is also scarce. Promotion of social capital may impact post-conflict recovery through both increased social cohesion and better mental health. However, studies on community interventions and social capital have mostly relied on cross-sectional study designs. We present a longitudinal study in Rwanda on the effect on social capital and mental health of sociotherapy, a community-based psychosocial group intervention consisting of fifteen weekly group sessions. We hypothesized that the intervention would impact social capital and, as a result of that, mental health. We used a quasi-experimental study design with measurement points pre- and post-intervention and at eight months follow-up (2007–2008). Considering sex and living situation, we selected 100 adults for our experimental group. We formed a control group of 100 respondents with similar symptom score distribution, age, and sex from a random community sample in the same region. Mental health was assessed by use of the Self Reporting Questionnaire, and social capital through a locally adapted version of the short Adapted Social Capital Assessment Tool. It measures three elements of social capital: cognitive social capital, support, and civic participation. Latent growth models were used to examine whether effects of sociotherapy on mental health and social capital were related. Civic participation increased with 7% in the intervention group versus 2% in controls; mental health improved with 10% versus 5% (both: p < 0.001). Linear changes over time were not significantly correlated. Support and cognitive social capital did not show consistent changes. These findings hint at the possibility to foster social capital and simultaneously impact mental health. Further identification of pathways of influence may contribute to the designing of psychosocial interventions that effectively promote recovery in war-affected populations.
Nicole Au and David W. Johnston
Self-assessed general health (SAH) is one of the most frequently employed health measures in social science research. Its generic nature means it captures elements of health that more guided measures cannot, and its brevity makes it possible for health information to be included in crowded multifaceted surveys. However, a shortcoming of SAH is that it provides little guidance to researchers as to what individuals are thinking of when they assess their health – when a survey respondent reports that their health is “poor”, is it because they are in pain, tired, depressed, unable to climb stairs, or something else entirely? This limits the possible inference from empirical research. It also means that important determinants and consequences of health can be missed if they are only weakly reflected in SAH. Given the continued use of SAH, it is important to better understand its structure. In this paper we use household panel data from Australia to answer two related questions: (i) what components of health does SAH most strongly represent? and (ii) does the use of SAH conceal important health effects? To answer the first question, we use a detailed health instrument and take a rigorous econometric approach to identify the health dimensions most strongly reflected in SAH. To answer the second question, we estimate the causal effects of income on SAH and on disaggregated health measures using instrumental-variables models. We find that some health dimensions – especially vitality – are consistently important to an individual when they assess their health, while other dimensions are inconsequential. We demonstrate that this fact provides insight in to why some studies find weak income gradients in SAH. Instrumental-variable regression results show that shocks to household income have no effect on SAH, but strongly improve several dimensions of health that are less commonly measured.
Neil Spicer, Dipankar Bhattackarya, Ritgak Dimka, Felenke Fanta, Lindsay Mangham-Jefferies, Joanna Schellenberg, Addis Tamire-Woldermariam, Gill Walt, Deepthi Wickremasinghe
Donors and other development partners commonly introduce innovative practices and technologies to improve health in low and middle income countries. Yet many innovations that are effective in improving health and survival are slow to be translated into policy and implemented at scale. Understanding the factors influencing scale-up is important. We conducted a qualitative study involving 150 semi-structured interviews with government, development partners, civil society organisations and externally funded implementers, professional associations and academic institutions in 2012/13 to explore scale-up of innovative interventions targeting mothers and newborns in Ethiopia, the Indian state of Uttar Pradesh and the six states of northeast Nigeria, which are settings with high burdens of maternal and neonatal mortality. Interviews were analysed using a common analytic framework developed for cross-country comparison and themes were coded using Nvivo. We found that programme implementers across the three settings require multiple steps to catalyse scale-up. Advocating for government to adopt and finance health innovations requires: designing scalable innovations; embedding scale-up in programme design and allocating time and resources; building implementer capacity to catalyse scale-up; adopting effective approaches to advocacy; presenting strong evidence to support government decision making; involving government in programme design; invoking policy champions and networks; strengthening harmonisation among external programmes; aligning innovations with health systems and priorities. Other steps include: supporting government to develop policies and programmes and strengthening health systems and staff; promoting community uptake by involving media, community leaders, mobilisation teams and role models. We conclude that scale-up has no magic bullet solution – implementers must embrace multiple activities, and require substantial support from donors and governments in doing so.
Jinhu Li, Anthony Scott, Matthew McGrail, John Humphreys, and Julia Witt
Many governments have implemented incentive programs to improve the retention of doctors in rural areas despite a lack of evidence of their effectiveness. This study examines rural general practitioners’ (GPs’) preferences for different types of retention incentive policies using a discrete choice experiment (DCE). In 2009, the DCE was administered to a group of 1720 rural GPs as part of the “Medicine in Australia: Balancing Employment and Life (MABEL)” study. We estimate both a mixed logit model and a generalized multinomial logit model to account for different types of unobserved differences in GPs’ preferences. Our results indicate that increased level of locum relief incentive, retention payments and rural skills loading leads to an increase in the probability of attracting GPs to stay in rural practice. The locum relief incentive is ranked as the most effective, followed by the retention payments and rural skills loading payments. These findings are important in helping to tailor retention policies to those that are most effective.
In light of its influence on food preferences, purchase requests and consumption patterns, food marketing—particularly for unhealthy foods—has been increasingly recognized as a problem that affects the health of young people. This has prompted both a scrutiny of the nutritional quality of food products and various interventions to promote healthy eating. Frequently overlooked by the public health community, however, is the symbolic and social meaning of food for teenagers. Food has nutritive value, but it has symbolic value as well—and this qualitative study explores the meaning of non-branded foods for teenagers. Inspired by the construct of brand personality, we conduct focus groups with 12–14 year olds in to probe their perspectives on the “food personalities” of unbranded/commodity products and categories of food. Despite the lack of targeted marketing/promotional campaigns for the foods discussed, the focus groups found a remarkable consensus regarding the characteristics and qualities of foods for young people. Teenagers stigmatize particular foods (such as broccoli) and valorize others (such as junk food), although their discussions equally reveal the need to consider questions beyond that of social positioning/social status. We suggest that public health initiatives need to focus greater attention on the symbolic aspects of food, since a focus on nutritional qualities does not unveil the other significant factors that may make foods appealing, or distasteful, to young people.
Peter Conrad and Meredith R. Bergey
Attention Deficit Hyperactivity Disorder (ADHD) has been medicalized in the United States since the 1960s. Primarily used in North America until the 1990s, ADHD diagnosis and treatment have increasingly been applied internationally. After documenting the expansion of ADHD in a global context, this paper presents five brief international examples examining ADHD usage and expansion: the United Kingdom, Germany, France, Italy and Brazil. We then identify and describe several vehicles that facilitate the migration of the ADHD diagnosis: the transnational pharmaceutical industry; the influence of western psychiatry; moving from ICD to DSM diagnostic criteria; the role of the Internet including the related advent of easily accessible online screening checklists; and advocacy groups. Finally, we discuss what this globalization of a diagnosis reflects about the potential global medicalization of other conditions.
Paige L. Sweet
Diagnostic categories for domestic violence have shifted over time, transforming from a disorder of psychological passivity and acute injury into a chronic and somatically invasive condition. This paper links these changing diagnoses to constructions of the abused body and to victim-blaming narratives. Based on an analysis of medical journal articles, this research identifies two logics that undergird domestic violence diagnoses, the body, and victim-blaming: 1) the logic of injury (1970s–1980s); and 2) the logic of health (late 1980s–present). The logic of injury is associated with overt victim-blaming, a temporally bounded and injured body, and psychological passivity. Once the feminist anti-violence movement gained mainstream credibility, however, the logic of injury fell out of favor as an explanation for domestic violence. What surfaced next was the logic of health, which is associated with chronic diagnoses and what the author calls a temporally extended body. The temporally extended body is flexible and layered, linking up past, present, and future states of disordered embodiment. The author suggests that, rather than ushering in hope and possibility via the logic of health’s somatic flexibility, this abused body creates spaces into which new forms of blame and self-responsibility can take shape.
Aunchalee E.L. Palmquist and Kirsten Doehler
Women in the U.S. face significant structural constraints in attempting to breastfeed as recommended in the first six months of their child’s life. Internet-facilitated human milk sharing is an emergent response to breastfeeding challenges. Little is known about the demographic characteristics of milk sharing donors and recipients and the ways structural factors circumscribe the biocultural context of lactation in milk sharing practices. Data regarding demographic characteristics, reproductive history, lactation history, and levels of social support and health care provider support for breastfeeding were collected via an online survey September 2013–March 2014. Statistical tests were executed to ascertain whether significant differences exist between donors and recipients. A total of 867 respondents (661 donors, 206 recipients) met the eligibility criteria for the study. Respondents were U.S. residents and primarily White, middle-class, well educated, and employed women. Both donors and recipients reported higher than the national average for household income, maternal educational attainment, breastfeeding exclusivity 0–6 months, and breastfeeding duration. Differences in lactation sufficiency and breastfeeding outcomes between donors and recipients were associated with both structural and biocultural factors. Donors reported significantly higher income, education, and support for breastfeeding from spouse/partner, other family, employers, and pediatricians. Donors also reported significantly higher rates of full term birth for child of most recent lactation. This study provides a foundation for understanding how milk sharing reflects a broader political economy of breastfeeding in the U.S.
Since the turn of the millennium, the major development agencies have been promoting “knowledge for development,” “ICT for development,” or the “knowledge economy” as new paradigms to prompt development in less-developed countries. These paradigms display an unconditional trust in the power of Western technology and scientific knowledge to trigger development—they taste of epistemic and technological determinism. This article probes, by means of a genealogy, how and when development cooperation began adhering to epistemic and technological determinism, and which forms this adhesion has taken over time. The genealogy shows, first, that knowledge and technology have always been integrally part of the very “development” idea since this idea was shaped during enlightenment. Second, while the genealogy reveals that epistemic and technological determinism were embedded in the development idea from the very beginning, it also illustrates that the determinism has always been challenged by critical voices.
Raoni Rajão and Ricardo B. Duque
This article examines the foundation myths of Brazil in the last two centuries, paying particular attention to the relationship between these myths and governmental attitudes toward the hybridity of Northern and Southern ethnic and technoscientific entities. Based upon this examination, the article argues that it is important to consider both the wider temporal frames and the shifts and sedimentations that have formed current foundation myths and shaped their relation to science and technology. Postcolonial science technology studies theories illuminate aspects of this trajectory, but our analysis suggests a more complex scenario that involves internal political dynamics and the work of local intellectuals. We argue that the example of Brazilian social scientists should encourage scholars to go beyond the current focus on breaking the myths of technoscience and undertake mythmaking initiatives with wider societal resonances.
Ryan E. Lawrence, Kenneth A. Rasinski, John D. Yoon, and Farr A. Curlin
Background: Recent decades have witnessed some integration of mental health care and religious resources.
Aim: We measured primary care physicians’ (PCPs) and psychiatrists’ knowledge of religious mental health-care providers, and their willingness to refer there.
Methods: A national survey of PCPs and psychiatrists was conducted, using vignettes of depressed and anxious patients. Vignettes included Christian or Jewish patients, who regularly or rarely attended services. We asked whether physicians knew of local religious mental health providers, and whether they would refer patients there.
Results: In all, 896/1427 PCPs and 312/487 psychiatrists responded. Half of PCPs (34.1%–44.1%) and psychiatrists (51.4%–56.3%) knew Christian providers; fewer PCPs (8.5%–9.9%) and psychiatrists (15.8%–19.6%) knew Jewish providers. Predictors included the following: patients were Christian (odds ratio (OR) = 2.2–2.9 for PCPs, 2.3–2.4 for psychiatrists), respondents were Christian (OR = 2.1–9.3 for PCPs) and respondents frequently attend services (OR = 3.5–7.0 for PCPs). Two-thirds of PCPs (63.3%–64%) and psychiatrists (48.8%–52.6%) would refer to religious providers. Predictors included the following: patients regularly attend services OR = 1.2 for PCPs, 1.6 for Psychiatrists, depression vignette only), respondents were Christian (OR = 2.8–18.1 for PCPs, 2.3–9.2 for psychiatrists) and respondents frequently attend services (OR = 5.1–6.3 for PCPs).
Conclusion: Many physicians would refer patients to religious mental health providers. However, less religious PCPs are less knowledgeable about local religious providers.
Yanhong Gong, Xiulan Zhang, Hong Zou, Donghua Tian, Zhiyong Qu, Weijun Zhang, Yongqiang Chu
Background: With the rapid development of economy, depression disorder is not only a public health issue but also a socioeconomic problem and attracting more and more attention in China.
Aims: The target of this study is to examine the prevalence of depression and the related risk factors in the Dibao population in northwestern China.
Method: A cross-sectional analysis in a random sample survey conducted in three northwestern Chinese cities in 2007. The data from 4459 respondents with completed Center for Epidemiological Studies–Depression (CES-D) scales were evaluated to explore the key risk factors for depression. Using depression as a binary variable according to the cutoff of the CES-D score and then as a continuous variable, multiple logistic and line regression analysis were performed to compare the odds ratio and the weight of different risk factors for depression.
Results: The prevalence of depression in non-Dibao population was 34.7% but that in the Dibao population was 50.0% (p < .001). After adjusting for important confounders, Dibao population had an odds ratio (OR) of 1.38 (95% confidence interval (CI): 1.16–1.63) to have possible depression compared to those non-Dibao people. Furthermore, depression was associated with a higher OR of indebtedness (OR: 1.59, 95% CI: 1.31–1.93), and a small amount of debt would increase the possibility of depression for Dibao people (OR: 1.69, 95% CI: 1.28–2.23). In addition, gender, body mass index (BMI), tobacco use and social network were also important risk factors for depression in the Dibao population. Using depression as a continuous variable, being a member of the Dibao population and being indebted will add 2.06 and 1.83 to the CES-D score, respectively, compared with the non-Dibao population and not being indebted. A comparison of the odds ratios of depression between the Dibao and the non-Dibao population showed that factors such as gender, BMI, tobacco use, social network and indebtedness were statistically significant in the Dibao population but were not statistically significant in the non-Dibao population. Additionally, having a savings account was statistically significant in the non-Dibao population but not in the Dibao population.
Conclusions: It was not surprising, as proved by other studies, that gender, obesity and social network were risk factors associated with depression in the Dibao population. Our findings indicated that a small amount of indebtedness was also closely related to depression in the Dibao population.
Munevver Hacioglu Yildrim, Zeynep Alantar, and Ejder A. Yildirim
Background: Schizophrenia is a severe mental disorder with substantial socioeconomic burden associated with poorer psychosocial functioning during the course of illness. In schizophrenia patients, multiple factors play a role in occupational functioning.
Aim: It was aimed to investigate the relationship between different working conditions and quality of life and self-esteem on patients with schizophrenia in Turkey.
Methods: A total of 100 patients diagnosed as schizophrenic were divided into three groups: competitive working, supported working and unemployed.
Results: The groups did not differ significantly with regard to psychotic symptoms, self-esteem and illness history. Working was associated with higher scores on quality of life subscales especially in supported working group, whereas unemployed patients had more depressive symptoms and autonomic drug side effects.
Conclusion: Structured working programs which may improve social life of patients with schizophrenia in many aspects is warranted in Turkey.
Ahmed M. Abdel-Khalek
Background: Several studies have revealed positive associations between religiosity, health and happiness. However, the vast majority of these studies were carried out on native English-speaking participants.
Aims: The objective of this study was to estimate the relations between religiosity, health and happiness among a sample (N = 372) of Qatari adolescents (M age = 15.2).
Method: The students responded to five self-rating scales to assess religiosity, mental health, physical health, happiness and satisfaction with life.
Results: Boys obtained a higher mean score on mental health than did their female counterparts. All the correlations between the rating scales were significant and positive. Principal component analysis disclosed one component and labelled ‘Religiosity, health and happiness’ in both sexes. The multiple stepwise regression indicated that the predictors of religiosity were the self-ratings of satisfaction with life and happiness in boys, whereas the predictors among girls were satisfaction with life and physical health.
Conclusions: On the basis of the responses of the present sample, it was concluded that those who consider themselves as religious were more happy, satisfied with their life and healthy.
Prabha S. Chandra, Padmavathy Doraiswamy, Anuroopa Padmanabh, and Mariamma Philip
Background: Several countries have prescribed standard guidelines for media professionals on suicide reporting. However, the implementation of these guidelines has been varied. Suicide rates in South Asia are one of the highest in the world, and it is known that media guidelines for suicide reporting are not followed adequately. However, there are no published reports available from this region.
Aim: This study aimed at assessing newspaper reports of suicide for quality of reporting based on standard reporting guidelines and to study differences between English and vernacular (Kannada) newspapers in Bangalore, South India.
Methods: A total of 341 newspaper reports of suicide from 550 newspapers (3 English and 3 Kannada) over 3 months were systematically assessed for compliance with reporting guidelines. Each report was evaluated on 2 domains and 36 parameters. Data were analyzed for frequency of inappropriate reporting and patterns compared between vernacular and English newspapers.
Results: In all, 87% of the reports were those of completed suicide. Non-compliant reporting – method of suicide was reported in 89% and 32% of reports were in prominent pages of the newspaper, 95% mentioned gender, 90% reported the name, 80% reported age and suicide location, 75% reported life events related to suicide, 70% reported occupation, 69% had headline explicity on suicide and 61% reported monocausality. Only 16% reported mental disorder related to suicide, and less than 3% included information on suicide prevention and helplines. Vernacular papers showed significantly better compliance in 16 of the 20 areas. However, protective characteristics were better reported in English newspapers.
Conclusion: Majority of reports on suicides in newspapers from Bangalore did not comply with standard guidelines of reporting. There is a strong need to evolve local guidelines and mechanisms for ensuring responsible reporting which have important implications in prevention of suicide.
R. Shobitha Shanthakumari, Prabha S. Chandra, Ekaterina Riazantseva, and Donna E. Stewart
Background: Not much is known about factors that contribute to resilience among women facing intimate partner violence (IPV), particularly from countries where patriarchy predominates. This qualitative study aimed to gather the perspectives of Indian women self-identified as resilient in the face of IPV and tried to understand the strategies and resources that helped them to maintain or regain resilience.
Materials: Data were collected from 16 consenting women who reported IPV and whose husbands were being treated for alcohol problems at a psychiatric centre in Bangalore, India. A semi-structured guided interview format that aimed at understanding factors that enabled them to feel resilient despite IPV in their challenging circumstances was used to gather narratives from the participants.
Discussion: Six themes were identified using QSR NVivo software. They were as follows: the support of women, men and family; personal attributes; dignity and work; being strong for the children; and faith in God. Among these women, supportive social networks, personal attributes and aspirations were major clusters contributing to resilience.
Conclusion: Attention to these factors may provide an important, strengths-based perspective for interventions to enhance women’s resilience when facing IPV.
Anette Lykke Hindhede
The increasing global prevalence of type 2 diabetes has given rise to numerous trials designed to preventing diabetes. Most of these trials focus on encouraging individuals, especially ‘high-risk’ individuals to make lifestyle changes to reduce their chance of developing diabetes. Based on group interviews with health care professionals and qualitative in-depth interviews with participants in a diabetes preventive intervention with a biomedical aim to reduce risk of diabetes, in this article I critically explore the transformative potential of the medical classification prediabetes. My analysis of these data was informed by Bourdieu’s theory of practice and his concept of habitus which he defined as ‘systems of durable, transposable dispositions, structured structures predisposed to function as structuring structures, that is, as principles which generate and organise practices and representations’. Health professionals especially doctors saw the categorisation of patients as prediabetic in biomedical terms as a technical exercise that made visible information that already existed. In contrast, I found that patients saw the categorisation as creating a more fundamental change, the making of a new ‘high-risk’ person who had to take action based on a dialectical interplay between freedom and constraint in their everyday life, to manage these risk factors. They defined themselves as having a medical condition, a ‘lifestyle disease’. For these individuals, the precise meaning of and potential course of action depended on context, for example being diagnosed with prediabetes, could lead to personal benefits for those who were able to lower their blood glucose level. However, for some, there were circumstances, such as genetics, age or race, which could be neither influenced nor controlled. In this article, I note that screening-based preventive interventions that fail to consider embodied social knowledge and lived experiences will not achieve their desired outcomes.
Julie Henderson, Annabelle Wilson, Samantha B. Meyer, John Coveney, Michale Cainan, Dean McCullum, Sue Lloyd, and Paul R. Ward
In this article we examine how and why the media construct food risks, from the perspective of ‘media actors’ (people involved in different types of media) using data from 30 interviews conducted in 2013 with media actors from Australia and the United Kingdom. In modern society, many risks are invisible and are brought to the attention of the public through representations in the mass media. This is particularly relevant for food safety, where the widening gap between producers and consumers in the developed world has increased the need for consumer trust in the food supply. We show the importance of newsworthiness in construction of media stories about food risk using Beck’s ideas on cosmopolitan risk to interpret the data. We note the ways in which the strategies that media actors use to construct stories about food risk amplify the risk posed potentially creating consumer anxiety about the safety of the food system. It is important for food regulators and public health professionals to be aware of this anxiety when presenting information about a food incident so that they can target their message accordingly to decrease anxiety.
Jaromir Junne and Christian Huber
In this article, we explore the risks associated with direct payments to users enabling them to purchase social care. These payments are intended to enable people with disabilities to make choices and increase their autonomy. However, there is little evidence in the existing literature about the risks involved in direct payments as seen by service users. In this paper, we draw on data from a qualitative study of direct payments for people with disabilities in a federal state of Germany. We interviewed 37 individuals involved in direct payment schemes including individuals receiving payments, care assistants, members of organisations providing care and the administrative officers of the local authorities between December 2011 and January 2014. In this article, we use a governmentality perspective to explore how individuals who received the payments saw and sought to manage the risks associated with the scheme. We found that while users reported that direct payments reduced the risk associated with being directly dependent on the care providers and hence increased their desired self-determination, they identified new risks linked to their liability for the transferred money, problems associated with their liquidity and cash flow, challenges presented by budget cuts, and sanctions resulting from violation of norms of ‘appropriate use’ and the difficulties of negotiating with the funders. To manage these perceived risks users indicated that they had subjected themselves to a new way of active self-control and self-management, normalising their behaviour. We note that risk to service users has been neglected in policy design and should be acknowledged more explicitly.
Cindy A. Sousa, Susan Kemp, and Mona El-Zuhairi
Political violence is increasingly played out within everyday civilian environments, particularly family homes. Yet, within the literature on political violence and mental health, the role of threats to home remains under-explored. Using focus group data from 32 Palestinian women, this paper explores the implications of violations to the home within political violence. Threats to the privacy, control, and constancy of the family home – key dimensions of ontological security (Giddens, 1990) emerged as central themes in women’s narratives. Surveillance, home invasions, and actual or threatened destruction of women’s home environments provoked fear, anxiety, grief, humiliation, and helplessness, particularly as women struggled to protect their children. Women also described how they mobilized the home for economic, familial and cultural survival. Study findings illuminate the impact of threats to intimate environments on the well-being of women and their families living with chronic political violence, and underscore the importance of attention to violations of place and home in research on civilian experiences of and responses to political violence.
Kelly Fenton, Michael Larkin, Zoë V.R. Boden, Jessica Thompson, Gareth Hickman, and Elizabeth Newton
Early Intervention in Psychosis services aim to keep young people out of hospital, but this is not always possible. This research used in-depth interviews to explore the experience of hospitalisation amongst young people with psychosis. Findings describe fear and confusion at admission, conflicting experiences of the inpatient unit as both safe and containing, and unsafe and chaotic, and the difficult process of maintaining identity in light of the admission. We discuss the need to move from construing psychiatric hospitals as places for ‘passive seclusion’, to developing more permeable and welcoming environments that can play an active role in recovery.
Understanding users׳ perceptions and expectations of health care provision is key to informing practice, policy and health-related measures. In this paper, we present findings from a qualitative study conducted with recently migrated Eastern European children and their parents, reporting on their experiences of accessing health services post-migration. Unlike the case of adults, the experiences of newly migrated children have rarely been explored in relation to health services. We pay particular attention to three key areas: (1) migrant families׳ views of health service provision; (2) barriers to health service use; and (3) transnational use of health services. By using a social capital approach, we show how concerns about the Scottish health care practices enacted by migrant parents are adopted by children and are likely to impact on families׳ health beliefs and behaviours. The study highlights the important role of migrants׳ active participation as users of health services. We conclude that appropriate health services need to consider more carefully migrants׳ expectations and complex health care activities, in order to be fully inclusive and patient-centred.
What role should mental health care professionals play in helping heal psychical wounds exposed in the aftermath of Ferguson and New York?
This question lies at the heart of calls that emerged from within psychiatry, psychology, social work, and other mental health professions over the weeks since grand jury deliberations ended, and protests began, in cities across the country. Professional organizations such as the American Psychological Association convened panels to address the “psychology of improving police-community relations.” The National Association of Social Workers urged “its members and the wider social work community” to become more involved in social justice issues. And individual psychiatrists, psychologists, social workers, and other mental-health professionals developed methods for identifying and treating post-traumatic symptoms that arose as a result of protests and violence in communities of color.
Such mental health mobilization makes sense on many levels. Protesters, their families, and often their communities remain traumatized by the specter of unwarranted state violence, and by a system that seemingly condones it. And indeed, voices from within minority communities have called for the types of help that mental health practitioners offer. “We are upset, we are hurting,” a spokesman for the groups Hands Up United and Organization for Black Struggle explained during the Ferguson protests. “They don’t send psychiatrist[s], they don’t send counselors. They send more National Guard.” Meanwhile, St. Louis alderman Antonio French asked Missouri Governor Jay Nixon to send “400…mental-health professionals to Ferguson to help residents deal with trauma, anxiety, and fear.”
Yet even while there is a clear need for healing, history provides an important caveat that mental health communities would do well to keep in mind. In times or racial political crisis, mental health rubrics have in the past been used to locate social “pathologies” in the minds of oppressed persons, while bolstering the very power structures that their protests fight against.
Consider the psychiatric response to the protests during the civil rights era of the 1960s and 1970s. A number of psychiatrists aligned with calls for racial justice and equality, decried the lack of “racial integration,” and critiqued how “white norms” produced psychological oppression. And the profession itself began its first slow steps toward training and hiring more black psychiatrists and psychologists.
During the same era, however, under the guise of “treating” mental anguish in African American populations, a number of high-profile research articles in psychiatric journals blatantly defined civil rights participation as a form of mental illness—or worse, depicted racial protest as a form of psychosis that produced anxiety…in whites.
The best known practitioners of this approach were psychiatrists Walter Bromberg and Frank Simon, who, in the aftermath protests in Detroit, Newark, and Los Angeles, wrote articles in the Archives of General Psychiatry that detailed how black anger was fuelled by a “protest psychosis”—a condition in which the rhetoric of the Black Power movement drove “Negro men” to forms of insanity (“…the stress of asserting civil rights in the United States these past ten years and the corresponding nationalistic fervor of Afro-American nations during the same time period has stimulated specific reactive psychoses in American Negroes”) marked by anger, hostility, and acts that Bromberg and Simon shockingly called “racial antagonism of the Negroes to the Caucasian group.”
The contention that participation in civil rights protests caused violent schizophrenic symptoms in “Negro populations” in ways that threatened “white” civilization appeared in any number of other articles in the 1960s and 1970s. In an article titled “Six Years of Sit-Ins: Psychodynamic Causes and Effects” in the International Journal of Social Psychiatry, Pierce and West argued that “Negroes developed…dangerous aggressive feelings” when they participated in civil rights sit-ins. Raskin, Crook, and Herman wrote in the Journal of Consulting & Clinical Psychology that “blacks” with schizophrenia rated higher than “whites” on a set of “hostility variables” due to delusional beliefs that “their civil rights were being compromised or violated.” And in a series of high-profile articles in Psychiatry: Journal for the Study of Interpersonal Processes, Brody linked “social conflict” with “schizophrenic types of behavior” in “young adult Negro males.”
Relatedly, as by now has been well-publicized, antipsychotic medication advertisements in these same journals used discriminatory language and iconography to pathologize angry black men protesting in urban streets.
What do we learn from these egregious examples from the not-so-distant past? To be sure, mental health professions—such as my own field of psychiatry—no longer tolerate the racism that lay not far beneath the surface of psychiatric assumptions in the 1960s, and indeed, a number of professional organizations now respectfully address minority mental health.
Ultimately however, the caveat provided by the past is not, simply, that mental health professionals need to be aware of their own overt biases when attempting to intervene in moments of heightened racial tension. The lesson is also that the frameworks that led potentially well-intentioned practitioners to racist assumptions did so because they misidentified the subject of psychiatry’s diagnostic gaze. Psychiatrists and other mental health practitioners in the 1960s implicitly assumed that their diagnostic machinery was put to best use diagnosing black protesters or the black “cultures” from which they emerged. After all, the overt “symptoms” of protesters likely seemed the most disruptive or insane to their own psyches and to society more broadly—who else but “crazy” people would burn down the very cities in which they lived?
Mental health professions in the civil rights era thereby misdiagnosed structural problems as psychological ones. Under the guise of empathy and care, psychiatry, psychology, and other mental health rubrics thus (and often unknowingly) bolstered the very oppression they aimed to treat. And the symptoms of “patients” ultimately represented the stereotypes, biases, and blind assumptions of “doctors” instead.
Thankfully, early signs suggest that the healing professions may have learned from past mistakes as clinical networks mobilize after the decisions in Ferguson and Ney York. For instance, the National Association of Social Workers statement in the aftermath of the Ferguson made no attempt whatsoever to diagnose (or diagnostically empathize with) protesters, but instead argued for “national standards on the use of lethal police force” and “national standards on how police handle persons living with mental illnesses or disabilities.” And, learning from our youth, growing numbers of medical students organized under the hashtag #whitecoats4blacklives to stage die-ins, hands-up protests, and other actions in medical centers across the U.S. These medical-student interventions self-reflexively focus medicine’s diagnostic gaze, not just on black lives, but on the political actions, biases, and silences of “white coats.”
These and other nascent interventions suggest the possibility of a new politics of mental health, and medicine more broadly, in the aftermath of Ferguson. In this new reality, psychiatrists, psychologists, and social workers continue to empathically treat psychological distress. But they also recognize ways that the very health systems of which they are a part can contribute to disparity and inequality. By so doing, mental-health practitioners can then use their socially sanctioned political platforms to speak with empathic authority about broader, psychologically pathogenic structures, networks, and economic systems that produce and sustain injustice in the present-day United States.
Jonathan M. Metzl (@jonathanmetzl) is the Frederick B. Rentschler II Professor of Sociology and Psychiatry, and the Director of the Center for Medicine, Health, and Society, at Vanderbilt University in Nashville, Tennessee. His books include The Protest Psychosis, Prozac on the Couch, and Against Health.
Here is the first installment of this month’s coverage of current journal articles.
This paper explores how concepts of hope, motherhood, responsibility, and science are mobilized and transformed in the marketing strategies of private cord blood banks in South Korea. Cord blood banking provides a useful case study of the “political economy of hope,” which emphasizes future expectations over current utility. In particular, appeals to hope are rendered natural as being applied in relation to various concepts of motherhood (e.g. “scientific motherhood” and “consumer motherhood”), thereby refiguring ideas of a mother’s responsibility to her child. In South Korea, cord blood banks rely heavily on the discourse of “scientific motherhood,” which is based on certain gender norms and ideas about science, modernity, and “advanced society.” By exploring the discourse of scientific motherhood, this study reexamines the “political economy of hope” through the lenses of gender and transnationalism.
Smoking at the Workplace: Effects of Genetic and Environmental Causal Accounts on Attitudes Toward Smoking Employees and Restrictive Policies
Ilan Dar-Nimrod, Mirod Zuckerman, and Paul Duberstein
People hold diverse beliefs regarding the etiologies of individual and group differences in behaviors which, in turn, might affect their attitudes and behaviors. It is important to establish how perceived etiologies of smoking might affect the effectiveness of policy initiatives and prevention efforts. The present study assessed whether exposure to genetic vs. environmental accounts for smoking affects attitudes toward (a) workplace-related smoking policies and (b) smokers at the workplace. Results indicate that exposure to a genetic explanation led to stronger objections to a smoking restrictive policy compared with a non-genetic explanation. Additionally, participants in the genetic condition were more accepting of a smoker in the workplace than those in the environmental condition. Evidently, beliefs about the etiology of smoking influence a range of attitudes related to smokers and smoking-related policies.
Governing Stem Cell Therapy in India: Regulatory Vacuum or Jurisdictional Ambiguity?
Shashank S. Tiwari and Sujatha Raman
Stem cell treatments are being offered in Indian clinics although preclinical evidence of their efficacy and safety is lacking. This is attributed to a governance vacuum created by the lack of legally binding research guidelines. By contrast, this paper highlights jurisdictional ambiguities arising from trying to regulate stem cell therapy under the auspices of research guidelines when treatments are offered in a private market disconnected from clinical trials. While statutory laws have been strengthened in 2014, prospects for their implementation remain weak, given embedded challenges of putting healthcare laws and professional codes into practice. Finally, attending to the capacities of consumer law and civil society activism to remedy the problem of unregulated treatments, the paper finds that the very definition of a governance vacuum needs to be reframed to clarify whose rights to health care are threatened by the proliferation of commercial treatments and individualized negligence-based remedies for grievances.
International Law, Public Health, and the Meanings of Pharmaceuticalization
Emily Cloatre and Martyn Pickersgill
Recent social science scholarship has employed the term “pharmaceuticalization” in analyses of the production, circulation and use of drugs. In this paper, we seek to open up further discussion of the scope, limits and potential of this as an analytical device through consideration of the role of law and legal processes in directing pharmaceutical flows. To do so, we synthesize a range of empirical and conceptual work concerned with the relationships between access to medicines and intellectual property law. This paper suggests that alongside documenting the expansion or reduction in demand for particular drugs, analysts of pharmaceuticalization attend to the ways in which socio-legal developments change (or not) the identities of drugs, and the means through which they circulate and come to be used by states and citizens. Such scholarship has the potential to more precisely locate the biopolitical processes that shape international agendas and targets, form markets, and produce health.
Discourse on Medicine: Meditative and Calculative Approaches to Ethics from an International Perspective
David Cruise Malloy, Ronald Martin, Thomas Hadjistavropoulos, Peilai Liu, Elizabeth Fahey McCarthy, Ilhyeok Park, N Shalani, Masaaki Murakami, and Suchat Paholpak
Heidegger’s two modes of thinking, calculative and meditative, were used as the thematic basis for this qualitative study of physicians from seven countries (Canada, China, India, Ireland, Japan, Korea, & Thailand). Focus groups were conducted in each country with 69 physicians who cared for the elderly. Results suggest that physicians perceived ethical issues primarily through the lens of calculative thinking (76%) with emphasis on economic concerns. Meditative responses represented 24% of the statements and were mostly generated by Canadian physicians whose patients typically were not faced with economic barriers to treatment due to Canada’s universal health care system.
The Royal College of Physicians of London published the 2013 national clinical guidelines on prolonged disorders of consciousness (PDOC) in vegetative and minimally conscious states. The guidelines acknowledge the rapidly advancing neuroscientific research and evolving therapeutic modalities in PDOC. However, the guidelines state that end-of-life decisions should be made for patients who do not improve with neurorehabilitation within a finite period, and they recommend withdrawal of clinically assisted nutrition and hydration (CANH). This withdrawal is deemed necessary because patients in PDOC can survive for years with continuation of CANH, even when a ceiling on medical care has been imposed, i.e., withholding new treatment such as cardiopulmonary resuscitation for acute life-threatening illness. The end-of-life care pathway is centered on a staged escalation of medications, including sedatives, opioids, barbiturates, and general anesthesia, concurrent with withdrawal of CANH. Agitation and distress may last from several days to weeks because of the slow dying process from starvation and dehydration. The potential problems of this end-of-life care pathway are similar to those of the Liverpool Care Pathway. After an independent review in 2013, the Department of Health discontinued the Liverpool Care pathway in England. The guidelines assert that clinicians, supported by court decisions, have become the final authority in nonconsensual withdrawal of CANH on the basis of “best interests” rationale. We posit that these guidelines lack high-quality evidence supporting: 1) treatment futility of CANH, 2) reliability of distress assessment from starvation and dehydration, 3) efficacy of pharmacologic control of this distress, and 4) proximate causation of death. Finally, we express concerns about the utilitarian-based assessment of what constitutes a person’s best interests. We are disturbed by the level and the role of medical authoritarianism institutionalized by these national guidelines when deciding on the worthiness of life in PDOC. We conclude that these guidelines are not only harmful to patients and families, but they represent the means of nonconsensual euthanasia. The latter would constitute a gross violation of the public’s trust in the integrity of the medical profession.
Spanning Our Differences: Moral Psychology, Physician Beliefs, and the Practice of Medicine
Ryan Antiel, Katherine Humeniuk, and Jon Tilburt
Moral pluralism is the norm in contemporary society. Even the best philosophical arguments rarely persuade moral opponents who differ at a foundational level. This has been vividly illustrated in contemporary debates in bioethics surrounding contentious issues such as abortion and euthanasia. It is readily apparent that bioethics discourse lacks an empirical explanation for the broad differences about various topics in bioethics and health policy. In recent years, social and cognitive psychology has generated novel approaches for defining basic differences in moral intuitions generally. We propose that if empirical research using social intuitionist theory explains why people disagree with one another over moral issues, then the results of such research might help people debate their moral differences in a more constructive and civil manner. We illustrate the utility of social intuitionism with data from a national physician survey.
Ebola, Epidemics, and Ethics – What We Have Learned
The current Ebola epidemic has presented challenges both medical and ethical. Although we have known epidemics of untreatable diseases in the past, this particular one may be unique in the intensity and rapidity of its spread, as well as ethical challenges that it has created, exacerbated by its geographic location. We will look at the infectious agent and the epidemic it is causing, in order to understand the ethical problems that have arisen.
Biomedicine is typically defined as the branch of medicine that is based on the principles of biology and biochemistry. A central tenet for biomedicine is the notion of disease and therapeutic specificity, i.e. the idea of tailored treatments for discrete disorders underpinned by specific pathologies. The present paper is concerned with how notions of disease and therapeutic specificity guide biomedical reasoning. To that end, the author proposes a model – the specificity triad – that draws on late philosopher and physician Ludwik Fleck’s concept of “style of thought” to offer a frame for investigating the intricate process through which links between disorders, mechanisms, and therapeutics are established by biomedicine. Next by applying the specificity triad model to scrutinize research efforts in two discrete areas of medicine—psychiatry and regenerative medicine—this paper seeks to stimulate pertinent discussions in and about biomedicine. These include discussions on the ambiguous epistemic status of psychiatry within contemporary biomedicine, as well as the relationship between developmental biology — historically relatively disjointed from biomedical enterprise — and the burgeoning field of regenerative medicine.
Reassessing the Approach to Informed Consent: The Case of Unrelated Hematopoietic Stem Cell Transplantation in Adult Thalassemia Patients
Salvatore Pisu, Giovanni Caocci, Ernesto d’Aloja, Fabio Efficace, Adriana Vacca, Eugenia Piras, Maria Grazia Orofino, Carmen Addari, Michela Pintor, Roberto Demontis, Federica Demuru, Maria Rita Pittau, Gary S. Collins, and Giorgia La Nasa
The informed consent process is the legal embodiment of the fundamental right of the individual to make decisions affecting his or her health, and the patient’s permission is a crucial form of respect of freedom and dignity, it becomes extremely important to enhance the patient’s understanding and recall of the information given by the physician. This statement acquires additional weight when the medical treatment proposed can potentially be detrimental or even fatal. This is the case of thalassemia patients pertaining to class 3 of the Pesaro classification where Allogenic hematopoietic stem cell transplantation (HSCT) remains the only potentially curative treatment. Unfortunately, this kind of intervention is burdened by an elevated transplantation-related mortality risk (TRM: all deaths considered related to transplantation), equal to 30% according to published reports. In thalassemia, the role of the patient in the informed consent process leading up to HSCT has not been fully investigated. This study investigated the hypothesis that information provided by physicians in the medical scenario of HSCT is not fully understood by patients and that misunderstanding and communication biases may affect the clinical decision-making process.
This essay examines medical and popular attitudes to cancer in the early modern period, c.1580–1720. Cancer, it is argued, was understood as a cruel and usually incurable disease, diagnosable by a well-defined set of symptoms understood to correspond to its etymological root, karkinos (the crab). It was primarily understood as produced by an imbalance of the humours, with women being particularly vulnerable. However, such explanations proved inadequate to make sense of the condition’s malignancy, and medical writers frequently constructed cancer as quasi-sentient, zoomorphising the disease as an eating worm or wolf. In turn, these constructions materially influenced medical practice, in which practitioners swung between anxiety over ‘aggravating’ the disease and an adversarial approach which fostered the use of radical and dangerous ‘cures’ including caustics and surgery.
Drawing on some 4000 pages of personal notes on medical practice written by the little known Bohemian physician Georg Handsch, this paper studies the oral transmission of medical knowledge from laypersons to academically trained physicians in the sixteenth century. In marked contrast to learned physicians’ attacks against ‘empirics’ and the ‘ignorance’ of the ‘vulgus’, numerous entries in Handsch’s notebooks reveal that he and his teachers and colleagues were prepared to learn from the common folks, from patients and friends, from family members and even from ‘wise women’ and unlicensed ‘empirics’. They valued their ideas, observations and skills as potentially useful for their own practice. This remarkable openness, the paper suggests, was due above all to the rise of empirical approaches in learned medicine, the need to improve outcomes in view of the competition from unlicensed healers and the physicians’ own upbringing in the medical lay culture of their time.
This article investigates the interrelation between processes of professional transformation in an artisanal trade and the identity-building of barbers and surgeons in German-speaking parts of Europe. From the late fifteenth to the middle of the eighteenth century this interrelation included acting in various juridical and political functions, engaging in medical book-writing and, therefore, in knowledge transfer. Such findings are based on a combined analysis of administrative and corporative manuscript sources, and of printed books. Against this background the intention in pictorial representations and the meaning in biographic material become apparent. The individuals and the group defined themselves as medical artisans despite the fact that they assimilated academic standards in their training and lifestyle. Families played a leading part in this adaptation to political, economic, scientific and social change, they even overruled confessional boundaries. For the formation of trade identity during the seventeenth and the first half of eighteenth centuries families were indispensable.
The impact of the American Civil War on medical modernisation is increasingly being recognised, yet the ways in which the Civil War challenged and changed doctors’ understanding of their professional role during the war remains underappreciated. By juxtaposing Union doctors’ personal and professional responses to the Civil War with the wider public reaction to Union medical care, this paper explores the tensions that arose between the public and the professional perceptions of medicine as these developed on the battlefields of the nation’s internecine conflict. It argues that the intersection between the positive and negative narratives of Union medical provision, specifically surgery, established an important discursive space within which Union doctors could negotiate their public and professional status. It finds that the negative narrative, far from a hindrance, was instrumental to the process of medical modernisation by enabling Union physicians to define, defend and develop a more modern medical role.
Historians of orthopaedics, artificial limbs and disability have devoted a great deal of attention to children and soldiers but have neglected to give sufficient space in their studies to industrial workers, the other patient group that has been identified as crucial to the development of these areas. Furthermore, this attention has led to an imbalanced focus on charitable and philanthropic activities as the main means of assistance and the neglect of a significant part of the voluntary sphere, the labour movement. This article, focusing on industrial south Wales, examines the efforts of working-class organisations to provide artificial limbs and a range of other surgical appliances to workers and their family members in the late nineteenth and early twentieth centuries. It finds that a distinctive, labourist conception of disability existed which envisaged disabled workers as an important priority and one to which significant time, effort and resources were devoted.
Drugs, Race and Tuberculosis Control in Baltimore, 1950-1978
Julia Ross Cummiskey
Two narratives dominate histories of post-WWII tuberculosis control. One emphasizes the successes of antibiotic therapy in the 1950s and 1960s, the subsequent decline in resources for tuberculosis management, and the resurgence of tuberculosis in the 1990s. The second centres on the development of the global DOTS strategy and privileges those aspects of earlier control efforts that appear to be precursors to DOTS. Both narratives underemphasize diverse efforts by public health authorities across the world to manage the possibilities and challenges of antibiotic therapy. These efforts were shaped by local social and political contexts. The history of Baltimore’s tuberculosis control programme between 1950 and 1978 illustrates the complex array of strategies public health officials employed as well as the way they adapted strategies from other jurisdictions. It highlights continuities between the pre-antibiotic and the post-antibiotic history of tuberculosis, and ways that persistent racial tropes influenced tuberculosis control programmes.
This paper focuses on the Centre for Mental Health and Research, an organisation launched in Athens in 1956 and that is still operational today. Its story up to 1970 is analysed as a case study of the development of mental hygiene and child guidance in Greece, where international movements became relevant within the context of the social transformations of the post-war period. Seizing the opportunities created by the ‘modernisation’ of Greece and the anxiety around it, the Centre managed to secure funding and develop a number of services and activities. It is concluded that, although it was not successful in its broader social projects, it had an impact at the micro-level of the family and played a part in opening up new possibilities for the ‘psy’ disciplines in post-war Greece beyond the pathological and the hospital, so addressing the ‘normal’ individual and society as a whole.
By the 1950s, American medical authorities declared obesity to be the nation’s leading health care problem prompting a society, already familiar with the rigours of weight control, to extend the bounds of their diet consciousness. This manifested in a ‘self-help movement for fatties’ which witnessed the proliferation of weight loss groups with names such as, Take Off Pounds Sensibly and Fatties Anonymous, and introduced an eclectic blend of mutual aid inspired by Alcoholics Anonymous and psychoanalytic psychiatry. This paper explores the emergence of these mutual aid groups in response to the growing concern about obesity and argues that the rise of weight loss groups was the result of many separate but interacting variables in the context of the post-war United States. The history of the self-help weight loss movement can offer new perspectives on the politics of current obesity management policies, as well as insight into mid-twentieth-century popular culture.
What Binds Biosociality? The Collective Effervescence of the Parent-Led Conference
Rebecca Dimond, Andrew Bartlett, and Jamie Levine
Questions of community are central to many research settings in the social sciences. Rabinow argued that, in the wake of the Human Genome Project, an increasingly important form of collectivity would be biosociality. Biosociality recognises a central role for biomedical knowledge in constructing genetic identities and producing and reproducing social relationships. Accordingly, it is often imagined as a new form of social solidarity. We draw on observations of parent-led conferences to explore the way in which biosociality is expressed at events organised around a particular genetic syndrome – 22q11 deletion syndrome. The parent-led conferences took place within the United Kingdom between 2007 and 2010 and were observed as part of a multi-sited ethnographic study. By bringing together a geographically dispersed group of people together within the same physical location, conferences offer an ideal platform to empirically examine sociality. Durkheim used the term collective effervescence to describe the collective expression of heightened emotion. We suggest that in the case of the 22q11 deletion syndrome activities discussed in this paper, collective effervescence is a mechanism through which individuals become a collective. We argue that parent-led conferences gather individuals in one location on the basis of common biological factors, but it is the shared emotional experience of being together that consolidates and renews the connection between members.
Latent and Manifest Empiricism in Q’eqchi’ Maya Healing: A Case Study of HIV/AIDS
James Waldram and Andrew Hatala
This paper presents a case study of the traditional treatment of a Q’eqchi’ Maya man in southern Belize in 2011 who is suffering from AIDS-related sickness. The purpose is to detail the empirical nature of Q’eqchi’ Maya medicine, distinguishing between manifest and latent empiricism, as evidenced in the healers evolving attempts to treat the patient in the absence of knowledge of his biomedical diagnosis. The paper argues for a more complete understanding of the empirical nature of much Indigenous healing, which parallels aspects of scientific medicine, and for better collaboration among traditional healers and biomedical practitioners in strongly Indigenous areas.
Interdisciplinary Promises Versus Practices in Medicine: The Decoupled Experiences of Social Sciences and Humanities Scholars
Mathieu Albert, Elise Paradis, and Ayelet Kuper
This paper explores social scientists’ and humanities (SSH) scholars’ integration within the academic medical research environment. Three questions guided our investigation: Do SSH scholars adapt to the medical research environment? How do they navigate their career within a culture that may be inconsistent with their own? What strategies do they use to gain legitimacy? The study builds on three concepts: decoupling, doxa, and epistemic habitus. Twenty-nine semi-structured interviews were conducted with SSH scholars working in 11 faculties of medicine across Canada. Participants were selected through purposeful and snowball sampling. The data were analyzed by thematic content analysis. For most of our participants, moving into medicine has been a challenging experience, as their research practices and views of academic excellence collided with those of medicine. In order to achieve some level of legitimacy more than half of our participants altered their research practices. This resulted in a dissonance between their internalized appreciation of academic excellence and their new, altered, research practices. Only six participants experienced no form of challenge or dissonance after moving into medicine, while three decided to break with their social science and humanities past and make the medical research community their new home. We conclude that the work environment for SSH scholars in faculties of medicine does not deliver on the promise of inclusiveness made by calls for interdisciplinarity in Canadian health research.
Inequalities in Social Capital and Health Between People with and without Disabilities
Johanna Mithen, Zoe Aitken, Anne Ziersch, and Anne Kavanagh
The poor mental and physical health of people with disabilities has been well documented and there is evidence to suggest that inequalities in health between people with and without disabilities may be at least partly explained by the socioeconomic disadvantage (e.g. low education, unemployment) experienced by people with disabilities. Although there are fewer studies documenting inequalities in social capital, the evidence suggests that people with disabilities are also disadvantaged in this regard. We drew on Bourdieu’s conceptualisation of social capital as the resources that flow to individuals from their membership of social networks. Using data from the General Social Survey 2010 of 15,028 adults living in private dwellings across non-remote areas of Australia, we measured social capital across three domains: informal networks (contact with family and friends); formal networks (group membership and contacts in influential organisations) and social support (financial, practical and emotional). We compared levels of social capital and self-rated health for people with and without disabilities and for people with different types of impairments (sensory and speech, physical, psychological and intellectual). Further, we assessed whether differences in levels of social capital contributed to inequalities in health between people with and without disabilities. We found that people with disabilities were worse off than people without disabilities in regard to informal and formal networks, social support and self-rated health status, and that inequalities were greatest for people with intellectual and psychological impairments. Differences in social capital did not explain the association between disability and health. These findings underscore the importance of developing social policies which promote the inclusion of people with disabilities, according to the varying needs of people with different impairments types. Given the changing policy environment, ongoing monitoring of the living circumstances of people with disabilities, including disaggregation of data by impairment type, is critical.
The Impact of Using Computer Decision-Support Software in Primary Care Nurse-Led Telephone Triage: Interactional Dilemmas and Conversational Consequences
Jamie Murdoch, Rebecca Barnes, Jillian Pooler, Valerie Lattimer, Emily Fletcher, and John Campbell
Telephone triage represents one strategy to manage demand for face-to-face GP appointments in primary care. Although computer decision-support software (CDSS) is increasingly used by nurses to triage patients, little is understood about how interaction is organized in this setting. Specifically any interactional dilemmas this computer-mediated setting invokes; and how these may be consequential for communication with patients. Using conversation analytic methods we undertook a multi-modal analysis of 22 audio-recorded telephone triage nurse–caller interactions from one GP practice in England, including 10 video-recordings of nurses’ use of CDSS during triage. We draw on Goffman’s theoretical notion of participation frameworks to make sense of these interactions, presenting ‘telling cases’ of interactional dilemmas nurses faced in meeting patient’s needs and accurately documenting the patient’s condition within the CDSS. Our findings highlight troubles in the ‘interactional workability’ of telephone triage exposing difficulties faced in aligning the proximal and wider distal context that structures CDSS-mediated interactions. Patients present with diverse symptoms, understanding of triage consultations, and communication skills which nurses need to negotiate turn-by-turn with CDSS requirements. Nurses therefore need to have sophisticated communication, technological and clinical skills to ensure patients’ presenting problems are accurately captured within the CDSS to determine safe triage outcomes. Dilemmas around how nurses manage and record information, and the issues of professional accountability that may ensue, raise questions about the impact of CDSS and its use in supporting nurses to deliver safe and effective patient care.
A Correlative STS: Lessons from a Chinese Medical Practice
Wen-yuan Lin and John Law
How might Science and Technology Studies learn more from the intersection between ‘Western’ and ‘other’ forms of knowledge? In this article, we use Eduardo Viveiros de Castro’s writing on equivocal translation to explore a moment of encounter in a Chinese Medical consultation in Taiwan in which a practitioner hybridizes Chinese Medicine and biomedicine. Our description is symmetrical, but creates a descriptive equivocation in which ‘Western’ analytical terms are used to describe a ‘Chinese’ medical reality. Drawing on the history of Chinese Medicine, we argue that the latter is not analytical, but ‘correlative’ in a specifically ‘Chinese’ manner that explores patternings, flows, and propensities in local collections of things and symptoms. In particular, it both handles difference without seeking to unearth stable causal mechanisms and absorbs new elements including relevant features of biomedicine. We conclude by briefly considering the scope of a possible post-colonial and ‘correlative’ STS and show that a ‘correlative’ description of the same Chinese Medical consultation would differ markedly from one making use of ‘Western’ analytical assumptions.
Science diplomacy supposedly builds international cooperation through scientific and technical exchange. In practice, however, there are important but often overlooked instances where it might create conflict instead – as with accusations of espionage surrounding the US Naval Medical Research Unit 2 (NAMRU-2) in Indonesia. Did American science diplomacy backfire in Indonesia and, if so, why? Most literature fails to anticipate this possibility, let alone explain it, since science diplomacy is rarely subject to critical analysis. Rather than shun politics or, similarly, simply blame the demise of NAMRU-2 on the military or avian influenza, I consider both the successes and failures of this research unit in the context of Indonesia’s transition to democracy and America’s legacy from the Cold War. Based on this history, I propose that the effects of science diplomacy depend on strategic communication and exchange, as well as elite influence and material incentives. Therefore, by challenging the conventional wisdom about science diplomacy, NAMRU-2 can help advance the theory and practice of this potentially useful tool of statecraft.
This article draws on ethnographic research at iThemba Pharmaceuticals, a small South African startup pharmaceutical company with an elite international scientific board. The word ‘iThemba’ is Zulu for ‘hope’, and so far drug discovery at the company has been essentially aspirational rather than actual. Yet this particular place provides an entry point for exploring how the location of the scientific knowledge component of pharmaceuticals – rather than their production, licensing, or distribution – matters. The article explores why it matters for those interested in global health and postcolonial science, and why it matters for the scientists themselves. Consideration of this case illuminates limitations of global health frameworks that implicitly posit rich countries as the unique site of knowledge production, and thus as the source of unidirectional knowledge flows. It also provides a concrete example for consideration of the contexts and practices of postcolonial science, its constraints, and its promise. Although the world is not easily bifurcated, it still matters who makes knowledge and where.
Zapatista Corn: A Case Study in Biocultural Innovation
In November 2001, Nature published a letter in which University of California Berkeley’s biologists claimed to have found evidence of genetically modified (GM) DNA in regional varieties of maize in Oaxaca, even though the Mexican government had banned transgenic corn agriculture in 1998. While urban protesters marched against the genetic ‘contamination’ of Mexican corn by US-based agricultural biotech firms, rural indigenous communities needed a framework for understanding concepts such as GM before they could take action. This article analyzes how the indigenous organization, the Zapatistas, mobilized a program to address this novel entity. Their anti-GM project entailed educating local farmers about genetics, importing genetic testing kits, seed-banking landrace corn and sending seeds to ‘solidarity growers’ around the world. This article explores material-semiotic translations to explain one of the central aspects of this project, the definition and circulation of Zapatista corn – an entity defined not only through cultural geography, but also technological means. Through its circulation, Zapatista corn serves to perform a biocultural engagement with Zapatista’s political project of resistance to neoliberalism. While much has been written about both regulatory policy and consumer activism against GM in the Global North, Zapatista corn also provides a case study in indigenous, anti-GM activism founded on biocultural innovation and the creation of alternative networks for circulating corn.
Genetic Fallout in Bio-Cultural Landscapes: Molecular Imperialism and the Cultural Politics of (not) Seeing Transgenes in Mexico
Christophe Bonneuil, Jean Foyer, and Brian Wynne
This article explores the trajectory of the global controversy over the introgression (or not) of transgenes from genetically modified maize into Mexican indigenous maize landraces. While a plurality of knowledge-making processes were deployed to render transgenes visible or invisible, we analyze how a particular in vitro based DNA-centered knowledge came to marginalize other forms of knowledge, thus obscuring other bio-cultural dimensions key to the understanding of gene flow and maize diversity. We show that dominant molecular norms of proof and standards of detection, which co-developed with the world of industrial monocropping and gene patenting, discarded and externalized non-compliant actors (i.e. complex maize genomes, human dimensions of gene flow). Operating in the name of high science, they hence obscured the complex biological and cultural processes that maintain crop diversity and enacted a cultural–political domination over the world of Mexican landraces and indigenous communities.
This article explores the fraught historical politics of a 20th-century controversy over a Classic Maya king. The controversy ostensibly concerned the age at death of a ruler discovered in 1952 in an elaborate sarcophagus at the Mexican site of Palenque. Combining osteological and epigraphic techniques, Mexican scholars estimated that the ruler died at about 40 or 50 years of age. Two decades later, an emerging collective of US hieroglyph experts claimed to have determined the grammatical structure of Maya glyphs for the first time and reevaluated the sarcophagus inscriptions. They concluded that the king, given the name ‘Pakal’, lived a remarkably long life of 80 years (603–683 ce). This reading sparked a controversy that would persist until 1999. At stake was not just how to tell the story of an ancient Maya lord, but who could tell it, with what evidence, and with what degree of certainty. The inclination of some Mexican archaeologists to adopt nationalist and Marxist orientations came into palpable tension with foreign scholars’ liberal, universalist knowledge practices. To address this problem, I rethink Pakal’s material mediation through bones and inscriptions as a ‘matter of concern’ (Bruno Latour) and ‘matter of care’ (Maria Puig de la Bellacasa). I show how these concepts facilitate the reconsideration of contradictory historical propositions as potential sites of coexistence among actors temporarily ill equipped to listen to each other’s claims. Ultimately, I present ‘listening’ as a technique of cosmopolitical care that complements the extensive emphasis on speech and spokespersonship in Latourian cosmopolitics.
Creeping Edgework: Carnivalesque Consumption and the Social Experience of Health Risk
James Cronin, Mary McCarthy, and Alan Collins
This article contributes to an understanding of voluntary health risk based on the regular, excessive intake of food and alcohol in the micro-cultural setting. By drawing on and extending edgework theory our aim is to conceptualise the riskiness of carnivalesque consumption as a medium for expression and performance in two separate community contexts. Using ethnographic research methods, we explore the consumption of calorie-dense, low nutrient food for gamers and the use of alcohol for hipsters. Our findings are reported over four key themes. The first and last consider how carnivalesque consumption provides sensations for multi-sensory loss of self and a shared emancipation from day-to-day moderation. The second and third explore how community members prepare and exercise control over their consumption to manage risks related to an ‘immediate edge’. We discuss how carnivalesque behaviour, when ritualised, establishes a trajectory that creeps towards a more ‘distant edge’ characterised by longer term health consequences. We argue that the transcendental experiences that are part and parcel of edgework can be enacted by products that are traditionally conceptualised as mundane and that the risks of consuming them are largely accumulative rather than instantaneous. Implications for health interventions are included.
The Pharmacy Gaze: Bodies in Pharmacy Practice
The body is a central feature of pharmacy practice. Despite this and the increased sociological focus on bodies in health and social care practice, the nature of the body and the work undertaken upon it in pharmacy have not been explored. Drawing on semi-structured interviews with hospital and community pharmacists, this article explores the ways in which bodies are constructed and managed in these two practice contexts. It is argued that pharmacists see patients’ bodies in particular ways given their expertise in medicines, which is conceptualised here as the pharmacy gaze. The notion of complexity, as a way of constructing the body, and the generation of algorithmic bodies, as a way of managing this complexity, are shown to be central to the pharmacy gaze in both hospital and community contexts. In hospitals, complexity was located in a singular body, that is, increasingly rationalised to reduce costs and toxicity. In community practice, complexity arose from the multiplicity of bodies with which pharmacists interact in their multifaceted role as retailers, dispensers and public health practitioners. The article concludes by reflecting on the ways in which current UK health policy may broaden the body work that English pharmacists undertake.
Approaches combining social and political theory with ontology have rarely been utilised in the evaluation of decision-making processes. Drawing on such an approach clarifies the questions that still need to be asked about the policy response to HIV/AIDS in The Netherlands in the early 1980s. The initial response in The Netherlands is internationally regarded as an example of successful cooperation between public authorities, health organisations, blood banks and the gay movement. In comparison with other countries, deeply dividing social conflicts as well as dramatic medical disasters were avoided. This image, however, is misleading. Although it was on a smaller scale than the disasters with contaminated blood products in other countries, The Netherlands had their blood scandal too. A reconstruction of this episode offers the opportunity to evaluate the role objects are granted in theories of institutionalisation and to critically examine the procedural notion of politics in actor network theory. The aim of the article is to show that analyses of decision-making processes under conditions of uncertainty ought to engage more carefully with processes of exclusion and the transformative role of objects.
‘This Wound has Spoilt Everything’: Emotional Capital and the Experience of Surgical Site Infections
Brian Brown, Judith Tanner, and Wendy Padley
In this article we explore the experience of suffering from a surgical site infection, a common complication of surgery affecting around 5 per cent of surgical patients, via an interview study of 17 patients in the Midlands in the UK. Despite their prevalence, the experience of surgical site infections has received little attention so far. In spite of the impairment resulting from these iatrogenic problems, participants expressed considerable stoicism and we interpret this via the notion of emotional capital. This idea derives from the work of Pierre Bourdieu, Helga Nowotny and Diane Reay and helps us conceptualise the emotional resources accumulated and expended in managing illness and in gaining the most from healthcare services. Participants were frequently at pains not to blame healthcare personnel or hospitals, often discounting the infection’s severity, and attributing it to chance, to ‘germs’ or to their own failure to buy and apply wound care products. The participants’ stoicism was thus partly afforded by their refusal to blame healthcare institutions or personnel. Where anger was described, this was either defused or expressed on behalf of another person. Emotional capital is associated with deflecting the possibility of complaint and sustaining a deferential and grateful position in relation to the healthcare system.
‘Active Play May be Lots of Fun, But it’s Certainly not Frivolous’: The Emergence of Active Play as a Health Practice in Canadian Public Health
Stephanie Alexander, Katherine Frohlich, and Caroline Fusco
In the context of what has been termed a childhood obesity epidemic, public health institutions have recently begun to promote active play as a means of addressing childhood obesity, thus advancing play for health. Drawing on Foucault, this article problematises the way that children’s play is being taken up as a health practice and further considers some of the effects this may have for children. Six Canadian public health websites were examined, from which 150 documents addressing children’s health, physical activity, obesity, leisure activities and play were selected and coded deductively (theoretical themes) and inductively (emerging themes). Bacchi’s (2009) question-posing approach to critical discourse analysis deepened our analysis of dominant narratives. Our findings suggest that several taken-for-granted assumptions and practices underlie this discourse: (i) play is viewed as a productive activity legitimises it as a health practice; (ii) tropes of ‘fun’ and ‘pleasure’ are drawn on to promote physical activity; (iii) children are encouraged to self-govern their leisure time to promote health. We underscore the need to recognise this discourse as contingent and as only one of many ways of conceptualising children’s leisure activities and their health and social lives more generally.
Pathways to Care: How Superdiversity Shapes the Need for Navigational Assistance
Gill Green, Charlie Davison, Hannah Bradby, Kristine Krause, Felipe Morente Meijías, and Gabriele Alex
The recently developed sociological concept of superdiversity provides a potentially interesting and useful way of developing an understanding of life in contemporary Europe. Here we report on research based on individual narratives about access to health care, as described by a range of people from very different sociocultural backgrounds in four European countries. This article notes the frequent appearance in first-person narratives of the need for navigational assistance in the form of knowledge, cultural competence and orientation that facilitate the identification and use of pathways to health care. Our dataset of 24 semi-structured interviews suggests that, in the context of needing health care, the feeling of being a ‘stranger in a strange land’ is common in people from a wide range of backgrounds. In social settings characterised by transnationalism and cultural heterogeneity, it is important to understand the need for navigational assistance, particularly at times of uncertainty, in the design and delivery of health services. The relationship between the inhabitants of contemporary Europe and the healthcare systems available in the places where they live is dominated by both complexity and contingency – and this is the cultural field in which navigation operates.
Keeping it in the Family: The Self-Rated Health of Lone Mothers in Different European Welfare Regimes
Sarah Van de Velde, Clare Bambra, Koen Van der Bracht, Terje Andreas Eikemo, and Piet Bracke
This study examines whether health inequalities exist between lone and cohabiting mothers across Europe, and how these may differ by welfare regime. Data from the European Social Survey were used to compare self-rated general health, limiting long-standing illness and depressive feelings by means of a multi-level logistic regression. The 27 countries included in the analyses are classified into six welfare regimes (Anglo-Saxon, Bismarckian, Southern, Nordic, Central East Europe (CEE) (new EU) and CEE (non-EU). Lone motherhood is defined as mothers not cohabiting with a partner, regardless of their legal marital status. The results indicate that lone mothers are more at risk of poor health than cohabiting mothers. This is most pronounced in the Anglo-Saxon regime for self-rated general health and limiting long-standing illness, while for depressive feelings it is most pronounced in the Bismarckian welfare regime. While the risk difference is smallest in the CEE regimes, both lone and cohabiting mothers also reported the highest levels of poor health compared with the other regimes. The results also show that a vulnerable socioeconomic position is associated with ill-health in lone mothers and that welfare regimes differ in the degree to which they moderate this association.
Trust in Health Care Encounters and Systems: A Case Study of British Pensioners Living in Spain
Helene Legido-Quigley, Martin McKee, and Judith Green
Research on trust in health care faces two enduring challenges. Firstly, there are conceptual ambiguities in distinguishing trust from related concepts, such as confidence or dependence. Second, the tacit understandings which underpin the ‘faith’ element of trust are difficult to explicate. A case study of British pensioners who have moved to Spain provides an opportunity to explore trust in a setting where they often have a choice of where to access health care (UK or Spain), and are therefore not in a state of dependence, and in which the ‘differences’ of a new field generates reflection on their tacit expectations of providers and systems. In accounting for decisions to use (or not to use) Spanish health care, British pensioners cited experiential knowledge of symbolic indicators of trustworthy institutions (they were hygienic, modern, efficient), which contributed to background confidence in the system, and interpersonal qualities of practitioners (respect for older people, embodied empathy and reciprocity) which evoked familiar relations, within which faith is implicit. In contrast, with limited recent access to the British system, their background confidence had been compromised by reports of poor performance, with few opportunities to rebuild the interrelational bases of trust.
Reconsidering Inequalities in Preventive Health Care: An Application of Cultural Health Capital Theory and the Life-Course Perspective to the Take-up of Mammography Screening
Sarah Missinne, Karel Neels, and Piet Bracke
While there are abundant descriptions of socioeconomic inequalities in preventive health care, knowledge about the true mechanisms is still lacking. Recently, the role of cultural health capital in preventive health-care inequalities has been discussed theoretically. Given substantial analogies, we explore how our understanding of cultural health capital and preventive health-care inequalities can be advanced by applying the theoretical principles and methodology of the life–course perspective. By means of event history analysis and retrospective data from the Survey of Health Ageing and Retirement, we examine the role of cultural capital and cultural health capital during childhood on the timely initiation of mammography screening in Belgium (N = 1348). In line with cumulative disadvantage theory, the results show that childhood cultural conditions are independently associated with mammography screening, even after childhood and adulthood socioeconomic position and health are controlled for. Lingering effects from childhood are suggested by the accumulation of cultural health capital that starts early in life. Inequalities in the take-up of screening are manifested as a lower probability of ever having a mammogram, rather than in the late initiation of screening.
Trust has long been regarded as a vitally important aspect of the relationship between health service providers and patients. Recently, consumer choice has been increasingly advocated as a means of improving the quality and effectiveness of health service provision. However, it is uncertain how the increase of information necessary to allow users of health services to exercise choice, and the simultaneous introduction of markets in public health systems, will affect various dimensions of trust, and how changing relations of trust will impact upon patients and services. This article employs a theory-driven approach to investigate conceptual and material links between choice, trust and markets in health care in the context of the National Health Service in England. It also examines the implications of patient choice on systemic, organisational and interpersonal trust. The article is divided into two parts. The first argues that the shift to marketisation in public health services might lead to an over-reliance on rational-calculative aspects of trust at the expense of embodied, relational and social attributes. The second develops an alternative psychosocial conception of trust: it focuses on the central role of affect and accounts for the material and symbolic links between choice, trust and markets in health care.
International epidemiological evidence demonstrates that more children than ever before now enter puberty before the age of 8. Early onset puberty can be an alarming experience for parents and is thought to entail short- and long-term physical and psychosocial risks, particularly for girls. ‘Puberty blocking’ hormonal medications are sometimes used to halt the progress of puberty in order to avoid these dangers. This article analyses medical and pharmaceutical discourses describing these medications, exploring how they articulate sex/gender, sexuality, age and health. Engaging with sociological literatures on pharmaceuticalisation and queer and feminist work on atypical sexual development and trans, I argue that prescribing puberty blockers should not be seen as a straightforward ‘solution’ to early sexual development. Learning from Elizabeth A. Wilson’s (2011) engagement with Karen Barad’s reconceptualising of bodies, I suggest how we might take account of the psychological and physical worldliness of early developing children when evaluating puberty blockers.
Posthuman Disability Studies
Dan Goodley, Rebecca Lawthom, and Katherine Runswick Cole
This article explores the human through critical disability studies and the theories of Rosi Braidotti. We ask: What does it mean to be human in the twenty-first century and in what ways does disability enhance these meanings? In addressing this question we seek to work through entangled connections of nature, society, technology, medicine, biopower and culture to consider the extent to which the human might be an outdated phenomenon, replaced by Braidotti’s posthuman condition. We then introduce disability as a political category, an identity and a moment of relational ethics. Critical disability studies, we argue, are perfectly at ease with the posthuman because disability has always contravened the traditional classical humanist conception of what it means to be human. Disability also invites a critical analysis of the posthuman. We examine the ways in which disability and posthuman work together, enhancing and complicating one another in ways that raise important questions about the kinds of life and death we value. We consider three of Braidotti’s themes in relation to disability: (i) Life beyond the self: Rethinking enhancement; (ii) Life beyond the species: Rethinking animal; (iii) Life beyond death: Rethinking death. We conclude by advocating a posthuman disability studies that responds directly to contemporary complexities around the human while celebrating moments of difference and disruption.
Governmentality, Subjectivity and AIDS
Nkululeko Nkomo and Carol Long
Our aim in this article is to examine the South African state’s discursive deployment of the African renaissance discourse to prompt a particular kind of HIV positive subjectivity, during the years 1996–2003. We interrogate this connection along two axes. First, the article offers an analysis of the state’s nudging of a new African subjectivity. Second, we examine the state’s representation of a new African HIV positive subjectivity. In this way, the representation of a new African subjectivity – and subsequently a new HIV positive subjectivity – and the realization of the African renaissance discourse of a reconstructed Africa were mutually supporting. A critical analysis of the state and the treatment lobby group’s representational practices implicates both in prompting the formation of an HIV positive subject who is rational, dignified and free.
Social Science and Neuroscience Beyond Interdisciplinarity: Experimental Entanglements
Des Fitzgerald and Felicity Callard
This article is an account of the dynamics of interaction across the social sciences and neurosciences. Against an arid rhetoric of ‘interdisciplinarity’, it calls for a more expansive imaginary of what experiment – as practice and ethos – might offer in this space. Arguing that opportunities for collaboration between social scientists and neuroscientists need to be taken seriously, the article situates itself against existing conceptualizations of these dynamics, grouping them under three rubrics: ‘critique’, ‘ebullience’ and ‘interaction’. Despite their differences, each insists on a distinction between sociocultural and neurobiological knowledge, or does not show how a more entangled field might be realized. The article links this absence to the ‘regime of the inter-’, an ethic of interdisciplinarity that guides interaction between disciplines on the understanding of their pre-existing separateness. The argument of the paper is thus twofold: (1) that, contra the ‘regime of the inter-’, it is no longer practicable to maintain a hygienic separation between sociocultural webs and neurobiological architecture; (2) that the cognitive neuroscientific experiment, as a space of epistemological and ontological excess, offers an opportunity to researchers, from all disciplines, to explore and register this realization.
Critical Neuroscience and Socially Extended Minds
Jean Slaby and Shaun Gallagher
The concept of a socially extended mind suggests that our cognitive processes are extended not simply by the various tools and technologies we use, but by other minds in our intersubjective interactions and, more systematically, by institutions that, like tools and technologies, enable and sometimes constitute our cognitive processes. In this article we explore the potential of this concept to facilitate the development of a critical neuroscience. We explicate the concept of cognitive institution and suggest that science itself is a good example. Science, through various practices and rules, shapes our cognitive activity so as to constitute a certain type of knowledge, packaged with relevant skills and techniques. To develop this example, we focus on neuroscience, its cultural impact, and the various institutional entanglements that complicate its influence on reframing conceptions of self and subjectivity, and on defining what questions count as important and what kind of answers will be valued.
Biomimicry: New Natures, New Enclosures
Jesse Goldstein and Elizabeth Johnson
Advocates of biomimicry encourage a new industrial paradigm that ostensibly leaves behind the crude violence of Francis Bacon, the domination of nature-as-machine, and a history of toxic production processes that have given rise to a present and coming climate crisis. As part of a broader trend towards the conceptualization and development of a ‘bioeconomy’, we argue here that biomimicry produces ‘nature’ in new ways. At face value, these new approaches to valuing nature may seem less violent and exploitative. Yet, new natures can and are tortured in new ways. We argue that biomimicry produces ‘nature’ through well-worn logics of resource enclosure and privatization, focusing upon two fundamental shifts in how nonhuman life is figured and put to work: (1) the production of nature as intellectual property (as opposed to raw materials); (2) the production of nature as an active subject (as opposed to a passive receptacle or vehicle).
An earlier version of this post first appeared on the author’s site, Aesop’s Anthropology.
What just happened in Anthropology? In the 2013 annual meeting there were zero abstracts or paper or panel titles featuring the word “Anthropocene”; this year there were 64! Compare that with “multispecies,” which has held steady at between 16-23 invocations after it first made its appearance in the program in 2010.[i] Why the surge of interest? More importantly, given overlapping concerns highlighted by these two keywords, why the sudden prevalence of one over the other?
Of the two, “Anthropocene” has a much broader public and also more cachet, as it comes from the Earth sciences and bears the imprimatur of geological objectivity. Anthropologists may also be drawn to the greater sense of crisis or urgency the term conveys. And it may be that we’re recognizing here an opportunity to exercise are often over-looked expertise. This concept is centrally about humans, and they are our specialty. But why would this term so suddenly overtake “multispecies” as a means to frame lines of inquiry and research projects?
Perusing the 2014 program, I first though the rise of this term reflected archaeologists’ use of Anthropocene, since the concept is really taking hold in that subfield. But few of the papers or panels are archeological, so that can’t be it. Perhaps it’s a matter of scope: Anthropocene—as a “charismatic mega-category”—takes in millennia and it frames the vast scale of industrialization and globalization. Also, because it focuses on climatic change and risk, the term orients to policy forums and managerial practices concerning environmental resources. In contrast, “multispecies” emerged from more boutique fields, cultural studies broadly (e.g. philosophical posthumanism and Donna Haraway’s companion species, etc) and ethnography in particular. Plus it’s mostly still associated with a method: ethnographic accounting for located relationships and encounters among species. But also its connotations are just weird and disconcerting, in a way that even global apocalypse is not, since that’s been lushly imagined actively over the last two thousand years at least.
Here’s the problem: You can think with and deploy “Anthropocene” without rethinking any of the fundamental assumptions that got us into the crisis it names. Anthropocene, as the name suggests, is anthropocentric: human-driven change is pushing the planet to the Sixth Extinction (see Elizabeth Kolbert). But the concept prompts scant challenges to the perspective of humanism that fueled our species dominance; nor does it require any revisioning of mission of anthropology. Both problems are evident in Paul Stoller’s recent characterization of the current moment.
What does “multispecies” do differently? First, it aims to decenter the human, striving to achieve some detachment from its precepts, assumptions, and conceits. The starting point of multispecies work is that the “human” is comprised of masses of nonhumans—internal swarms of bacteria, viruses, and fungi vastly outnumber our human cell by a ratio of about 9 to 1. We fundamentally misunderstand the human if we see it as a singular, unified agent; rather, what “we” are as a species is utterly entangled in copious folds of nonhumans, without which we would not exist. The challenge is to displace the centrality of the human. In contrast with “Anthropocene,” “multispecies” is first and foremost an effort to dethrone the dominance of the human, which solutions to the crisis of the Anthropocene must entail.
As an exploratory frame, “Anthropocene” bears this potential, too. From the perspective of anthropogenic change, we can see the human with a greater degree of distance than ever before, perhaps gaining a crucial quantum of detachment from its perceptual, conceptual apparatus—in order to think differently from the modes of thought that placed planetary life in peril. Here lies the potential to achieve “species thinking,” which Dipesh Chakrabarty (see “The Climate of History”) characterized as a means to reconstitute critical analysis of climate change. But this comes with the challenge of resisting the evident tendency to construe the Anthropocene as the human writ large across the entire globe. Also, these two keywords entail starkly contrasting assumptions about agency of nonhumans, which we’ll have to engage if we are to counter human-driven change. This must happen at the scale of individuals—as with surging interest in microbiomes—and of commodity chains, as well as managerial efforts to conserve or “rewild” “nature” and environmental mobilizations to constrain rampaging industries.
A crucial way of proceeding with both displacing the human and rethinking forms of agency, while building from the overlapping potential of both “Anthropocene” and “multispecies,” begins surprisingly by reimagining social theory. Since Durkheim, social theory developed to account for forces that pattern our existence and that crosscut—alternately dooming or blessing—individual lives, animating the structures through which all humans pass. At this moment, as we contend with the far-flung extent of impacts of human sociality, perhaps we gain a different purchase on the attendant predicament if we now begin to recognize the social in its nonhuman manifestations and operations. If the human is the problem of the current global crisis, as the term, “Anthropocene,” suggests, social theory is uniquely positioned to decenter this entity by developing the basic insight that sociality extends well beyond the human.
“Anthropocene”—a term to name an epoch of geological time, distinct from the Holocene—was first proffered by Nobel laureate Paul Crutzen, in a 2002 article in Nature (“Geology of Mankind,” Vol 415). Debate over this assertion continues to be lively—as chronicled in “An Epoch Debate,” (Science, October 7, 2011, Vol 334)—and widespread: see, “The New World of the Anthropocene” (Environmental Science & Technology, 44, 2010), “The Anthropocene: From Global Change to Planetary Stewardship” (Ambio, 40, 2011), and “Conservation in the Anthropocene” (Conservation Biology, 26, 2011). These now are helpfully curated by the just-inaugurated journal, The Anthropocene Review.
John Hartigan is Professor of Anthropology and Director of the Américo Paredes Center for Cultural Studies at the University of Texas, Austin. His recent books include Anthropology of Race: Biology, Genes, and Culture, (School of Advanced Research Press, 2013), What Can You Say? America’s National Conversation on Race (Stanford University Press, 2010) and Race in the 21st Century: Ethnographic Approaches, (Oxford University Press 2010), and more recently, Aesop’s Anthropology: A Multispecies Approach, (University of Minnesota Press, 2014). The Aesop’s Anthropology project can also be followed at https://twitter.com/aesopsanthro and http://www.aesopsanthropology.com/blog/
[i] 2013 may have been an odd year. There 7 references to “Anthropocene” in both 2012 and 2011. But references to “multispecies” in Anthrosource outnumber those for “Anthropecene,” with the former mostly in journal titles and abstracts and the latter confined to Section discussions in Anthropology News in 2013.
Image: Detail of “Adam Naming the Animals” from the Northumberland Bestiary. J. Paul Getty Museum. ca. 1250
Rethinking Infrastructures for Global Health: A View from West Africa and Papua New Guinea by Alice Street
“Without staff, stuff, space and systems, nothing can be done”. Paul Farmer’s reflections on his recent trip to Liberia in The London Review of Books reiterated in stark terms what health experts have been saying for months. There is by now a fairly clear consensus in the global health community that the uncontrolled spread of Ebola in West Africa this year was due to the collapse of already weak infrastructure. Ebola, we all know, is fairly difficult to transmit and easy to contain. The rapid and catastrophic spread of the disease in West Africa has therefore highlighted the absence of the most basic equipment and expertise: where there is no running water, no ambulances, no gloves or protective clothing, and few health workers or laboratories, what seems easy elsewhere becomes exceedingly difficult, and thousands of lives are lost.
Suddenly, the phrase ‘health infrastructure’ is rolling off everyone’s tongues. Reports of West Africa’s ‘poor infrastructure’, of Ebola working through the ‘cracks in fragile health infrastructure’, and of the disease spurring a ‘collapse in health infrastructure’ abound. Following the botched admission and death of a patient with Ebola at Dallas Hospital, in Texas, we are told that Obama has even been briefed on the ‘preparedness of the US health infrastructure.’ The phrase ‘health infrastructure’ sounds so prosaic we might think it had been around forever, yet it is only with the policy fallout from Ebola in 2014 that it has become a commonplace expression in the global health lexicon. Given the sudden ubiquity of the expression, it is important to interrogate what exactly ‘health infrastructure’ means and what potential value it may have for improving healthcare and reducing inequalities.
To talk about infrastructure is to draw attention to the sheer materiality of health system architecture. For years social scientists and health experts have been emphasizing the importance of ‘health system strengthening’ and have highlighted the violence done to health systems by vertical disease-centric programmes that focus on magic-bullet solutions to seemingly isolated problems. But the focus on systems can also lead to abstractions. Health systems are imagined from afar, from offices in government buildings or donor agency headquarters. They are depicted in diagrams and drawn on white boards.
Health infrastructure, by contrast, conjures presence; the sticky materiality of being there. Paying attention to health infrastructure is about paying attention to the relentless particularity of material life: what you wear (a t-shirt? a paper mask? personal protective equipment (PPE)?), what you pick up (the edge of a used sheet? an old flannel? a paper tissue?), and after you have used it to wipe a mouth or sweaty forehead, where you put it down (a table? a hazardous waste receptacle? a concrete floor?) when you are doing healthcare. As Uli Beisel has recently written here, the object that has become more emblematic of the life-saving simplicity of material infrastructure than any other in recent weeks is the rubber glove—an object that is both entirely innocuous and entirely necessary, whose presence or absence signals a material politics that prompts us to question the infrastructural histories of colonial and postcolonial medicine.
Yet dangers lurk if we endeavor to reduce infrastructure to materiality.
In 2011 I followed the rollout of rapid diagnostic tests for malaria in Papua New Guinea. RDTs are designed for places with weak public infrastructure. Places that do not have a network of laboratories, power-grids, or doctors. The RDT for malaria is a simple lateral flow test that requires a health worker to deposit a drop of blood from a fingertip in a small hole, to add buffer, wait 15 minutes, and then read off from a series of up to three blue lines that appear in a small screen. Technologies like the rapid diagnostic test, in other words, are designed to substitute for absent infrastructure. They are what Peter Redfield has called a “solution in a box”. Yet, as the problems that emerged during the RDT rollout in PNG illustrate, infrastructural externalities abound. RDTs have to be transported from medical stores to rural health centres and where there are no roads they must be carried. RDTs must be stored under 30 degrees centigrade for their accuracy to be preserved, but medical stores, dispensaries and road-side dropping off points all regularly exceed this threshold. The value of the RDT depends entirely on their result being acted upon by a health worker, who has also been equipped with a new treatment protocol that requires them not to treat patients with negative results. Yet those same health workers have few other treatment options and no other diagnostic options. For decades they have also been trained to treat all fever presumptively for malaria.
Infrastructures cannot be built into boxes.
Paul Farmer undoubtedly has it right. Staff (health workers who are there when the patients, or the RDTs turn up), stuff (the rapid diagnostic test, anti-malarial medication), and space (the dense forest that must be traversed for the RDTs to reach the health facility, the breezy verandah where health workers can attend to patients) and systems (the supply and distribution system that enables the RDTS to be reliably transported) are crucial. But he did not, I suspect, intend those items to be read as a checklist. If technologies do not work autonomously, then it is the relationships between stuff, space, people and systems that matter.
Infrastructure is relational.
Take something as mundane as how life-saving devices get from one place to another. According to Papua New Guinea’s medical supply and distribution system, medicines and equipment are transported from Madang Province’s medical store to Begasin Health Centre, a 10 mile hike from the edge of the national highway into the thick bush and steep inclines of Usino-Bundi District, by community volunteers: People walking on bush tracks substitute for trucks on bitumen roads. The grueling work of carrying up to 50kg in weight over ravines, through gorges and along slippery tracks is, according to the bureaucrats who devised and depend on this system, the work of public citizenship. It is called ‘community work’ and has a long colonial legacy.
In 2010 the son of a Nursing Officer at the health centre had an affair with the Officer in Charge’s local babysitter, resulting in her pregnancy, and the community revolted. For several weeks, until the Nursing Officer and her family had fled and suitable compensation payments had been made, no medicines were carried and the health centre was closed. For young men and women living in the vicinity of the health centre the hard graft of carrying supplies is not only ‘community work’, it is also a personalized exchange; part of a history of transactions with the health workers who have come to live in their midst. The physical infrastructure that enables medicines and equipment to move from one place to another depends fundamentally on those relationships and transactions.
In 2012, when RDTs were finally rolled out in Madang Province, the Global Fund and its recipients did not want to take any chances. Personal relationships, the thinking went, are much too unreliable. Commercial transactions, by contrast, were deemed predictable and controllable. One day an unknown youth group from a village near the highway turned up in Begasin, carrying boxes of RDTs. They had each been paid 20 kina (£6) by a newly established medical logistics company in the town. 3 months later, when the next shipment was due, it did not turn up. Longstanding tensions had erupted in several skirmishes between the people living by the highway and those in the Begasin interior, and the youths were too scared to walk through the villages between their own and the health facility.
Why, young people from Begasin wanted to know, did paid contracts for carriers go to youth groups from another area? (They suspected political nepotism.) And why did they not get paid for carrying everyday medicines, like antibiotics, when carriers of ‘special’ medicines and equipment received a fee? I wondered how soon it would be before people from Begasin refused to carry any medicines at all without payment; a cost the embattled health ministry could hardly afford. The commodification of relationships spreads quickly but, as with other kinds of social relationships, it cannot always be controlled.
If infrastructure is relational the hardest lesson is surely that it cannot be routinized.
Infrastructure is neither an abstract system nor physical stuff; it is the relationships between people, stuff, and space that enables health systems to work. When a nurse at Dallas Hospital in Texas carried out a CDC issued checklist that revealed the man she was examining had travelled from Liberia, why was he not subsequently admitted and diagnosed with Ebola? We do not yet know the precise answer to this question. What we do know is that the checklist, which we have learnt from Atul Gawande is an ingeniously simple and powerful device, was nonetheless not able to script its own use. What technology ever can completely?
So, infrastructure, yes. As an anthropologist whose research has focused on the materiality of Papua New Guinea’s under-resourced hospitals and rural health systems, it is gratifying to see infrastructures for global health rise up the agenda of international organisations like the WHO.
But also, relational infrastructures. Otherwise we are doomed to end up with the technological determinism that so often led to the depletion of those very health infrastructures we hope to strengthen in the first place.
Alice Street is a Chancellors Fellow in Social Anthropology and Director of the MSc Programme in Medical Anthropology at the University of Edinburgh. Her book, Biomedicine in an Unstable Place: Infrastructure and Personhood in a Papua New Guinean Hospital, is published with Duke University Press. A recent lecture on issues related to those addressed in this post can be viewed here.
Image: Mark Doyle
Anthropologies of American Medicine, NYU Press
This book series will feature U.S.-based ethnographic research into the relations between health, culture, power and knowledge. While focused on the U.S., the series will also explore the place of U.S. institutions in the world-wide reach of biomedicine through migration, transnationalism, corporate influence and other global processes. This series fills a critical gap in medical anthropology, one of the most vibrant and well-recognized subfields in the discipline of anthropology.
The series will cover both established and emerging topics in medical anthropology, such as the formation of professional subjectivities in health care, pharmaceuticals and everyday life, and the social context of biomedical technologies. It aims to achieve several important goals:
- to help bring medical anthropology’s unique perspectives to broader debates about health and health care in the U.S., helping anthropologists gain a voice at the table of policy-making, medical education, and patient and community advocacy movements;
- to highlight the importance of anthropological research on the body, medicine, health, and health care for understanding social, cultural, and political-economic changes in the United States;
- to raise the visibility and significance of ethnographic work in the US as a key site in theoretically developed anthropological research.
The majority of books are anticipated to be single- or dual-authored. The overarching argument and “big picture” contribution of the work must be clear. Writing must be both accessible and engaging. We seek theoretically powerful manuscripts that present rich ethnographic analyses of significant health issues. Works in this series will not only advance anthropological scholarship but will also address at least one additional audience such as patient advocacy organizations; health care planners and policy makers; health care providers (specific groups such as nurses, obstetricians, physical therapists), the organizers and participants in community service work/volunteer health missions; and students entering into health professional fields. The books are anticipated to be of interest to additional readerships outside of anthropology, such as the study of health/health inequality, science and technology studies, and biopolitics.
Paul Brodwin, University of Wisconsin-Milwaukee
Michele Rivkin-Fish, University of North Carolina at Chapel Hill
Susan Shaw, University of Arizona
Submissions should take the form of a 3-5 page proposal outlining the intent and scope of the project, its merits in comparison to existing texts, and the audience it is designed to reach. You should also include a detailed Table of Contents, 2-3 sample chapters, and a current copy of your curriculum vitae. Please refer to NYU Press’s submission guidelines.
Please direct queries and submissions simultaneously to:
Department of Anthropology
University of Wisconsin-Milwaukee
Department of Anthropology
University of North Carolina at Chapel Hill
School of Anthropology
University of Arizona
Des Fitzgerald and Felicity Callard have recently offered some advice, a normative orientation even, for those engaging in collaboration:
“Living well in a collaborative mode is about resisting the urge to sort things out – it is about quelling the desire to be clear, at all times, on who ‘I’ am, and what ‘I’ am doing, and whether or not ‘I’ am getting anything out of this anyway. Indeed, much of our own learning to live in this mode has not at all been about clarifying things, but about learning to play with them – and play, as Andrew Balmer reminds us in his association of collaboration with BDSM, is a complex and at times violent ethical structure. Certainly, it allows the collaborator to confuse her subjectivity and her subjection. It might even help her to learn to find joy and insight in that confusion.”
One wonders what to make of such happy advice. The dictionary offers two possible definitions of confusion: (1) the lack of understanding; uncertainty; and (2) the state of being bewildered or unclear. There can be no doubt that close engagement with the contemporary sciences generates uncertainty—after all, the contemporary sciences operate midst a certain level of opacity about their own objects, problems, or futures. And it is certainly the case that this uncertainty and opacity can serve as one setting within which joy and insight become possible for collaborators. John Dewey put it well when he insisted that breakdown and indeterminacy are occasions for thinking, and thinking, when worked through generates a certain pleasure.
But collaboration can generate pleasure for many reasons and those reasons are linked to a diverse range of possible modes of engagement. So the question is less whether or not collaboration, however difficult, generates the possibility of pleasure—even joy. The question, rather, is: what modes of interaction generate which kinds of affects, to what effect, and at what cost?
“Joy and insight” internal to a state of confusion might be the result of (a) once having been confused, (b) engaging in inquiry and reflection, and (c) resolving the confusion in a certain (if limited) fashion (or at least giving it some determinate form). Operating in this mode, one must remain resolutely attentive to both the veridictional and ethical stakes of the engagement: seeking to clarify the truth of the situation in order make determinations about its significance—however partial and fleeting.
Another mode of engagement is one that sidesteps the Deweyan labor of moving from lesser to greater determination by bracketing questions of truth and power. This mode seems to be at play in a collaborative engagement with neuroscientists and sociologists described by Fitzgerald and colleagues (not with Callard). In a recent paper Fitzgerald et al describe neuroscientific-sociological efforts to put to the test the neuroscientific endeavor to localize “valid acts of deception within the body and brain of an individual” (Fitzgerald et al 2014: 706), i.e. to determine the neurobiology of lie detection. They report that, in the end, this engagement proved to be an experiment in confirming something the sociologists already knew (but which was not the primary goal): viz. that “the experiment recapitulated biologically a point that we already knew historically” (713): neurobiological tests reproduce flawed assumptions in older biological lie detection tests.
What conclusions might one draw from the fact that neuroscientists are pursuing work whose flaws are already known by their sociological counterparts? How should this fact be made a part of the ethics of scientific engagement under the sign of collaboration? What could collaborative inquiry mean within such a setting?
Given the pervasive emphasis on “the politics of knowledge” in today’s academy the aims of collaborative inquiry might be programmatic: to participate in the work of helping to determine the kinds of questions that science within a particular domain and within a certain political economy can and should be asking. This, however, is not the direction that the Fitzgerald and his collaborators seem to espouse:
“we have pursued a transdisciplinary mode of intervention in which the neurobiological legibility of ‘truth’, for example, is not simply affirmed scientifically or criticized sociologically; instead, this legibility is expanded and complicated through more risky and generous imaginaries of cross-disciplinary connection” (Ibid: 714).
It is not clear what “expansion” and “complication” mean in this paragraph, though perhaps the terms are more fully explained elsewhere. A series of questions might nonetheless be posed: in what manner is the neurobiological legibility of “truth” affirmed or denied? What can a sociologist learn from making such a judgment about legibility and how does she determine the veridictional norms of expansion and complication? And how is the question of the modes and forms of risky and generous truth-practice critically engaged as part constituting the terms of collaboration between the neuroscientists and the sociologists?
The fashion in which one would pursue an answer to these questions within the frame of collaboration would not be obvious under any conditions, but it becomes less clear under the conditions of ethical self-limitation proposed by Fitzgerald et al:
“Our proposal is that … success might have come precisely because we did not speak frankly; we did not seek the truth; we totally failed to acknowledge – let alone discuss – the consequences of our experimental situation. What we did, instead, was to try to work and live within a zone that was just about ambiguous enough to keep everything together – that was sufficiently averse to frank-speaking to keep the worst of the resentments at bay” (Ibid: 716).
We worry that this determined self-limitation marks a troubling turn in the practice of truth and ethics (c.f. Stavrianakis, Bennett and Fearnley 2015), a moment whose defining feature is that those dedicating their lives to knowledge practices choose to eliminate from their repertoire of ethical and intellectual equipment exercises of critical self-formation that prepare one to take up truth-practices in the face of shifting power relations and the attendant need to speak frankly about both power and the truth as one finds it.
If one is willing to pay the price of such a double elimination (i.e. truth and ethics), then a certain playfulness might indeed become available. But such playfulness is unlikely to be constituted as the uninhibited and spontaneous activity of scientific curiosity. Rather, it is more likely to be a species of ethically deformative bureaucratic administration (or the incorporation of ‘artistic critique’ into management, as Eve Chiapello has described it). Such a species consists in managing the affective norms of a space (whatever you do, don’t get angry!), and minimizing practices of truth and mutual care.
A critical space evacuated of frank-speech becomes a bureaucratic discipline of just getting along. In view of the problem of collaboration, and the question of truth and ethics, we think it is worth returning to Robert Merton’s re-characterization of the dysfunctional aspects of Weber’s ideal-type of bureaucracy. Merton refers to Veblen’s concept of “trained incapacities” (c.f. Rabinow and Bennett 2012: 80-90) and Dewey’s notion of “occupational psychosis” as hallmarks of deformative bureaucratic organization: “states of affairs in which one’s abilities” (such as the ability “to get along”, “to play the game” “to be part of the administration”) “function as blind spots” (Merton 1957: 252). They are blind spots insofar as reliable and successful bureaucracy requires an internalized feel for the limitation of one’s authority and competence relative to the regulated action one seeks.
Deformative bureaucratic organization, in other words, stunts the private use of reason, in Kant’s sense of the term. Collaboration animated in the spirit of such organization remains anti-political—and not in the scientific sense of seeking objectivity, but rather in the self-delimiting sense of turning away from the demands of the day. Science and politics, after all, both require the public use of reason.
Perhaps the confusion arising out of the play of subjectivity and subjection described by Fitzgerald and Callard is not primarily scientific but rather ethical (“not being clear on what I am doing/who I am/what am I getting out this collaboration”), given that (at least in the case of the paper cited) Fitzgerald et al. don’t report learning anything new. If so, then it seems fair to ask: as scholars concerned with inquiring into, and critically appraising biology and medicine, what is the worth and what are the costs of being playful in situations of blocked veridictional possibility?
Perhaps the joys of ethical confusion arise out of a state of equilibrium in which the tensions of disagreement and agonistic critique are released through an internalized resolve to bite one’s tongue and therewith through the pleasure of being allowed participate in an experiment with powerful actors: an experiment in sustaining adjacency to power. But what would and should the critical hallmarks of such adjacency consist in if one indeed does need to confront questions of justice and the mutuality of desire? Can engagement with powerful actors be judged successful if it risks becoming an exercise in the maintenance of rapport?
It bears underscoring that we agree that scientific collaboration thrives in situations of uninhibited creative engagement and production. It thrives in situations where something like intellectual play is actively pursued, made possible, and has even become a norm of engagement. But as we have written elsewhere (Rabinow and Bennett 2012; Rabinow and Stavrianakis 2013; 2014), that play, in our view, requires undertaking the difficult and sometimes uncomfortable labor of cultivating a disposition of agonistic friendliness and a care for undertaking scientific practice together, with the accompanying questions of truth and ethics that such cultivation and practice require.
Anthony Stavrianakis is an IFRIS Postdoctoral Fellow, CERMES 3, Research Centre of Health, Medicine, Science and Society, Paris.
Gaymon Bennett is Assistant Professor of Religion, Science, and Technology in Religious Studies, Arizona State University.
Lyle Fearnley is Postdoctoral Fellow, Humanities, Science and Society Cluster at Nanyang Technological University, Singapore.
Paul Rabinow is Professor of Anthropology, UC Berkeley
Fitzgerald, Des, et al. “Ambivalence, equivocation and the politics of experimental knowledge: A transdisciplinary neuroscience encounter.” Social Studies of Science (2014).
Merton, Robert. K. Social Theory and Social Structure. New York: The Free Press, 1957.
Rabinow, Paul and Gaymon Bennett. Designing Human Practices: An Experiment with Synthetic Biology. Chicago: University of Chicago Press, 2012.
Rabinow, Paul and Anthony Stavrianakis. Demands of the Day: On the Logic of Anthropological Inquiry. Chicago: University of Chicago Press, 2013.
________ Designs on the Contemporary: Anthropological Tests. Chicago: University of Chicago Press, 2014.
Stavrianakis, Anthony, Gaymon Bennett, and Lyle Fearnley. Science, Reason, Modernity: Readings for an Anthropology of the Contemporary. New York: Fordham University Press. 2015.
Duke University Press, 2014, 688 pages.
“The conquest of the earth, which mostly means taking it away from those who have a different complexion or slightly flatter noses than ourselves, is not a pretty thing when you look into it too much. What redeems it is the idea only. An idea at the back of it; not a sentimental pretense but an idea; and an unselfish belief in the idea – something that you can set up, and bow down before, and offer a sacrifice to.” – Joseph Conrad, Heart of Darkness
“Seeing is an art…which must be learnt.” – William Herschel
The relationship of history and empire is nothing if not complex. While the history of European empire has traditionally been written through conventional cultural frameworks – say, economy, politics, or even science – these longue duree-type narratives can leave a lot of imperial history untold. In the spaces between grand narratives live micro-histories, artifacts, and images. Oft-overlooked aspects of history like images, visions, and pictorial practices, add a tangible dimensionality to the complexity of empire. The integration of broad topics like empire and postcolonialism through smaller, more detailed slices of history is an ambitious endeavor. And Empires of Vision: A Reader is one such determined project.
In Empires of Vision’s introduction, editor Sumathi Ramaswamy tells readers what brought the collection together. “The essays collected here consider the transformations undergone by these technologies, practices, and subjectivities as they get entangled in empire-building, nationalist reactions, postcolonial contestations, and transnational globalization.” In other words, how does scholarship-writ-large deal with the material parts – artifacts? objects? practices? – that are inexorably intertwined with the very process of writing about “seeing” empire and its postcolonial existence? Empires of Vision brings those elements full circle – the essays examine how image and picture come together to make, convey, and experience empire. In order to tackle something so overwhelming, the editors remain firmly committed to the interdisciplinary and, indeed, cross-disciplinary nature of work that such a collection necessitates.
Empires of Vision highlights recent trends in scholarship that ask readers to consider the reciprocal nature of the link between “object” (or “image”) and “empire.” Ramaswamy asks “Does the empire not only speak and write back but also look back in unexpected ways, and at whom and with what effect?” For the authors –21 of them in addition to the two editors –the images of empire, colony, and postcolonial history are not mere representations. The images are where the struggles for narrative control are painted, printed, and dissembled to audiences. The image, the editors suggest, exists in a very Derridean sense, where the history of the image is between the seeing and the looking. All of the authors describe the pattern of “seeing” and “looking” as having a particular historical contingency – that the temporal chronology of that same seeing and looking (of an image being made and interpreted) extends the archives of European nation-building and empire-making.
Empires of Vision is broken into two main sections (The Imperial Optic and Postcolonial Looking) with six sub-sections (Empires of the Palette; The Mass-Printed Imperium; Mapping, Claiming, Reclaiming, The Imperial Lens; Subaltern Seeing: An Overlap of Complexities; Regarding and Reconstituting Europe.) The twenty-one chapters address pictorial semiotics, from Serge Gruzinski in “The Walls of Image” to Christopher Pinney’s treatment of photography in “Notes from the Surface of the Image: Photography, Postcolonialism, and Vernacular Modernism.” Simon Gikandi’s “Picasso, Africa, and the Schemata of Difference” and Krista Thompson’s “Picturesque in History and Art in the Postcolony” show that imperial history does not simply “stop” with the “end” of empire; rather, essays from the section Postcolonial Looking demonstrate that the colonial and postcolonial are dialectic parts of a historical relationship.
Editor Martin Jay argues, “It is clear that no simple generalisation about the “imperial eye” or “colonial gaze” will do justice to the plethora of different examples we have of the visual cultures in different periods and empires.” Each author brings a unique set of research and topics to the table.
Nicholas Thomas’s chapter, “Objects of Knowledge: Oceanic Artifacts in European Engravings,” seems to balance all of the thematic threads of the essay collection. Thomas notes, “The particular power of engravings may also be derived from the long-prevalent notion that visual images have a special capacity to convey truth that words do not.” What Thomas’s chapter conveys, interestingly, is the notion that “truth” can be found in – or at least, that narrative can be constructed around – the explanatory power that actual, tangible images had in networks of European empires and their systems of exchange. These images – engravings in the mid-eighteenth century to film in the twentieth – have traditionally been within the textual domain of anthropologists and art historians. Thomas’s take is to refocus how images of non-Europeans have operated within the realms of private collectors and other less institutional agendas. For example, Thomas cites the popularity of images of non-Europeans from Captain James Cook’s 1770s voyages and that Cook’s books and similar voyage works were exceptionally popular and frequently reprinted for the audience of empire, once the images were physically present. For Thomas, the image as an object has a particular staying power.
In “Mapping an Exotic World,” Benjamin Schmidt examines what, exactly, Dutch geography of the eighteenth century mapped. Schmidt notes the universal attraction to eighteenth-century Dutch geography and asks the reader to consider how the framing and creation of the map, itself bounded notions of materiality and ideas of empire. “Consider the fantasy cabinet of Jan van Kessel, which purports to portray a collector’s ideal …Whatever the panel’s many charms, one is hard pressed to identify a single them, or a signal object, that draws the view into this undeniably compelling collection. On the contrary, one is struck by the abundance and variety of stuff and by the shapeless bric-a-brac quality of its arrangement.” In such an example, the “fantasy cabinet” (or cabinet of wonder/cabinet of curiosities) is the material manifestation of exotic and the image depictions of things within the cabinet further exemplify wonder and amazement at the reaches of colonial empire.
If we pursue the idea that images are objects, then the rhetoric used by Thomas and Schmidt shows that these images have a very deep life history or even a biological-cultural identity. Early twentieth-century philosopher Ernst Cassirer argued that understanding very nature of such objects required such an integrative approach. Although Thomas and Schmidt (or the other nineteen essayists in Empires of Visions) don’t specifically call out Cassirer’s Objekt-philosophy or notions of object-ness, there is a sense that each object (or, more specifically, each image) contains a physical, psychological, and cultural element – Cassirer’s writing intended that triad to include history.
In other words, it isn’t enough to simply have a physical tangibility and psychological meaning; to really read and understand objects, one has to read and understand their history. “For the physical, the psychic, and the historical do in fact necessarily belong to the concept of the cultural object [Objekt]. They are the three elements from which it is constructed…It must be situated historically in its place in time, it must be examined with respect to age and origin, and it must be understood as the expression of certain fundamental psychic attitudes, with which we can, in some way, empathize. Thus physical, historical, and psychological concepts continually enter into the description of a cultural object.” For projects like Empires of Vision, it is difficult to imagine any essay in it not conveying this kind of historical reading; this seems to be at the very core of the collection’s scholarship.
The power of Empires of Vision is in its trans-disciplinary scope, but is also in its ambition. The themes and essays come together and prod the reader to consider the multi-dimensionality of image and empire. It moves beyond mere collections and museums; it moves beyond observed and observer. Empires of Vision examines the nature of empire through oft-forgotten and frequently overlooked historical characters.
It gives voice and presence to those who are visually depicted in the projects of empire writ large, but it also gives presence to the act and staying power that such depiction created. The editors leave us with their assessment, “Without attending to the role visual cultures does play, no history of imperialism can ever claim to be complete. Nor, so these essays also make clear, can a history of Western visually afford to look past to defining role played by the dialectics of recognition and misrecognition, gaze and countergaze, visibility and invisibility that at once undergirded and undermined the imperialist project.”
Lydia Pyne is a research fellow at the Institute for Historical Studies at the University of Texas at Austin. Trained as both an archaeologist and historian of science, her research and writing interests focus on the history of paleoanthropology and archaeology. She is the co-author of The Last Lost World: Ice Ages, Human Origins, and the Invention of the Pleistocene.
 Martin Jay and Sumathi Ramaswamy, Empires of Vision: A Reader (Durham: Duke University Press Books, 2014), pp. 1.
 Ibid, pp. 3.
 Ibid., p. 617-618.
 Ibid., pp 142.
 Ibid., pp. 258.
 Lorraine Daston and Katharine Park, Wonders and the Order of Nature, 1150-1750 (Zone Books, 1998).
 Ernst Cassirer, The Logical of the Cultural Sciences (New Haven: Yale University Press, 2000), pp. 57.
 Jay and Ramaswamy, Empires of Vision, p 618-619.
Cassirer, Ernst. The Logical of the Cultural Sciences. New Haven: Yale University Press, 2000.
Daston, Lorraine, and Katharine Park. 1998. Wonders and the Order of Nature, 1150-1750. Zone Books, 1998.
Jay, Martin, and Sumathi Ramaswamy. Empires of Vision: A Reader. Durham: Duke University Press Books, 2014.
This past weekend I attended the Reframing Disaster conference held under the auspices of the Postcolonial Disaster project at the University of Leeds. The conference motto was “disaster is not an event”, highlighting the processes and long-term consequences of catastrophes. I led a session on zine writing where we collected offline and online voices on environmental justice. The conversation will continue under the hashtag #RDzine, and the digital zine will soon be online.
Elsewhere on the web, disasters, displacement and recovery were discussed from various perspectives. Elizabeth Angell in her guest post on Savage Minds positions risk, blame and risk communication within the story of the 2009 earthquake in L ‘Aquila, Italy. In this case, seven experts and scientists had been charged with involuntary manslaughter for failing to adequately warn the public about the risks of an earthquake that struck L’Aquila in 2009 and resulting in 297 deaths (the ruling was reversed on November 11th for six of the seven convicted). Angell refers to Mary Douglas’ cultural theory of risk and argues that as an anthropologist she is interested in the cultural contexts of politics of risk and responsibility.
Risks of climate-sensitive environmental disasters include population displacement. The Nansen Initiative, a governmentally funded process aiming to put climate change and displacement on the UN agenda, specifically refrains from defining climate-induced displaced persons as refugees. Over at anthropologyworks, Barbara Miller and Sean Carey cite a report by Louise Redvers in allfrica that discusses the politics of funding allocation for (internally) displaced persons and refugees. The problem: labeling potentially creates artificial distinctions. On the other hand, as stated by the Nansen initiative, legally displacement and seeking refuge are separate processes. And, as allafrica quotes Dawn Chatty, professor of anthropology at the University of Oxford: “not everybody wants to be called a refugee”. The potential for representational violence within these terminologies would be an interesting topic to look at.
Rising sea levels are one type of climate-induced slow-onset disasters. In “Water’s Edge. The crisis of rising sea levels”, Reuters reports in longform about the risks and preparations U.S. coastal regions are facing.
Justin Elliott’s “Crisis of Trust at the Red Cross” at Guernica covers a survey of American Red Cross employees, the majority of whom responded they did not see a bright future for the Red Cross. Finally, why do we help others during disasters at all? Michelle Trudeau at NPR writes about a scientific explanation: altruism is possibly physically rooted in the brain.
Other links of interest:
A photo update on Ferguson: “Scenes from Ferguson – and beyond” – Slate
Disaster painted: “Hieronymus Bosch, the Trendiest Apocalyptic Medieval Painter of 2014″ - The Atlantic
“Violence against women and girls” – The Lancet
and related: “Do online death threats count as free speech?” - New York Times
And on a more lighthearted note:
Zombie disasters in “Ghosts are back!” – New York Times
Une vie politique [A Political Life]
Interviews with P. Artières and E. Favereau, with the collaboration of Joséphine Gross.
Editions du Seuil, Paris, 2014
On 25 September 1984, Daniel Defert wrote a letter to his friends proposing that they create a non-profit organization to address an emerging disease: AIDS. “In face of a medical crisis and a moral crisis, which is also an identity crisis, I propose that we create a space for reflection, solidarity and transformation,” he wrote. A few weeks later, the association AIDES (which means “help” in French) was founded. Its objective was to address the HIV/AIDS epidemic through community outreach, awareness campaigns and political lobbying. It remains the largest HIV/AIDS-related organization in France.
Thirty years later, Defert, who is a sociologist and was Michel Foucault’s partner, recounts his time at AIDES in a new book entitled Une vie politique (A Political Life). This publication is significant not only because Defert played such a key role in the HIV/AIDS movement for decades and thus has a unique perspective on the epidemic, but also because, surprisingly, the author has written very little on the subject. In spite of his involvement with AIDES, his sociological research had nothing to do with HIV, dealing mostly with the study of travel writing.
While HIV/AIDS activism in France has been the subject of several studies (Pinell, 2002; Dodier, 2003; Broqua, 2006; Le Talec, 2008; Girard, 2013), this book offers additional insight into the first years of the epidemic in France. An ethnographic and intellectual work, A Political Life is essential reading for anyone wishing to understand the birth of HIV/AIDS activism in France.
A Political Life is a biographical and reflective look at Defert’s political journey, told through personal interviews with the activist conducted by historian Philippe Artières and Eric Favereau, a journalist for the left-leaning French newspaper Libération. It also contains a second section containing previously unpublished or rare essays, speeches and articles written by Defert.
The first section of the book consists of ten biographically-oriented chapters. The first five of these explore Defert’s intellectual and political journey before the HIV/AIDS epidemic. Defert’s life, at the time, was political in more ways than one: the self-discovery of his homosexuality in France in the 1950s, his activism against the Algerian war, then his Maoist affiliations and his involvement in the Groupe d’Information sur les Prisons (Prison Information Group) during the 1970s. Defert’s trajectory is emblematic of the radicalization of activists in pre- and post-1968 France. The year 1968 is an important point of reference in French history as the country was shaken by a massive social movement, beginning with student protests and quickly expanding into a general strike. The movement was a political reaction to the conservative post-war regime of general and president Charles de Gaulle, but also a manifestation of the politicization of a generation of young men and women. May 1968 opened the door for the emergence of the feminist movement as well as the gay and lesbian liberation movement, among others. Defert and Foucault, who were Maoist sympathisers in the 1970s, later joined other social movements, notably the anti-psychiatry movement and the anti-prison movement. The common thread in all of these movements is their critical stance towards the objectification and institutionalization of individuals by the state. Therefore, these five chapters shed light onto the origins of Defert’s political philosophy, which is founded on a belief that actions taken to mitigate the HIV/AIDS epidemic and raise awareness about it should come from the grassroots rather than from governmental organizations, a stance that inevitably informed the construction and orientation of AIDES.
In Chapter 6, Defert discusses the social and historical context of Foucault’s death in June 1984. Facing the HIV/AIDS epidemic, the gay community in France was far from united, paralysed by fear of contracting the disease, misinformation, as well as the fear of the stigmatisation of gay men. On the medical front, without any treatment options, physicians did not know how to deal with the disease. Foucault’s doctors lied to Defert, telling him that Foucault did not have AIDS, though they were fully aware that he was dying of it. The experience deeply angered Defert, and he cites it as one of the factors that led him to create AIDES.
Chapter 7 outlines the origins of AIDES. Since its creation AIDES has defined itself above all as deeply involved in a social movement dedicated to awareness around HIV/AIDS, built by those afflicted by the disease and their loved ones. According to Defert, this is what permitted the group to be successful at a time in France when most homosexuals still lived in secrecy. For the founders of AIDES, one’s identity (both individual and group) as homosexual should not be the basis from which to combat the HIV/AIDS epidemic: the group distanced itself from individual confessions, both of one’s homosexuality and of one’s HIV status (“l’aveu”). Instead, the activists involved with AIDES strove to create a collective voice about the disease, rather than making the disease a rallying point for the construction of homosexual identity. It is this issue that created conflict, starting in the late 1980s, between AIDES and Act Up-Paris, a chapter of the New York-based AIDS advocacy group.
The mobilization model used by AIDES was distinct from pre-existing charitable or medical approaches to other diseases such as cancer and tuberculosis. AIDES’s model focused on a singular conception of activism around the group’s own definition of “volontaire”. In French, the term “volontaire” (“volunteer”) is more neutral than the term “bénévole” (also glossed as “volunteer”), which has a more religious and sometimes condescending connotation (as the cared for and the caregiver are not considered equals). AIDES wanted the word “volontaire” to evoke an equality between the two—it could be translated as “buddy” (as it was in the US) or “ally”. Being a “volontaire” was characterized by a commitment to grassroots activism and also to acquiring both practical and emotional skills to help those afflicted with the disease, though a training program within the organization.
This training process helped foster the development of the lay expertise that became the hallmark of AIDES and the wider societal mobilization to combat the HIV/AIDS epidemic in France. AIDES taught these “volontaires” not only how to provide support to those living with the disease, but also how to interact as equals with physicians and researchers. By doing so, AIDES introduced a new form of partnership with public health officials and the media in France. The objective was to convince them of the need for a non-coercive approach to the disease.
Quickly, the organization was able to establish its activities in many different areas: grassroots support for HIV-positive people either in hospitals or in their homes, the creation of a telephone helpline, informational meetings, prevention brochures, and other activities. The support groups created by AIDES also played a central role in the association, which Defert implicitly links to Foucault’s idea of “technologies of the self”: “If [in my vision of AIDES] I stress the importance of the support groups, it is because the special intimacy created in the groups was not centred, I believe, around personal confession but rather facilitating access to both the self and the other, as a part of the same movement (…) Through these groups, a new discourse has been produced in which the most intimate became collective and at the same time political “(p.165–6).
In Chapter 8, Defert discusses the internal conflict that caused divisions between Defert and other members of AIDES in 1986-87. The project that ignited tensions was the creation of a “sérotheque“: a databank containing blood samples of HIV-positive men, run by the association for the purpose of research. Far from being a hiccup in the organization’s history, this conflict exacerbated ongoing tensions about the strategic direction of the group. Through the “sérotheque” project, dissidents were attempting to direct the association towards a more substantial focus on medical research. For Defert, this represented a challenge to the group’s founding principles. By orienting activism towards the medical profession, he felt AIDES would be stepping away from the grassroots model it was founded on. In the end, Daniel Defert’s vision won out: AIDES remained an association of “volontaires”, organized around the lay experience of the disease. However, as a result of the conflict, many of the founders of AIDES left the group and joined another organization, Arcat-Sida (Association for research, communication, and action for access to treatment-AIDS).
Chapter 9 outlines the expansion of AIDES, as it moved beyond its Parisian origins and opened offices in other regions of France during the late 1980s. During this time, the group encountered several challenges, some linked to its expansion and others related to conflicting beliefs about the appropriate orientation of AIDES and similar groups. In the early 1990s, issues emerged around the decision to move toward the professionalization of the organization (having paid employees versus being entirely volunteer-run). At the same time, the creation of Act Up-Paris in 1989 sparked new tensions within the HIV/AIDS activist movement in France. Unlike AIDES, Act Up activists were focused more on their identity as gay, HIV-positive men. For Defert, this homosexual-identity–based orientation of the group opposed the community-based health approach that included all people affected by the disease, regardless of race, sexual orientation or gender. But the two associations also differed on strategies vis-à-vis the state: as opposed to Act Up’s highly confrontational relationship with the state, Defert offered a “pedagogy of society” (p.189), which involved a more cooperative approach and sought to create alliances between those afflicted and affected by the disease and public health officials.
In Chapter 10, Defert recounts the end of his presidency at the organization. In 1991, his successor, Arnaud Marty-Lavauzelle, a gay psychiatrist living with HIV, embodied a new image and orientation for the association. From that point forward, its actions became increasingly focused on clinical trials and international solidarity. In the conclusion, Defert looks to the past and highlights the originality of early AIDES HIV/AIDS activism: “I think this kind of associative [non-profit] work is not only to experiment, to invent answers or to fill gaps in state interventions. Its historical function is to question the moral values of a society “(p.205).
The book’s second section contains a selection of some of Defert’s political writings and communications from 1971 to 2001, consisting of fifteen articles in non-academic journals, essays in collective works on HIV/AIDS, as well as several public speeches. These rare documents were previously only available in archives and specialized libraries and inaccessible to a wide audience (Hirsch, 1991). The book notably includes his famous 1984 letter, quoted at the beginning of this article, his public speech on the patient as “a social reformer” (given in Montreal in 1989) as well as his essay on the “homosexualization” of HIV/AIDS, published in the French gay and lesbian weekly newspaper Gai Pied in 1990.
The book has a few shortcomings, most of which relate to topics left unaddressed or under-addressed. The first shortcoming is chronological: the book covers Defert’s presidency in detail (1984–1991), but only briefly discusses the rest of the organization’s history. The reader is left wondering about the author’s perspective on more recent developments in the HIV/AIDS epidemic, current forms of activism and involvement in the movement, as well as debates around prevention. The second concerns the author’s opinions of the other associations involved in the fight against HIV/AIDS. Though Act Up is mentioned, the reader is only provided with a superficial understanding of the group. Comparisons between the social movements in France versus those in other countries are also rare. As a result, Defert’s experience sometimes comes across as being isolated from the larger picture. Lastly, the author makes little reference to the research conducted in the social sciences on the epidemic. Though he himself is a sociologist, Defert does not accord much significance to academic research around HIV/AIDS, which was still only in its infancy in the 1980s, but came to play an increasingly important role through the next decade and up to the present day.
A Political Life is nonetheless a significant book not only because it offers insight into one of the key players in the development of AIDES, which remains one of the largest HIV/AIDS organizations in Europe, but also because it is an exciting intellectual contribution to the understanding of the epidemic.
Gabriel Girard is a sociologist and postdoctoral fellow at l’Institut de recherche en santé publique of l’Université de Montréal (Canada) and Collège d’études mondiales (France). His work focuses on risk, biomedicalization, HIV prevention and gay men. He writes about ongoing research activities on his blog : www.gabriel-girard.net. He can be reached on Twitter at @gbrlgirard and by email at email@example.com
The “Foreign Correspondents” series features reviews of books published in languages other than English. It is edited by Stephanie Lloyd (Laval University). If you would like to suggest a non-English language book for review or if you are interested in reviewing for “Foreign Correspondents,” please contact Stephanie directly at firstname.lastname@example.org.
Broqua Christophe. Agir pour ne pas mourir! Act Up, les homosexuels et le sida. 2006. Paris: Presses de Sciences Po
Dodier Nicolas. 2003. Leçons politiques de l’épidémie de sida. Paris: Éditions de l’EHESS
Girard Gabriel. 2013. Les homosexuels et le risque du sida. Individu, communauté et prevention. Rennes: Presses Universitaires de Rennes
Hirsch Emmanuel. 1991. AIDES. Solidaires. Paris: Éditions du Cerf
Le Talec Jean-Yves. 2008. Folles de France. Repenser l’homosexualité masculine. Paris : La découverte
Pinell Pinell (Dir.). 2002. Une épidémie politique. La lutte contre le sida en France, 1981-1996. Paris: Presses Universitaires de France
Caring as existential insecurity: quarantine, care, and human insecurity in the Ebola crisis by Sung-Joon Park
In August of this year, when the Ebola outbreak escalated in Liberia and a state of emergency had been declared for the country, Fatu Kekula, a young Liberian nursing student, improvised personal protective equipment (PPE) to care for her father, mother, sister, and cousin. After three of the relatives survived, her method was featured prominently in the international news media as the “trash bag method” (CNN, 2014). The reports were meant to ignite a spark of hope in the Ebola epidemic in Guinea, Sierra Leone, and Liberia. International organizations, like UNICEF, even started to promote this ‘better-than-nothing’ method. In most other Ebola reports, by contrast, health workers in white or yellow PPEs, collecting dead bodies or admitting sick patients to isolation units, have come to symbolize the grim and desperate situation in the region. What strikes us most in the story of Kekula’s improvised PPE is how notions of security and safety are reinscribed into gloves, trash bags, and rubber boots to enable a form of care in the context of a broken health system. When we recall that during the first months of the epidemic many people were caring for their sick relatives without any protection measures, then Kekula’s trash bag method reveals quite dramatically how care itself has become a source of existential insecurity.
In this piece we pull together a set of observations on quarantine measures and care to ask how security is embodied in everyday practices of care in a public health system which is short of the beds and basic equipment needed to address Ebola. To follow this question, it is necessary to ask how global health has transformed the intricate relationship between security and care, turning care into a source of existential insecurity. Moreover, are there alternative views on security and care which may help to orient global health approaches to the Ebola epidemic?
Between security and care
The prevalence of unprotected and unrecorded practices of care at hospitals and at homes, as well as the death of more than 5,000 people, have to be understood against the background of a public health system that even in normal times is hardly able to provide and sustain basic health services: Kekula’s father was first turned away by several hospitals occupied by Ebola patients, before he was eventually admitted. It is assumed that he contracted Ebola in the hospital and was taken home by his daughter, as the hospital was unable or unwilling to help him. However, the media coverage of Kekula’s trash bag method ignores the more fundamental and underlying questions of ‘What alternatives did Fatu have?’ and ‘Who else would have cared for her sick relatives?’
What the current outbreak certainly shows is that Ebola does not easily fit into the logic of global health. Both quarantine measures to contain the spread of Ebola and the establishment of isolation units to care for patients require extensive infrastructure. Médicins Sans Frontières’ (MSF) humanitarian intervention in Guinea, which ran for several months before it eventually reached the limits of its capacities, revealed the enormous logistical challenges of moving tons of material to maintain a few isolation units and provide care to Ebola patients. The national public health systems in the affected countries were hardly able to replicate these efforts.
Such problems are characteristic of global health challenges more broadly. The extraordinary amount of funding for global health was over the last few years largely spent on life-saving medicines like antiretrovirals, antimalarials, test kits, and other equipment to address HIV, malaria, and tuberculosis. Little or no attention was paid to the importance of a functioning public health system. According to Uli Beisel, global health operates in a spatio-temporal logic of “vertical and time-bound projects” (Beisel, 2014), privileging measurable impacts and focusing on specific diseases. In the view of most global health organizations investments into public health systems are not easily measured and accounted for. Medicines and equipment are largely distributed through projects constituting a complex and fragmented global health infrastructure that bypasses national public health systems.
It is crucial to note that Ebola was not even entirely off the global health agenda. According to Andrew Lakoff, one has to distinguish two regimes of global health (Lakoff, 2010). The humanitarian side of global health’s attempts to respond to emergency situations—this would include the MSF operations in Guinea, and then in Sierra Leona and Liberia—dovetails with two decades of intensive work on the creation of a global infrastructure for pandemic preparedness in the name of global health security. These infrastructures include high-tech futuristic isolation wards, where trained personal can approach infected people, as protective gears allow for hermetic isolation of the caregiving individual. But such an understanding of security is largely preoccupied with its application in Western settings and is less concerned with the translatability of the concept into non-Western settings. Thus in a response to calls to step up quarantine measures, Laurie Garrett, a global health specialist, cautions that the “hubris is the greatest danger in wealthy countries – a sort of smug assumption that advanced technologies and emergency-preparedness guarantee that Ebola and other germs will not spread” (Garrett 2014).
The convergence of these two regimes of global health in the Ebola crisis reflects a biopolitical moment in global health. Foucault’s analysis of security as a dispositif may be useful in capturing how pandemic preparedness inscribes a distinct notion of security into technologies and infrastructures to contain Ebola. Following Foucault (2007), such technologies reveal a political rationality to regulate populations by isolating ‘bad’ circulations from ‘good’ circulations (protective care from dangerous care, infected from non-infected people moving across space and time). The difference between underequipped hospitals in Sierra Leone, Liberia, and Guinea turning away sick people and their relatives and the trust or illusion that 50 beds in specialized clinics in Germany or France are able to contain the spread of Ebola in Europe reflects the uneven distribution of security in global health infrastructures. According to Guillaume Lachenal and Vinh-Kim Nguyen, the geopolitics in these infrastructures of pandemic preparedness “produced this Ebola epidemic” (Lachenal, 2014; Nguyen, 2014).
What interests us most is how contradictions in these two overlapping regimes of global health turned hospitals and public health systems in Liberia, Sierra Leone, and Guinea into vectors for Ebola (Abramowitz 2014). Furthermore, these contradictory regimes of security and care form the background for understanding how practices of care became an existential insecurity. For Benjamin Hale, the tragedy of Ebola is that this epidemic “preys on care and love” and ultimately on “humanity” (Hale, 2014). This tragedy involves confusion and dilemmas about how and by whom patients will be cared for. According to public health instructions, patients should not be touched—not at the isolation wards in the hospital nor at home. One risk indicator for Ebola that summarizes the problem of existential insecurity is “have you helped someone confirmed with Ebola?“ But how should one not help nor care? What does care mean when closeness, intimacy, and sociality must be avoided? Instructions to report relatives with Ebola to hospitals immediately may have in fact been one of the first confusions in Ebola responses. Once patients and their relatives reach a hospital, they are often told to wait, as most hospitals are short in beds. Ebola patients, including those at risk, are only admitted to isolation units if someone dies; even then, these units often lack gloves, medicines, PPEs, and other basic equipment, transforming hospitals into hot zones of infection. Families are discouraged from burying their dead and are told to wait for government agencies to come and collect the dead bodies. The isolation of infected individuals from families and the prevention of burying them with proper rituals undermines the intuitive response to take greater care in times of distress and crisis. For healthcare workers, safety and care too is a dilemma. MSF employees are aware of this dilemma: “It is very hard to turn down patients and to know also there are many people out there that don’t have the possibility to come in.” Health workers are rigorously instructed to implement safety measures in underequipped hospitals. In spite of this, hundreds of health workers (and doctors) have already died, aggravating the lack of staff at hospitals.
These dilemmas demonstrate that care goes beyond the provision of medical relief. Matters of individual and collective security are at stake. Care is a technology of belonging, which restores security by producing closeness, intimacy, and trust. In current efforts to step up quarantine measures, these dimensions of care constitute a risk for contracting Ebola. While the measures are necessary, our major concern is that ignoring a broader notion of security in care may lead to exacerbate the confusions, mistrust, and stigma in current global health interventions to contain Ebola.
Human security – an alternative notion of security to understand care in crisis?
The reports and comments depict the tragedies and vicious circles in the embodiment of care in isolation units and at homes by health workers, patients, and their wider networks. The confusions created by current global health suggest that prevailing notions of security are insufficient to capture how care has become an existential insecurity.
Certainly, immediate action is now needed to contain Ebola and provide medical support so that as many patients as possible survive the virus. Still, we believe that it is not too late to embark on a discussion of alternative notions of security. As the Ebola epidemic has clearly surpassed the reach of biomedical interventions and requires a political response, we need to think more urgently about alternative notions of security, in order to build a more consistent global public health response, which goes beyond the current militarization of Ebola interventions (Waal 2014).
A few of our observations on the nexus of safety, insecurity, and care call for elaboration. First, it strikes us that the concept of human rights has so far played only a minor role in the discussion of quarantine measures. A human rights framework may prove to be useful to open a discussion about whose individual freedoms and human dignity are at stake in quarantine measures. Protecting individuals from contracting Ebola is certainly necessary, but large-scale militarized interventions, cordoning off cities, districts, and whole regions raise the question of how far quarantine measures can be expanded. In regards to the detrimental effects of such measures, the scope of quarantine measures cannot be determined by global health rationalities and individual governments alone. Yet, there is little public debate, which reflects the emergence of novel moral and political borders in the militarization of Ebola epidemic. A human rights perspective may help to steer such a debate and mobilize a broader range of actors and organizations to improve care. By contrast, to paraphrase the philosopher Mary Zournazi, if we only evoke security for our benefit, ignoring others’ loss of security, we run risk of creating a global public health system based on fear (Zournazi, 2003, p. 15).
A human rights framework is certainly not enough to capture how care itself has become an existential insecurity. Another important impulse to address these insecurities may come out of the concept of ‘human security’, which has been discussed for some years by authors like Mary Kaldor and Thomas Hylland Eriksen (Kaldor, 2007; Eriksen, 2010). This concept was originally fuelled by critical engagements with the securitization of development and humanitarian interventions (Duffield, 2005). To counter these tendencies, this concept has been promoted to construct a people-centered, rather than state-driven, notion of security.
The concept of human security builds upon ongoing human rights advocacy, but argues that freedom from want and fear must be the main pillars of any program aimed at addressing people’s experiences of radical insecurity under current conditions of globalization. The emphasis on a people-centered approach to security is most crucial for understanding how Fatu Kekula, whom we mentioned above, and many others maintain care under radically changed circumstances. Human security is in this respect a holistic framework that captures the complex interactions between post-Cold War conflicts, natural disasters, poverty, social inequality, and broken institutions, which all characterize the point of origin of the spread of Ebola in Guinea, Sierra Leone, and Liberia.
What does an understanding of security as freedom from fear and want mean for global public health? We believe it could be taken as a point of departure to embark on efforts to understand health as a global public good and reflect critically on the securitization of public life. Such an understanding in turn underlines the importance of stronger health institutions in reducing existential insecurities. Care is the most important but also the most vulnerable institution to address human insecurities arising out of the nexus of war, poverty, and disease in the Ebola crisis. Taking the complex interplay of these insecurities into account is not only helpful to fully understand the contradictions in current Ebola responses, but also essential for prompting a more holistic response. Despite of its holistic ambition, it is not a new concept. International organizations have been using it already as an analytic framework (e.g. Human Security Commission 2003; World Bank 2011). It thus does not contradict the demand for immediate action. What it does, hopefully, is prompt a people-centered notion of security, which we are desperately missing in debates on what to do against Ebola.
Sung-Joon Park is a lecturer at the Department of the University of Leipzig. He received his PhD in Anthropology from the University of Halle and worked at the Max-Planck-Institute for Social Anthropology in Halle. He is currently working on a book manuscript with the title Hope in Global Health, which looks at the stock-out of antiretroviral medicines in mass HIV treatment programmes in Uganda and explores the contradictions and hopes of contemporary global public health.
René Umlauf is a research fellow at Bayreuth University. He works in the collaborative research program “Translating Global Health Technologies: Standardisation and organisational learning in health care provision in Uganda and Rwanda,” funded by the German Research Foundation. He is currently pursuing his PhD in Sociology with a thesis on the introduction of novel technologies for the treatment and diagnosis of malaria in Uganda.
Abramowitz, Sharon Alane. “How the Liberian Health Sector Became a Vector for Ebola.” Fieldsights – Hot Spots, Cultural Anthropology Online, October 07, 2014.
Duffield, Mark. 2005. Getting savages to fight barbarians: Development, security and the colonial present. Conflict, Security & Development 5 (2): pp. 141–160.
Eriksen, Thomas Hylland. 2010. Human security and social anthropology. In A World of Insecurity: Anthropological Perspectives on Human Security. Ed. Ellen Bal and Oscar Salemink. London: Pluto.
Foucault, Michel. 2007. Security, Territory, Population : Lectures at the Collége De France, 1977-78. Basingstoke: Palgrave Macmillan.
Garrett, Laurie- 2014. “Five Myths about Ebola.” Washington Post. 10 October 2014.
Hale, Benjamin. “The Most Terrifying Thing About Ebola: The disease threatens humanity by preying on humanity.“ Spate, 19 September 2014.
Human Security Commission. 2003. Human security now. New York: Human Security Commission.
Jefferys, Anne. “In Sierra Leone’s Ebola hot zone: A series of reports.” Irin News 10 October 2014.
Kaldor, Mary. 2007. Human Security: Reflections on Globalization and Intervention. Cambridge, UK; Malden, MA: Polity.
Lakoff, Andrew. 2010. Two regimes of global health. Humanity 1 (1): 59–79.
Lachenal, Guillaume. 2014. “Ebola 2014. Chronicle of a well-prepared disaster.” 31 October 2014.
Nguyen, Vinh-Kim. “Ebola: How We Became Unprepared, and What Might Come Next.” 7 October 2014.
“Dying of Ebola at the Hospital Door.” New York Times, 11. September 2014.
Irin News; “Ebola workers urge safety, solidarity”; 14 October 2014;
Waal, Alex de. 2014. “Militarizing Global Health.” Boston Review.
World Bank. 2011. World Development Report 2011: Conflict, Security, and Development. Washington, DC: World Bank
Zournazi, Mary. 2003. Hope: New Philosophies for Change. New York: Routledge. p. 15.
 On September 29 John Campbell, a Senior Fellow for African Policy Studies at the Council on Foreign Relations emphasized in a video message that “the affected African states cannot stop Ebola without outside help. Quarantine, tracing contacts and treatment for Ebola victims requires the resources only the international community can provide.” While nobody would dispute the need of international collaboration and combined efforts to tackle the epidemic ironically the statement was aired a couple of days before nurses in Spain (October 5) and the US (October 12) contracted the virus during quarantine treatment of two infected patients.
In anticipation of the American Anthropological Association’s annual conference in Washington DC from December 3-7, we wanted to point out a number of panels on which various members of Somatosphere’s editorial team will be presenting, as well as several other interesting panels, roundtables, lectures, and events:
On Wednesday, December 3rd from 12-1:45pm in Jefferson will be the session “Uncertainty and scenario,” organized by Limor Samimian-Darash (Hebrew University) and Jon Bialecki (University of Edinburgh) and featuring Ryan J. Sayre (Yale University, Meg Stalcup (University of Ottawa), James D. Faubion (Rice University), Tomas A. Matza (Duke University), Elizabeth Angell (Columbia University), and Janet Roitman (The New School for Social Research).
On Wednesday, December 3rd from 12-1:45pm in Washington Room 4 will be the session “Anthropology of becoming,” organized by Joao Biehl (Princeton University) and Bridget Purcell (Princeton University) and featuring Angela N. Garcia (Stanford University), Lucas Bessire (University of Oklahoma), Adriana M. Petryna (University of Pennsylvania), and Michael M.J. Fischer (MIT).
On Wednesday, December 3rd from 2-3:45pm in Washington Room 3 will be the session “What possessed you: Sovereignties, selves, and spirits (Part II),” organized by J. Brent Crosson (New York University) and featuring Alexander Rocklin (Independent Scholar), Netta R. van Vliet (Duke University), Sara M. Bergstresser (Columbia University), Louis P. Romer (New York University), Bruce M. Knauft (Emory University), and Morten Axel Pedersen (University of Copenhagen).
On Wednesday, December 3rd from 2-3:45pm in Marriott Balcony B will be the session “‘Global’ knowledge, ‘local’ care, and subjectivity: Producing an anthropology of psychosis,” organized by Neely A. Myers (Southern Methodist University) and featuring Ippolytos A. Kalofonos (University of California), Michael Joseph D’Arcy V (University of California Berkeley), Emily Ng (University of California Berkeley), Mary-Jo Del Vecchio Good (Harvard University), Elizabeth Bromley (University of California Los Angeles), and Janis H. Jenkins (University of California San Diego).
On Wednesday, December 3rd from 4-5:45pm in Washington Room 5 will be the session “Metabolizing environment: Anthropology of metabolism between molecular and eco-political scales,” organized by Amy Moran-Thomas (Brown University) and Nadine Levin (University of Exeter) and featuring Michael A. Fortun (Rensselaer Polytechnic Institute), Ian Whitmarsh (University of California San Francisco), Michael Montoya (University of California Irvine), Harris S. Solomon (Duke University), and Lenore H. Manderson (University of the Witwatersrand).
On Thursday, December 4th 9-10:45am in Marriott Ballroom Salon 3 will be the session “What constitutes medical knowledge? Part 1 of a discussion of Affliction with Veena Das” organized by Clara Han (Johns Hopkins University) and featuring Janet F Carsten (University of Edinburgh), Sophie Day (Goldsmiths, London), Gregoire Hervouet-Zeiber (Johns Hopkins University), Anne M Lovell (INSERM University Paris Descartes), Veena Das (Johns Hopkins University), and Michael Lambek (University of Toronto).
On Thursday, December 4th 11-12:45pm in Marriott Ballroom Salon 3 will be the session “What constitutes medical knowledge? Part 2 of a discussion of Affliction with Veena Das” organized by Clara Han (Johns Hopkins University) and featuring Arthur M Kleinman (Harvard University), Michael M.J. Fischer (MIT), Aditya Bharadwaj (Graduate Institute of International and Development Studies), Vincanne Adams (University of California, San Francisco), Richard Rechtman (Ecole des Hautes Etudes en Sciences Sociales), and Veena Das (Johns Hopkins University).
On Thursday, December 4th from 11-12:45pm in Congressional A will be a roundtable honoring the work of Richard Shweder – “Universalism without uniformity, Part I: Best practices? Morality and Cultural Pluralism” organized by Julia Cassaniti (Stanford University) and Usha Menon (Drexel University) and Robert LeVine (Harvard University), John Lucy (University of Chicago), Fuambai Sia Ahmadu, Pinky Hota (Smith College), Thomas S Weisner (University of California Los Angeles), Jacob R Hickman (Brigham Young University), and Stanton E F Wortham (University of Pennsylvania).
On Thursday, December 4th from 11-12:45pm in Thurgood Marshall West will be the session “Re-imagining paths not taken: Conversations with Emily Martin on culture and mind,” organized by Emily C. Cohen (City University of New York) and featuring Karen-Sue Taussig (University of Minnesota), Monica L. Schoch-Spana (University of Pittsburgh Medical Center), Dana Walrath (University of Vermont), Emily Yates-Doerr (University of Amsterdam), Wenrui Chen (New York University), Dwaipayan Banerjee (New York University (NYU) and Dartmouth College), and Lorna A. Rhodes (University of Washington).
On Thursday, December 4th from 2:30-4:15pm in Virginia Suite A will be the session “Assembling the biosocial: Embodied environments, health and modes of interdisciplinarity in the life sciences and anthropology,” organized by Eugene A. Raikhel (University of Chicago) and Stephanie J. Lloyd (McGill University) and featuring Des Fitzgerald (King’s College London), Nikolas Rose (King’s College London), Ilina Singh (Kings College London), Elizabeth F. S. Roberts (Univerisity of Michigan), Daniel H. Lende (University of South Florida), Martine Lappe (University of California Los Angeles), and Maurizio Meloni.
On Thursday, December 4th from 6:30-8:15pm in Virginia Suite A will be the session “The role of anthropologist as teachers: Innovative strategies for helping students learn about violence,” organized by Catherine M. Mitchell Fuentes (University of North Carolina at Charlotte) and featuring M. Nell Quest (Rutgers-Robert Wood Johnson Medical School), Rachel A. Hall-Clifford (Agnes Scott College and NAPA-OT Field School), Christine M. Labuski (Virginia Tech), Nia C. Parson (SMU), Catherine M. Mitchell Fuentes (University of North Carolina at Charlotte), and Deanna E. Barenboim (Sarah Lawrence College).
On Thursday, December 4th from 6:30-8:15pm in Washington Room 2 will be the session “Encountering epidemiology: Risk, uncertainty, and the politics of evidence,” organized by Jennifer A. Liu (University of Waterloo) and Thurka Sangaramoorthy (University of Maryland) and featuring Katherine A. Mason (Columbia University and Brown University), Jennifer A. Liu (University of Waterloo), Adia Benton (Brown University), and James Trostle (Trinity College).
On Friday, December 5th from 9-10:45am in Roosevelt Room 5 will be the session “Producing data, cracking data cultures,” organized by Megan M. Foreman (University of Pittsburgh) and Natasha D. Schull (MIT) and featuring Helene Mialet (University of California Berkeley), Jamie Sherman (Intel Labs), Christopher M. Kelty (University of California, Los Angeles), and Lucy Suchman (Lancaster University).
On Friday, December 5th from 9-10:45am in Washington Room 5 will be the session “Microbes and (in)corporeal infrastructures: Producing visibility in the age of the microbiome,” organized by Alex M. Nading (University of Edinburgh) and Frederic Keck (Musee du Quai Branly and CNRS) and featuring Amber Benezra (New York University), Erin Koch (University of Kentucky), Andrew Lakoff (USC), David Napier, and Thomas D. Cousins (Stellenbosch University).
On Friday, December 5th from 1:00-2:15pm in Johnson the Science, Technology, and Medicine Interest Group of the SMA will hold its open business meeting.
On Friday, December 5th from 2:30-4:15pm in Taft will be a roundtable honoring the work of Richard Shweder – “Universalism without uniformity, Part II: One mind, many mentalities – Self, health, and emotion” organized by Julia Cassaniti (Stanford University) and Usha Menon (Drexel University) and featuring Byron J Good (Harvard University), Tanya M Luhrmann (Stanford University), Janis H Jenkins (University of California San Diego), Charles William Nuckolls (Brigham Young University), and Lene Arnett Jensen (Clark University).
On Friday, December 5th the Society for Medical Anthropology will hold its business meeting, awards ceremony, and presidential address in the Empire Ballroom from 8:30-10:30pm. A reception with a cash bar will follow
On Saturday, December 6th from 9-10:45am in Roosevelt Room 2 will be the session “Grammars of obligation: Substance, matter and life in anthropology,” organized by Aaron Goodfellow and featuring Jane Bennett (Johns Hopkins University), Sruti Chaganti (Johns Hopkins University), Columba Gonzalez Duarte (University of Toronto), Isaias Rojas-Perez (Rutgers University – Newark), Thomas D. Cousins (Stellenbosch University), and Sylvain Perdigon (American University of Beirut).
On Saturday, December 6th from 9-10:45am in Marriott Ballroom Salon 3 – Blue will be the session “Role playing games, interpersonal engagement, and wellbeing,” featuring Greg Batchelder (University of Alabama), Jeffrey G. Snodgrass (Colorado State University), and Nicholas J. Mizer (Texas A&M University).
On Saturday, December 6th from 9-10:45am in Jackson will be the session “Successful aging: The anthropology of a 21st-century obsession,” organized by Sarah E. Lamb (Brandeis University) and Jessica C. Robbins-Ruszkowski (Wayne State University) and featuring Susan R. Whyte (University of Copenhagen), Anna I. Corwin (University of California, Los Angeles), Mark R. Luborsky (Wayne State University), Chulanee Thianthai (Chulalongkorn University), Jessica C. Robbins-Ruszkowski (Wayne State University), and Janelle S. Taylor (University Washington).
On Saturday, December 6th from 2:30-4:15pm in Truman will be the session “Ordering, morality and triage: Producing medical anthropology beyond the suffering subject, part 2: Mental health and illness,” organized by Nolan Kline (University of South Florida) and Bo Kyeong Seo (Australian National University) and featuring Murphy J. Halliburton (Queens College and Graduate Center, CUNY), Zhiying Ma (University of Chicago), Hanna Kienzler (King’s College London), Jennie M. Simpson (American Anthropological Association), Katie Kilroy-Marac (University of Toronto Scarborough), and Shana Lessing (City University of New York Graduate Center).
On Saturday, December 6th from 2:30-4:15pm in Wilson A will be the session “‘Care’ful consideration: Examining notions of care within and toward ethnography,” organized by A. Elizabeth DeLuca (University of California Irvine) and Aaron T. Seaman (University of Chicago) and featuring Chloe Silverman (Drexel University), Janelle S. Taylor (University Washington), Mareike Winchell (University of California Berkeley), Matthew Furlong (University of Chicago), Athena McLean (Central Michigan University), and Andrea P. Sankar (Wayne State University).
On Saturday, December 6th from 4:30-6:15 in Marriott Ballroom Salon 2, Bruno Latour (Sciences Po) will deliver the AAA Distinguished Lecture: “Anthropology at the time of the anthropocene: a personal view on what is to be studied.”
On Saturday, December 6th from 6:30-8:15pm in Washington Room 3 will be the session “Bio-logics of American citizenship: Medicine, science and the state,” organized by Matthew J. Wolf-Meyer (University of California, Santa Cruz) and featuring Seth D. Messinger (CRSR and UMBC), Anna B. Zogas (University of Washington), and Karen-Sue Taussig (University of Minnesota).
On Saturday, December 6th from 6:30-8:15pm in Johnson will be the session “Critical engagements with ‘community’ in global public health,” organized by Anna M. West (Stanford University) and Lindsey J. Reynolds (Stellenbosch University) and featuring Damien Droney (Stanford University), Clare Cameron (UCSF/UC Berkeley), Salla Sariola (University of Oxford), and Oliver Human (University of Amsterdam).
On Sunday, December 7th from 8-9:45am in Maryland Suite A will be the session “The ‘Coefficient of Weirdness': Paranoia, conspiracy, and the unintelligible in rational institutions,” organized by Leo Coleman (The Ohio State University) and Noelle J. Mole (New York University) and featuring Bill Maurer (University of California Irvine), Talia Dan-Cohen (Washington University in St. Louis), and Elizabeth Anne Davis (Princeton University).
by Johan Asplund
Bokförlaget Korpen, 1987/2000, 268 pages.
Johan Asplund, whose work has been rather underrepresented in the international academic arena, is frequently seen as the “father” of contemporary Swedish social psychology. Remarkably productive, Asplund gained popularity in the 1970–1980s, and his books are still widely used in academic curricula across the country (Eriksson, 2005). The Elementary Forms of Social Life is one of Aslpund’s most famous and favored writings. Released in 1987, it introduces a distinctive view of the nature and mechanisms of sociality: the theory of social responsiveness. The concept is employed to explain a concrete social phenomenon – burnout – and, thus, has the potential to attract the attention of academics, policy makers, and the general public. The author refers to a variety of social and philosophical theories, as well as to fiction literature, although his ground is symbolic interactionism, which sees an individual as a social creature and thus virtually inconceivable outside relationships with others.
The book comprises three parts that are organized as a discussion of the fundamental aspects of human sociality. Each chapter is divided into a number of subsections, which facilitate the reader’s navigation. The book opens with an extended introduction that outlines the main concepts therein and provides a brief overview of the text. This is followed by a detailed presentation of the central theoretical framework (Chapter 1), a discussion of burnout in terms of the theory of social responsiveness (Chapter 2), and the author’s ideas on the implications of his findings for the foundations of social psychology as an academic field (Chapter 3). I will focus on the first two chapters as directly related to the issue of the social determinants of health and illness.
Asplund borrows the notion of “elementary forms” of social life – a collective basis of individual behavior (p. 30) – from the classics of social theory, striving to develop a distinctive social-psychological conception, grounded in the notion of social responsiveness. Social responsiveness is pre-normative but not pre-linguistic, potentially creative and destructive, driven by spontaneity to make up a social individual. Asplund explains: “That a human is a responsive creature means just that she has a general tendency to respond to stimuli” (p. 33, my translation here and throughout), although, in contrast to reflex, the response is never pre-programmed. Responsiveness is not a mechanistic and standardized reaction, and a responsive individual appears as an “interested creature” (p. 34).
To exemplify the concept of social responsiveness as an elementary form of social life, Asplund reflects upon an interaction between a kite and kite flyer. The kite’s free-floating movements in the sky and its erratic “reply” to the directions of the kite flyer help to illustrate the type of unstructured social exchange associated with social responsiveness. In the introductory chapter, the author warns the reader not to take the example literally: the kite flyer just “imagines the activity to be social,” “personifying” the kite or “taking its position,” in Herbert Mead’s terms (p. 15). Similarly, in another example of the interaction between a car and a driver, Asplund does not claim to acknowledge the agency of non-humans (objects and machines), as do Callon (1986) and Latour (2005), relying instead on elaborations of symbolic interactionism about an ongoing conversation between different parts of the self. This idea becomes especially useful in the further discussion on burnout, which I will turn to shortly.
Extreme forms of responsiveness may produce contradictory effects and, therefore, are frequently subjected to societal control. Asplund discusses the phenomenon of fetishism as an exaggerated manifestation of social responsiveness resulting from obsession with an object or stimulus and one’s eventual identification with it, followed by a stimulus-response stereotypy. He explains: “The fetishist emerges as a libidinous machine. The ambiguous and uncertain social responsiveness becomes unambiguous and deterministic. The fetish is confusingly similar to a key stimulus, something which triggers a fixed pattern of motions” (p. 74). When social responsiveness reaches its extreme, it transforms into social reflex and may play out as deviant actions that society tends to control by means of total institutions, such as psychiatric clinics and prisons. Asplund refers to the Foucauldian notion of “discipline” to explain a mechanism of the societal regulation of responsiveness. The spontaneity of stimulus-reaction relationships becomes restricted and organized. Discipline works through the invention of time scheduling, isolation, and the suppression of elementary affective replies.
Social responsiveness is considered in a complex relationship with its opposition, namely elementary asocial unresponsiveness or natural tiredness, leading to a switch of focus from the current to another stimulus (p. 13). Apart from that, the author elaborates on the notion of secondary asocial unresponsiveness as an effect of life in modern society. Natural attitude becomes restricted by in-socialized norms and developed rituals. The Little Prince, a fairy-tale by Antoine Saint Exupéry, is introduced as an example to ensure the reader’s comprehension of the concept. A childhood failure in getting adults to recognize a snake that swallowed an elephant uncovers a gap between the early-age social responsiveness and the secondary asocial unresponsiveness of the grown up and civilized individual. The prince appears as a “genius in social responsiveness,” whose behavior is authentic, informal, and meaningful (p. 115). His behavior contrasts with modern sociality, structured and limited by norms and (self-) regulations, a world of interactions characterized by self-absorption, lack of imagination, isolation, insensitivity, and standardization. Asplund emphasizes that ritualization of social life leads to the development of asocial unresponsiveness in society members suppressing social improvisation.
In the second chapter, the author replies to the Christina Maslach’s book Burnout: The Cost of Caring, published in 1985, with respect and a number of critical points, followed by a reformulation of the central phenomenon – burnout – in terms of the theory of social responsiveness. According to Maslach, burnout affects professionals whose labor content presupposes social interactions, such as in the sphere of welfare and service provision (e.g., a psychologist or social worker). Asplund immediately notices that many of these professions are relatively new, and, moreover, they deal with social interactions shaped by practices and ideologies of (post) industrial society. Burnout is “a process and a product of the social interactions” (p. 142). It manifests, according to Maslach, with three symptoms: emotional exhaustion, depersonalization, and a limited effectiveness of job performance (p. 143). Asplund is interested in emotional exhaustion, which is explained with the metaphor of an empty pot. This pot was once filled with water that had eventually evaporated. Thus, emotions appear as an internal resource of a person that is brought into social relationships from within and consumed. Asplund resists such a “mechanical” interpretation of emotions – “as if feelings would be petrol and that a social worker consequently would need to be filled up after the end of the workday” (Ibid.) – and the separation of emotions from interactions.
Work overloads, workplace conflicts, and unclear working requirements are some of the prerequisites of burnout for Maslach, but for Asplund, a tired social worker shouting at a client or a tired school principal who quits his job after several tough years does not necessarily suffer from burnout. What should be stressed instead, he insists, is an absence of feedback that would come as recognition of one’s existence: “If one is assumed as non-existing, so finds one oneself in a risk zone for burnout, or the experience of non-existence is already a full-developed burnout” (p. 149). Emotions are constitutive for feedback. They can be imagined as a “pendulum” in the interactive process: “When burnout has happened, the pendulum has stopped beating between ego and alter” (p. 150). Thus, burnout originates outside the individual as an outcome of social interactions; the absence of a response aborts emotionality (Ibid.).
What can cause this condition? One’s identification with their social role as a result of misbalanced relationships between the socialized and the affective part of the self, replies Asplund. In the context of the “abstract sociality” that emerged as a byproduct of the industrial-era modernization and the expansion of social sciences, people increasingly live in a “clean and empty, and abstract society”, “an invisible but omnipresent medium which pervades all specific social institutions, without coinciding with them and instead is somehow separate from them or stands above them” (p. 152). Asplund insists that burnout is a morbid state of an “abstract individual in an abstract society” (Ibid).
Abstract sociality is non-productive and blank. Interactions are not internally grounded and enacted for their own sake. Responses are “pure,” feelings are “empty”; they emerge and subside in a formalized exchange (p. 171). Concrete sociality, in contrast, is focused and meaningful. It is like a flow of the lively exchanges in which “[r]esponses and feelings do not need to consume themselves without power to speak outside” (Ibid.). Asplund acknowledges that concrete sociality is not without shortcomings (e.g., domestic conflicts). Furthermore, natural tiredness can cause a state of elementary asocial unresponsiveness, which is, however, differentiated from burnout. A doctor, who associates fully with the role of a mass-service provider, develops fixed routines and a style of reception of patients as “abstract social beings”, should be defined, according to Asplund, as suffering burnout; even beyond that, “[O]ne cannot harbor caring with abstract social creatures, empathize with them or treat them in a personal way, especially not if oneself is forced to act as an abstract social creature. Consequently, there will be not only burnout, but burnout plus a feeling of guilt” (p. 173).
Maslach’s book concludes with an emphasis on physical exercise and psychological relaxation, and Asplund does not find much new in this suggestion. He instead problematizes the role of relaxation courses as rather strengthening an individual’s experience of the self as an abstract being involved in an abstract activity. Burnout is not about the exhaustion that results from an overload of work; it signifies a shortage or lack of social responsiveness in contemporary society, which is dominated by abstract social relationships. “The pure, empty and abstract sociality is a reality and we cannot escape it. We cannot take off our social creature, our role-playing doppelganger, as if it was an overcoat” (p. 178). The only way to deal with burnout, as follows from the book, is by fostering social responsiveness in society members and the re-humanization of both private and professional interactions.
Asplund is rather an atypical writer, very popular, but hardly fully accepted within the national academic domain (Eriksson, 2005), probably due to his trans-disciplinary ambition and certain fascination with an underrepresented field of social psychology. However, his view on burnout and his critique of Maslach’s US-based studies can be seen as reflecting a particularity of the national intellectual and social-economic landscape. The developed Swedish labor protective legislation and practices, as well as the expansion of welfare state in the spheres of health care and social work (Lundström and Wijstrom, 1997) that tend to entail institutionalization, professionalization and, eventually, industrialization of service provider-consumer relationships, allow one to imagine the specific type of burnout described in Asplund’s theory. Work overload seems to be not the primary issue in the national context. Instead, the scholar views the formalization of social interactions as a major risk factor for people’s wellbeing at work. He is somewhat pessimistic in his prognosis and offers a rather limited range of solutions, since the reason for burnout is defined not as individual-psychological, but as emerging from a wide social transformation toward the standardization of different spheres of social life. Asplund appear to long for the unstructured interactions that he believes are essential and fundamentally healthy for the individual. Psychological troubles, in his view, result from suppressing and disciplining the elementary social spontaneity. This interpretation contrasts with yet another US-based exchange-type theory of overwhelming work duties and unsatisfying emotional feedback that service workers increasingly receive from their customers (Hochschild, 2005). Asplund’s book can hardly clarify whether burnout is the same for American flight attendants and health care workers in Sweden, but it certainly provokes this question and offers an alternative theoretical framework to assist the search for possible answers. The contextualization of Asplund’s writing allows the recognition of its value for a contemporary discussion of the issues of health and social-psychological wellbeing.
Lika Rodin is a lecturer in social psychology at the University of Skövde, Sweden.
The “Foreign Correspondents” series features reviews of books published in languages other than English. It is edited by Stephanie Lloyd (Laval University). If you would like to suggest a non-English language book for review or if you are interested in reviewing for “Foreign Correspondents,” please contact Stephanie directly at email@example.com.
Asplund, J. (1987). Det sociala livets elementära former. Göteborg: Bokförlaget Korpen.
Callon, M. (1986). Some elements of sociology of translation: Domestication of the scallops and the fishermen of St Brieuc Bay. In J. Law (ed.), Power, action and belief: A new sociology of knowledge? (pp. 196–223). London: Routledge & Kegan Paul.
Eriksson, B. (2005). Johan Asplund: Ideas and positions. Acta Sociologica, 48(4), 284–291.
Hochschild, A.R. (2005). The managed heart: Commercialization of human feeling. Berkley, Los Angeles, London: University of California Press.
Latour, B. (2005.) Reassembling the social: An introduction to Actor–network theory. Oxford New York: Oxford University Press.
Lundström, T., and Wijstrom, F. (1997). The nonprofit sector in Sweden. Manchester and NY: Manchester University Press.
Two journals recently published special issues on the emergence of Global Mental Health as a coherent, recognizable “formation of knowledge and practice seeking to address mental illness on a global scale” (Bemme and D’souza 2012). Together, the articles address the contours of the category, as well as the challenges and possibilities it presents, from a range of perspectives.
First, the October issue of the International Review of Psychiatry is a special issue, “Globalization, Culture and Mental Health,” guest edited by Rachel Tribe and Stephen Melluish. The issue and its content arise out of a conference held at the University of Leicester in 2012. As Tribe and Melluish write in their editorial:
While much of the tone of this special edition is critical of globalization as aligned with neoliberal capitalism, there is acknowledgement that globalization has also created new momentum for defending local uniqueness, individuality and identity. Psychology and psychiatry in the West has obviously reflected the norms and values of this region, but there are increasing calls for psychology and psychiatry to concern themselves more with global issues and culture, and a call for protecting indigenous psychologies. This special issue aims, in a small way, to develop awareness of applied psychology and psychiatry across the globe. It offers a critical perspective on any universalizing approach or any misguided imposition of westernized notions and raises the importance of a psychological perspective on how cultural and social differences play out in a global context and impact on people’s mental health and well-being. The message from the papers in this edition is that applied psychologists can make a contribution to the debates and discussions around globalization by offering more nuanced understandings of cultural differences and of indigenous psychologies.
The twelve articles that follow, along with Dinesh Bhugra’s closing commentary, productively explore this tension of globalization and mental health.
Globalization, culture and psychology
This article outlines the cultural and psychological effects of globalization. It looks at the impact of globalization on identity; ideas of privacy and intimacy; the way we understand and perceive psychological distress; and the development of the profession of psychology around the world. The article takes a critical perspective on globalization, seeing it as aligned with the spread of neoliberal capitalism, a tendency towards cultural homogenization, the imposition of dominant ‘global north’ ideas and the resultant growing inequalities in health and well-being. However, it also argues that the increased interconnectedness created by globalization allows for greater acknowledgement of our common humanity and for collective efforts to be developed to tackle what are increasingly global problems. This requires the development of more nuanced understandings of cultural differences and of indigenous psychologies.
Surprisingly little has been published directly from user/survivors in the burgeoning (and sometimes contentious) field of global mental health (GMH). This is important both ethically and practically if GMH is to benefit from the experiential expertise that user/survivors can bring, especially when they come from those lower or middle income countries (LMICs) where GMH programmes are targeted. Whether user/survivors from higher income countries (HICs) (whose experiential expertise has usually been developed in cultural/social/health/ economic/political contexts which are very different to those in LMICs) could also provide useful input to GMH is less clear. In this article I consider this directly from my perspective as a user/survivor in a HIC. I discuss how, in spite of contextual differences, there appear to be striking resonances between GMH in LMICs and mental health in HICs, particularly areas of concerns, e.g. diagnosis, treatment and cultural difference. I illustrate this using aspects of my own personal experience in a reflexive narrative way, and suggest that such narrative-illustrations could provide useful input in GMH. I also touch on other ways in which HIC user/survivors might become involved in GMH. I conclude by stressing that, however HIC user/survivors become involved in GMH, they must do so ethically, ensuring that those in LMICs always remain at the forefront.
The concept of globalization has been applied recently to ways in which mental health may be developed in low- and middle-income countries (LMICs), sometimes referred to as the ‘Third World’ or developing countries. This paper (1) describes the roots of psychiatry in western culture and its current domination by pharmacological therapies; (2) considers the history of mental health in LMICs, focusing on many being essentially non-western in cultural background with a tradition of using a plurality of systems of care and help for mental health problems, including religious and indigenous systems of medicine; and (3) concludes that in a post-colonial world, mental health development in LMICs should not be left to market forces, which are inevitably manipulated by the interests of multinational corporations mostly located in ex-colonizing countries, especially the pharmaceutical companies.
Increasing mental health capacity in a post-conflict country through effective professional volunteer partnerships: A series of case studies with government agencies, local NGOs and the diaspora community
Rachel Tribe, Dilanthi Weerasinghe, and Shanthy Parameswaran
The focus of this paper is on working in partnership with local practitioners and communities to strengthen local capacity building in the area of mental health and well-being in Sri Lanka. This paper will examine the context, organizing concepts, organizational processes, and the development of good working relationships and partnership building behind this work. Our involvement was based on requests which came to the authors as a result of their previous work in Sri Lanka over several decades. This work had been undertaken on behalf of the UK–Sri Lanka Trauma Group (UKSLTG), a UK-based charity which was set up in 1994, and of which the authors are founding members (www.uksrilankatrauma.org.uk). In the first section of the paper, contextual issues will be discussed. The second section of the paper provides details of the training undertaken on mental health promotion among young people in Sri Lanka for the Directorate of Mental Health. The third section of the paper reviews work undertaken with a major psycho-social/mental health organization on issues relating to writing and implementing an ethical code for mental health practitioners and briefly discusses some of the dilemmas associated with this.
Current status of psychology and clinical psychology in India – An appraisal
Baboo Sankar Virudhagirinathan and Subbiah Karunanidhi
This paper provides an overview of the social and cultural context for the emergence and development of psychology in India and also more specifically of the development of clinical psychology. It details the range of universities offering psychology programmes and the various bodies involved in supporting the development of the psychology. The paper also describes the development of clinical psychology in India and the variety of roles undertaken by clinical psychologists. Finally, it raises a number of issues facing the development of Indian psychology into the future.
Developing cognitive behaviour therapy training in India: Using the Kolb learning cycle to address challenges in applying transcultural models of mental health and mental health training
Andrew Beck, B. S. Virudhagirinathan, Sangita Santosham, and Faiz Jahan Begum
Although mental health workers in India across all major professional groups have identified an unmet need for training in cognitive behaviour therapy (CBT), the uncritical export of models of mental health, therapy provision and training to low- and middle-income countries is a problematic process. This paper describes the context for the first stand-alone CBT training programme in India, based in Chennai. This paper includes an evaluation of the first phase of the training and information from trainees regarding the quality and applicability of the training to their working context. The paper provides an overview of some of the critiques that are pertinent to this process and considers the way that the Kolb learning cycle can be used as a framework within training to go some way to addressing these difficulties.
Globalization of psychology: Implications for the development of psychology in Ethiopia
Rachel Swancott, Gobinderjit Uppal, and Jon Crossley
The present article reports on the variation of mental health resources across the globe and considers the merits or otherwise of the process of globalization in low- and middle-income countries (LMIC), with a specific emphasis on Ethiopia. Although globalization has gained momentum in recent years, there is a concern that the globalization of Western mental health frameworks is problematic, as these concepts have been developed in a different context and do not accommodate the current diversity in understanding in LMIC countries. The importance of understanding the mental health frameworks of LMIC like Ethiopia, prior to considering if and how aspects of high-income countries (HIC) conceptualizations may be appropriately imported, is therefore reflected upon. Traditional approaches in managing mental health difficulties and possible reasons for the limited engagement with clinical psychology in Ethiopia are considered. Current developments within the fields of mental health and clinical psychology in Ethiopia are discussed, and the need to develop more local research in order to increase understanding and evaluate treatment interventions is recognized. Further consideration and debate by Ethiopian mental health professionals as well as those from HIC are recommended, to promote both reciprocal learning and new local discourses about mental health.
The introduction and development of psychology in Ethiopia has been mainly limited to Addis Ababa University in the capital city, and also to educational and school psychology which was highly influenced by the field of education at this pioneering university. Similarly, mental health services have been principally developed at the Amanuel Mental Hospital in Addis Ababa that has existed since the 1950s. However, the expansion of higher learning institutions on one hand, and the apparent growing prevalence of mental illness on the other, seem to have contributed to the development of both mental health training and services in other regional cities and towns. Although the influence of the education-oriented psychological training of the Addis Ababa University is still present, clinical psychology education and services are now being started in other universities. One of these is the master’s programme in clinical psychology opened for the first time in the University of Gondar. This article sheds light on the development of psychology in Ethiopia and addresses some of the issues raised about the factors that have influenced its development such as traditional beliefs, poverty and comparisons between mental health in lower middle-income countries and higher middle-income countries (Uppal et al., 2014). The paper also proposes future directions for the education, research, infrastructure and services of clinical psychology and mental health in Ethiopia.
Globalization has created great transformations, not only in economics, but also in social and cultural relations, and has influenced political practices and governments. If not critically analysed, globalization may at first appear positive, but, in parallel with its development, high levels of poverty and exclusion have occurred and these may affect men and women differently. The objective of this article is to reveal the subjective or individual consequences that derive from globalization and the contexts it creates. This analysis centres on a gender perspective within a Cuban context and tries to challenge the prevailing view of the most poor and excluded groups. Psychiatry and psychology have a long way to go in the search for an understanding of the impact of globalization on human well-being, but critical thinking and the social sciences can offer an alternative to the transformation of this constructed order by giving prominence to people’s own subjectivities and experiences.
Cuban internationalism – An alternative form of globalization
Maria Castro, Steve Melluish, and Alexis Lorenzo
This paper looks at how the principles of internationalism have been integral to the Cuban healthcare system and to Cuba’s cooperation and medical support in other countries around the world. The paper details the range and scope of Cuban health internationalism and the principles that underpin the Cuban approach of long-term collaboration, humane care, contextualization, trans-disciplinarity, respect for collective/historical memory and an ethical stance. The paper details the role of Cuban psychologists who have contributed to disaster relief work and gives an example of the Cuban approach in relation to Haiti following the earthquake in 2010.
Counterflows for mental well-being: What high-income countries can learn from Low and middle-income countries
Ross White, Sumeet Jain, and Catalina Giurgi-Oncu
Global mental health is a comparatively new area of study and research that is concerned with addressing inequities and inequalities in mental health provision across the globe. In recent years concerted efforts have been made to scale up mental health services in low- and middle-income countries (LMIC). As such, there has been tendency to view LMIC as recipients of mental health-related knowledge, rather than providers of knowledge. Critics have referred to the prevailing flow of information from high-income countries (HIC) to LMIC as a form of medical imperialism. To redress the apparent imbalance in knowledge exchange, this paper reflects on valuable lessons that HIC can potentially learn from LMIC in terms of supporting mental well-being. Specifically, the paper reflects on how a greater willingness to embrace pluralism in HIC may facilitate people to engage with forms of support that they believe to be appropriate for them. The paper also explores examples of what are termed ‘counterflows’ of knowledge; ideas that have originated from LMIC that are influencing mental health-related practice in HIC. Barriers to potential counterflows are discussed.
Using a cultural formulation for assessment of homicide in forensic psychiatry in the UK
Ali Ajaz, John Owiti, and Kamaldeep Bhui
Healthcare inequalities for black and minority ethnic (BME) patients in forensic mental health services in the UK are stark. Despite the level of attention given to this over the last 15 years there has been little progress to address disparities. There is a great deal of confusion over what is understood by culture, and what aspects of culture signal specific needs of BME patients. In addition, we have a lack of empirical research demonstrating what it means for psychiatrists to be culturally competent. These are all important barriers against progress in this area. Using a homicide case study that illustrates the typical issues encountered in practice, we explore how to use a cultural formulation in order to assess the role of culture within a forensic psychiatry setting. Finally, practical advice is offered to assist expert witnesses in preparing court reports that adequately consider the significance of defendants’ cultural beliefs and practices.
Globalization, culture and mental health
Individual changes due to the impact of globalization and also resulting cultural changes may be at conflicting positions, especially in the area of expressing and managing emotional and psychological distress. In this volume, Tribe, Melluish, and their colleagues have brought together a rich smorgasbord of intellectual thoughts on the subject of globalization. This topic is likely to give rise to a range of increasing possibilities, challenges, and discussions in the future and may require our continued attention as the inter-relationships between globalization, culture, and mental health continue to evolve. The heterogeneous response of cultures to globalization could be seen as a positive step. However, powerful and profitable vested interests resist criticism for their actions, but have to be challenged. As clinicians, each of us has a major responsibility to advocate for our patients to ensure that their interests are maintained and indeed protected.
Second, the December issue of Transcultural Psychiatry also addresses the subject in a special section entitled “Global Mental Health“. (For a write-up in Somatosphere of the conference that led to this publication, see Bemme and D’souza 2012). Abstracts for the articles, along with an introduction by Laurence Kirmayer and Duncan Pedersen, are below.
Toward a new architecture for global mental health
Laurence J. Kirmayer and Duncan Pedersen
Current efforts in global mental health (GMH) aim to address the inequities in mental health between low-income and high-income countries, as well as vulnerable populations within wealthy nations (e.g., indigenous peoples, refugees, urban poor). The main strategies promoted by the World Health Organization (WHO) and other allies have been focused on developing, implementing, and evaluating evidence-based practices that can be scaled up through task-shifting and other methods to improve access to services or interventions and reduce the global treatment gap for mental disorders. Recent debates on global mental health have raised questions about the goals and consequences of current approaches. Some of these critiques emphasize the difficulties and potential dangers of applying Western categories, concepts, and interventions given the ways that culture shapes illness experience. The concern is that in the urgency to address disparities in global health, interventions that are not locally relevant and culturally consonant will be exported with negative effects including inappropriate diagnoses and interventions, increased stigma, and poor health outcomes. More fundamentally, exclusive attention to mental disorders identified by psychiatric nosologies may shift attention from social structural determinants of health that are among the root causes of global health disparities. This paper addresses these critiques and suggests how the GMH movement can respond through appropriate modes of community-based practice and ongoing research, while continuing to work for greater equity and social justice in access to effective, socially relevant, culturally safe and appropriate mental health care on a global scale.
Why mental health matters to global health
Global health has been defined as an area of study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. This article provides an overview of some central issues in global mental health in three parts. The first part demonstrates why mental health is relevant to global health by examining three key principles of global health: priority setting based on the burden of health problems, health inequalities and its global scope in particular in relation to the determinants and solutions for health problems. The second part considers and addresses the key critiques of global mental health: (a) that the “diagnoses” of mental disorders are not valid because there are no biological markers for these conditions; (b) that the strong association of social determinants undermines the use of biomedical interventions; (c) that the field is a proxy for the expansion of the pharmaceutical industry; and (d) that the actions of global mental health are equivalent to “medical imperialism” and it is a “psychiatric export.” The final part discusses the opportunities for the field, piggybacking on the surge of interest in global health more broadly and on the growing acknowledgment of mental disorders as a key target for global health action.
Global mental health research is needed to inform effective and efficient services and policy interventions within and between countries. Ethical reflection should accompany all GMHR and human resource capacity endeavors to ensure high standards of respect for participants and communities and to raise public debate leading to changes in policies and regulations. The views and circumstances of ethno-cultural and disadvantaged communities in the Majority and Minority world need to be considered to enhance scientific merit, public awareness, and social justice. The same applies to people with vulnerabilities yet who are simultaneously capable, such as children and youth. The ethical principles of respect for persons or autonomy, beneficence/non-maleficence, justice, and relationality require careful contextualization for research involving human beings. Building on the work of Fisher and colleagues (2002), this article highlights some strategies to stimulate the ethical conduct of global mental health research and to guide decision-making for culturally responsible research, such as developing culturally sensitive informed consent and disclosure policies and procedures; paying special attention to socioeconomic, cultural, and environmental risks and benefits; and ensuring meaningful community and individual participation. Research and capacity-building partnerships, political will, and access to resources are needed to stimulate global mental health research and consolidate ethical practice.
Challenges of creating synergy between global mental health and cultural psychiatry
Joop T. V. M. de Jong
This article addresses four major challenges for efforts to create synergy between the global mental health movement and cultural psychiatry. First, although they appear to share domains of mutual interest, the worlds of global mental health and cultural psychiatry have distinct lineages. Expanding their horizons by learning from adjacent disciplines would be mutually beneficial. A second challenge concerns the conceptualization of a new classification system for mental health problems. Adopting a classification system that integrates new insights from socio-neurobiology and from a networks perspective could bring cultural psychiatry and global mental health closer and change the way each field addresses the mental health gap, which constitutes the third challenge. I summarize attempts to achieve comprehensive mental health coverage around the globe and question whether the strategies employed to achieve these goals have been successful, both in high- (HIC) and low- and middle-income countries (LMIC). In LMIC, the dominant strategy needs to be complemented by mobilization of other community resources including local practitioners. A fourth challenge is the lack of mathematical models to guide action and research and solve major preoccupations such as access to care or multi-level analyses in complex ecological or health systems.
Ritual healing and mental health in India
Ritual healing is very widespread in the Indian state of Uttarakhand, and is by far the most common option for those with serious behavioral disturbances. Although ritual healing thus accounts for a very large part of the actual health care system, the state and its regulatory agencies have, for the most part, been structurally blind to its existence. A decade of research on in this region, along with a number of shorter research trips to healing shrines and specialists elsewhere in the subcontinent, and a thorough study of the literature, suggest that such techniques are often therapeutically effective. However, several considerations suggest that ritual healing may not be usefully combined with mainstream “Western” psychiatry: (a) psychiatry is deeply influenced by the ideology of individualism, which is incompatible with South Asian understandings of the person; (b) social asymmetries between religious healers and health professionals are too great to allow a truly respectful relationship between them; and (c) neither the science of psychiatry nor the regulatory apparatus of the state can or will acknowledge the validity of “ritual therapy”—and even if they did so, regulation would most likely destroy what is most valuable about ritual healing. This suggests that it is best if the state maintain its structural blindness to ritual healing.
Global mental health and its discontents: An inquiry into the making of global and local scale
Doerte Bemme and Nicole A. D’souza
Global Mental Health’s (GMH) proposition to “scale up” evidence-based mental health care worldwide has sparked a heated debate among transcultural psychiatrists, anthropologists, and GMH proponents; a debate characterized by the polarization of “global” and “local” approaches to the treatment of mental health problems. This article highlights the institutional infrastructures and underlying conceptual assumptions that are invested in the production of the “global” and the “local” as distinct, and seemingly incommensurable, scales. It traces how the conception of mental health as a “global” problem became possible through the emergence of Global Health, the population health metric DALY, and the rise of evidence-based medicine. GMH also advanced a moral argument to act globally emphasizing the notion of humanity grounded in a shared biology and the universality of human rights. However, despite the frequent criticism of GMH promoting the “bio”-medical model, we argue that novel logics have emerged which may be more important for establishing global applicability than arguments made in the name of “nature”: the procedural standardization of evidence and the simplification of psychiatric expertise. Critical scholars, on the other hand, argue against GMH in the name of the “local”; a trope that underlines specificity, alterity, and resistance against global claims. These critics draw on the notions of “culture,” “colonialism,” the “social,” and “community” to argue that mental health knowledge is locally contingent. Yet, paying attention to the divergent ways in which both sides conceptualize the “social” and “community” may point to productive spaces for an analysis of GMH beyond the “global/local” divide.
On January 17th 2014, Catherine Eagles, a federal judge for the Middle District of North Carolina, struck down as unconstitutional a portion of North Carolina’s 2011 Women’s Right to Know Act. The portion in question would have required abortion providers in the state to perform an ultrasound and display and describe the images presented to every woman seeking an abortion. Eagles concluded that this so-called “speech-and-display provision” was “performative rather than informative” and therefore served no medical purpose. She determined this in part because the original text of the law suggested that women might choose not to look at these ultrasound images: “Nothing in this section shall be construed to prevent a pregnant woman from averting her eyes from the ultrasound images required to be provided to and reviewed with her.” In a 42-page memorandum outlining her decision, Eagles wrote, “Requiring a physician or other health care provider to deliver the state’s content-based, non-medical message in his or her own voice as if the message was his or her own constitutes compelled ideological speech and warrants the highest degree of First Amendment protection.”
Abortion rights advocates in North Carolina hailed the ruling as an important victory. Yet the remainder of the Women’s Right to Know Act still stands: women must receive counseling with specific, state-mandated information at least 24 hours prior to an abortion procedure. To comply with the law, then, an abortion provider must “deliver a content-based, non-medical message in his or her own voice.” In our ongoing project, we are examining how abortion providers in North Carolina have grappled with this legal mandate. We have been especially interested in the social, ethical, and communicative dimensions of scripted abortion counseling.
Scripts play a key role in anthropology and science and technology studies. Foundational concepts like cultural scripts and technological scripts reflect a disciplinary preoccupation with the ways in which certain domains of human social life are partially predetermined. Yet the potential for social actors to stray from the script to improvise new possibilities and create new modes of action is also embedded in these concepts. In other words, the very presence of any script implies its logical opposite: that we also speak and act in fundamentally unscripted ways. In this way, the script reflects longstanding tensions in contemporary theoretical debates—between structure and agency, determinism and emergence, constraint and possibility, compulsion and choice.
Scripts are ubiquitous in science and medicine. Hospital procedures, informed consent documents, experiment protocols, standardized therapies, and ultrasound technologies all rely on scripts to order work processes, guide thoughts, speech, and action, and specify roles and relationships. As institutionally authored documents, scripts enact and shape worlds by conveying the author’s intended meaning. Yet scripts do more than relay referential meaning. They also produce effects, sometimes unintended, through the ways that they are implemented and performed. Such productivity can help us to bypass the dualisms mentioned above and generate potential new sites of theoretical inquiry.
The script at play in state-mandated abortion counseling is a highly formalized version of a much broader techno-social category. Clinicians rely on various scripts in conversations with patients—for example, asking “What brings you in today?” A few things distinguish abortion counseling scripts from colloquial uses of scripts in medicine: their legally compulsory nature, their selection of particular speech elements, and their capacity to transform healthcare providers into agents of the state. The state, an amorphous political subject, has relatively little power to speak to citizens in everyday life. By compelling providers to speak its message, the state flips the script undergirding most clinical interaction.
Most abortion providers in our study found both the state’s intentions and the potential effects of the counseling script on patients to be objectionable. As one physician told us, “I find it very condescending. As if women aren’t being given proper informed consent or decision-making about their abortion care. While others, you know, like legislatures, are trying to take away their decision-making and autonomy.” Because of this disdain for the script, the many possibilities for undermining its content have been empowering and even liberating. Some providers prefaced the script with disclaimers and apologies. Others read the script “word by word” to show that the words were not their own. Still others set the script in front of the patient to distinguish it as a legal artifact that they viewed as falling outside of normal clinical practice. Each of these actions served to denounce authorship, disaffiliate speakers from the animated content, and invite patients not to listen. Several providers noted that such strategies had the unanticipated consequence of fostering patient-provider rapport, revealing a misalignment between perceived legislative intent and the script’s performance. This highlights how the rift between meaning and intent can cut both ways, working both for and against the author’s agenda.
In our study, providers routinely distinguished scripted abortion counseling from the informed consent procedures that they were already doing prior to the law. As an enumeration of the risks and benefits associated with clinical treatment, drug research, or specimen donation, informed consent also relies on scripts. Providers distinguished the scripts used in state-mandated counseling and clinical informed consent on the basis of whether the content was medically relevant and necessary to women’s informed decision-making. This difference is also implicit in Judge Eagles’ distinction between the performative (i.e. non-medically relevant) and informative functions of the search-and-display provision. In making this distinction, both Judge Eagles and our interlocutors attempted to frame the law as an illegitimate instance of script-flipping—that is, appropriating the language, format, and authoritative voice of informed consent for another purpose. Yet insofar as informed consent is both one of the most routinized scripts in medicine and a paradigmatic example of information delivery in healthcare, this distinction begins to break down. Informed consent assumes the genre of disclosure that many patients in the United States have learned to view as a legal performance, an institutional requirement necessary to move along one’s clinical care. In other words, informed consent procedures have both informative and performative dimensions. By distinguishing between state-mandated abortion counseling and standard informed consent procedures, the providers in our study reified informed consent as purely informative, neglecting the performative dimensions of this everyday scripted practice.
State-mandated abortion counseling is a specialized case of the use of scripts in medicine. Medicine relies on many other taken-for-granted and routinized scripts. One strength of the script for scholars of science and medicine is that it “reads” across the ethical and legal, as in the case of informed consent. In doing so, it shows how the medical and the legal are not separate professional domains but necessarily co-constituted.
Mara Buchbinder is Assistant Professor of Social Medicine and Adjunct Assistant Professor of Anthropology at the University of North Carolina at Chapel Hill. She is author of Saving Babies? The Consequences of Newborn Genetic Screening (with Stefan Timmermans, University of Chicago Press, 2013) and All in Your Head: Making Sense of Pediatric Pain (University of California Press, forthcoming, 2015). Dragana Lassiter is a PhD candidate in the Department of Anthropology at the University of North Carolina-Chapel Hill. She researches bioethics, regenerative medicine, and organ transplant in Serbia. They are grateful for insightful comments from Keith Murphy and Stefan Timmermans, and for the editorial suggestions of Commonplaces Editors Tomas Matza and Harris Solomon.
 For the full legislative text of the North Carolina Woman’s Right to Know Act, see http://www.ncleg.net/gascripts/BillLookUp/BillLookUp.pl?BillID=H854&Session=2011.
 For the full text of this memorandum, see http://dig.abclocal.go.com/wtvd/docs/utrasound_rluling_011714.pdf.
 This work has been supported by grants from the Society for Family Planning and the Greenwall Foundation, in collaboration with Rebecca Mercier, Amy Bryant, and Anne Drapkin Lyerly.
 Madeline Akrich, “The de-scription of technical objects, in Shaping Technology / Building Society. Studies in Sociotechnical Change. W. Bijker and J. Law, eds. (Cambridge, MA: MIT Press, 1992); and Stefan Timmermans, “Saving lives or saving multiple identities?: The double dynamic of resuscitation scripts,” Social Studies of Science, 26(4) (1996): 767–797.
Carr (2011, 191) suggests that script flipping is an example of what Bakhtin (1984) calls vari-directional double-voiced discourse, “in which one’s speech has a semantic intent contrary to that which one mimics.” See E. Summerson Carr, Scripting Addiction: The Politics of Therapeutic Talk and American Sobriety (Princeton: Princeton University Press, 2011). See also Mihkail Bakhtin, Problems of Dostoevksy’s Poetics. C. Emerson, trans. and ed. (Minneapolis: University of Minnesota Press, 1984).
 Erving Goffman, Forms of Talk (Philadelphia, PA: University of Pennsylvania Press, 1981).
 Marie-Andrée Jacob, “Form-made persons: consent forms as consent’s blind spot,” Political and Legal Anthropology Review, 30(2) (2007): 249–268. doi:10.1525/pol.2007.30.2.249
Image: “Lacy Script, by Evelyn Flynt.” Flickr.
Somatosphere seeks a Managing Editor to help run the day-to-day operations of the website, as well as to develop new projects and initiatives. The Managing Editor will work with members of the site’s Editorial Collaborative, regular and guest contributors to: oversee the submission, editing, and formatting of posts; manage the site’s social media presence; and aid in developing new series and projects. We are looking for candidates with: strong written and verbal communication skills; experience in editing scholarly writing; familiarity with WordPress, HTML and social media; a background in a particular field of the social sciences and humanities of medicine, health, and science (anthropology, sociology, history, STS, geography, etc.); a commitment to Somatosphere’s aims and potential. Candidates with experience in academic publishing and/or SEO management are particularly welcome.
This is a part-time paid position, with an expected time commitment of approximately 7-10 hours per week. Candidates can be located anywhere geographically, but must have regular internet access.
Somatosphere (http://somatosphere.net) is a collaborative scholarly website which has been covering the social sciences and humanities of medicine, health, and science — and particularly medical anthropology — since 2008.
Please submit a cover letter, CV, and list of three references to Eugene Raikhel, Editor at eraikhel AT uchicago DOT edu by December 1.
Happy November! Please find below the first half of this month’s roundup including selections from American Ethnologist; Health; Philosophy, Ethics, and Humanities in Medicine; Sociology of Health and Illness; and Social Theory and Health. In addition, Medical Anthropology Theory (MAT) went live this month. There is a previous write-up on MAT on Somatosphere—you can find it here. Enjoy.
The paradoxical victim: Intimate violence narratives on trial in Italy
Victims’ testimony plays a pivotal role in domestic violence hearings in Italy. In examining this role, Gribaldo approaches the Italian legal field as a heterogeneous system of knowledge and power that engages in complex relations with techniques of subjection and discourses of truth and, thus, as eminently suited to investigating the production of the victim-subject. Paradoxically, the testimony of female victims of abuse is trapped between the normativity of justice system requirements and the confessional device, rendering it legally insignificant and thus essentially inadequate. In this context, the women’s credibility and agency are central. Gribaldo outlines one legal case in which race and class intersect and the required modes of testimony are disrupted through the use of communication styles drawn from popular culture.
The context of empowerment and self-care within the field of diabetes
Sasha Scambler, Paul Newton, and Koula Asimakopoulou
There is a growing emphasis within the diabetes literature on the importance of empowerment as a way of encouraging people to take control of and responsibility for the successful management of their disease. Patients are actively encouraged to become active participants in their care, and there is an expectation that health-care professionals will facilitate this process. This article uses Bourdieu’s concept of field, as a bounded social space in which actors conduct their lives day-to-day, to explore the context within which issues of empowerment are addressed and negotiated. The practice of empowerment within the biologically defined and biomedically ‘policed’ field of diabetes is explored using empirical data from a study of diabetes health-care professionals’ understanding and practices around empowerment. It is concluded that rather than promoting active self-management and empowerment, the nature of the field of diabetes, and in particular its privileging of the biomedical, can mitigate against people with diabetes negotiating the field effectively and taking control of the disease and its management.
Local status and power in area-based health improvement partnerships
Katie Powell, Miranda Thurston, and Daniel Bloyce
Area-based initiatives have formed an important part of public policy towards more socio-economically deprived areas in many countries. Coordinating service provision within and across sectors has been a common feature of these initiatives. Despite sustained policy interest in area-based initiatives, little empirical work has explored relations between area-based initiative providers, and partnership development within this context remains under-theorized. This article addresses both of these gaps by exploring partnerships as a social and developmental process, drawing on concepts from figurational sociology to explain how provider relations develop within an area-based initiative. Qualitative methods were used to explore, prospectively, the development of an area-based initiative targeted at a town in the north west of England. A central finding was that although effective delivery of area-based initiatives is premised on a high level of co-ordination between service providers, the pattern of interdependencies between providers limits the frequency and effectiveness of co-operation. In particular, the interdependency of area-based initiative providers with others in their organization (what is termed here as ‘organizational pull’) constrained the ways in which they worked with providers outside of their own organizations. ‘Local’ status, which could be earned over time, enabled some providers to exert greater control over the way in which provider relations developed during the course of the initiative. These findings demonstrate how historically constituted social networks, within which all providers are embedded, shape partnership development. The theoretical insight developed here suggests a need for more realistic expectations among policymakers about how and to what extent provider partnerships can be managed.
This paper critically appraises the discourse around international medical migration at the turn of the 21st century. A critical narrative review of a range of English-language sources, including grey literature, books and research reports, traces the development and spread of specific causative models. The attribution of causative relations between the movement of skilled medical workers, the provision of health care and population health outcomes illustrates how the global reach of biomedicine has to be understood in the context of local conditions. The need to understand migration as an aspect of uneven global development, rather than a delimited issue of manpower services management, is illustrated with reference to debates about ‘brain drain’ of Africa’s health-care professionals, task-shifting and the crisis in health-care human resources. The widespread presumed cause of shortages of skilled health-care staff in sub-Saharan Africa was overdetermined by a compelling narrative of rich countries stealing poor countries’ trained health-care professionals. This narrative promotes medical professional interests and ignores historical patterns of underinvestment in health-care systems and structures. Sociological theories of medicalization suggest that the international marketization of medical recruitment is a key site where the uneven global development of capital is at work. A radical reconfiguration of medical staffing along the lines of ‘task-shifting’ in rich and poor countries’ health-care systems alike offers one means of thinking about global equity in access to quality care.
Roslyn Weaver, Ian Wilson, and Vicki Langendyk
Previous research has pointed to the role television can play in informing health practices and beliefs. Within the academic setting in particular, some educators have raised concerns about the influence of medical dramas on students. Less research, however, draws on the perspectives of students, and this study therefore explores medical students’ perceptions of medical practice and professionalism in popular medical television programs. Qualitative data from surveys of Australian undergraduate medical students showed that students perceived professionalism in dichotomous ways, with three main themes: cure–care, where a doctor’s skill is either technical or interpersonal; work–leisure, where a doctor is either dedicated to work or personal life; and clinical–administration, where work is either direct patient care or administration. There continue to be imagined divisions between curing and caring for students, who express concerns about balancing work and leisure, and expectations that doctors should have little administrative work. Given students were able to identify these important contemporary issues around professionalism on television, there is pedagogical value in using popular images of the medical world in medical education.
The experiences of close persons caring for people with chronic kidney disease stage 5 on conservative kidney management: Contested discourses of ageing
Joe Low, Jason Myers, Glenn Smith, Paul Higgs, Aine Burns, Katherine Hopkins, and Louise Jones
Chronic kidney disease stage 5 is a global health challenge in the context of population ageing across the world. The range of treatment options available to patients at all ages has increased and includes transplantation and dialysis. However, these options are often seen as inappropriate for older frailer patients who are now offered the option of conservative kidney management, which is presented as a non-invasive alternative to dialysis, involving symptom management and addressing psychosocial needs. In this study, we conducted qualitative interviews with 26 close persons caring for someone with chronic kidney disease stage 5 in the United Kingdom to investigate how conservative kidney management interacted with implicit ideas of ageing, in both the experience of conservative kidney management and the understanding of the prognosis and future care of the kidney disease. Our findings highlighted participant confusion about the nature of conservative kidney management, which stems from an initial lack of clarity about how conservative kidney management differed from conventional treatments for chronic kidney disease stage 5. In particular, some respondents were not aware of the implicit palliative nature of the intervention or indeed the inevitable end-of-life issues. Although these findings can be situated within the context of communication failure, we would further argue that they also bring to the surface tensions in the discourses surrounding ageing and old age, drawing on the use of a ‘natural’ and a ‘normal’ paradigm of ageing. In the context of chronic kidney disease stage 5, more patients are being dialyzed at older ages, but conservative kidney management is being advanced as a better option than dialysis in terms of quality of life and experience. However, in doing so, conservative kidney management implicitly draws on a notion of older age that echoes natural ageing rather than advocate a more interventionist approach. The role of discourses of ageing in the provision of treatments for conservative kidney management has not previously been acknowledged, and this article addresses this gap.
Parent-led conferences as sites of medical work
Conferences are novel sites for understanding medical work. Through describing styles of presentation that take place at conferences attended by patients and parents, this article highlights how clinicians on stage present ordinary and extraordinary aspects of medicine. Attention is drawn to the reaction of the parents in the audience. The power of the presenter to direct proceedings highlights the potential vulnerability of the audience. The relationship between clinician on stage and parents in the audience reflects the clinical relationship between doctor and patient. But through identifying insiders and outsiders, the conference setting also enables new relationships and collective identities to be formed. Drawing on an ethnographic study of rare disease conferences, this article extends understanding of medical work by identifying how conferences offer new ways of witnessing the clinical gaze, the doctor–patient relationship and the formation and enactment of a conference community.
Timescapes of obesity: Coming to terms with a complex socio-medical phenomenon
Ulrike Felt, Kay Felder, Theresa Öhler, and Michael Penkler
Obesity is generally considered to be a growing global health problem that results from changes in the way we live in late modern societies. In this article, we argue that investigating the complexities of contemporary timescapes (i.e. the entanglement of physical, culturally framed and personally experienced times) is of key importance for understanding how ‘the obesity phenomenon’ is conceptualized, performed and acted upon. Analyzing both focus groups and print-media articles, we identified three major groups of temporal narratives that shape our perception of obesity: trajectories, temporalities and timing. Each group of narratives follows a different logic and performs a specific kind of ordering work: ontological work that defines what obesity ‘really is’, diagnostic work that assesses the state of contemporary society and moral work that assigns responsibility to act. We show how the narratives are assembled into distinct timescapes that distribute agency in specific ways. Combining data from both focus groups and media articles allows us to analyze how these two discursive arenas are intertwined, as it makes visible how stories travel and converge, but also diverge in quite important ways. This highlights the importance of a multi-arena approach to fully understand the tensions between different framings of health-related issues. The article argues that the difficulties of controlling body weight are closely entangled with a perceived lack of control over time on both collective and individual levels. In conclusion, we suggest time-sensitive approaches for the analysis of health phenomena and the development of corresponding policy measures.
Discourse on medicine: meditative and calculative approaches to ethics from an international perspective
David Cruise Malloy, Ronald Martin, Thomas Hadjistavropoulos, Peilai Liu, Elizabeth Fahey McCarthy, Ilhyeok Park, N Shalani, Masaaki Murakami and Suchat Paholpak
Heidegger’s two modes of thinking, calculative and meditative, were used as the thematic basis for this qualitative study of physicians from seven countries (Canada, China, India, Ireland, Japan, Korea, & Thailand). Focus groups were conducted in each country with 69 physicians who cared for the elderly. Results suggest that physicians perceived ethical issues primarily through the lens of calculative thinking (76%) with emphasis on economic concerns. Meditative responses represented 24% of the statements and were mostly generated by Canadian physicians whose patients typically were not faced with economic barriers to treatment due to Canada’s universal health care system.
Nonconsensual withdrawal of nutrition and hydration in prolonged disorders of consciousness: Authoritarianism and trustworthiness in medicine
Mohamed Y Rady and Joseph L Verheijde
The Royal College of Physicians of London published the 2013 national clinical guidelines on prolonged disorders of consciousness (PDOC) in vegetative and minimally conscious states. The guidelines acknowledge the rapidly advancing neuroscientific research and evolving therapeutic modalities in PDOC. However, the guidelines state that end-of-life decisions should be made for patients who do not improve with neurorehabilitation within a finite period, and they recommend withdrawal of clinically assisted nutrition and hydration (CANH). This withdrawal is deemed necessary because patients in PDOC can survive for years with continuation of CANH, even when a ceiling on medical care has been imposed, ie, withholding new treatment such as cardiopulmonary resuscitation for acute life-threatening illness. The end-of-life care pathway is centered on a staged escalation of medications, including sedatives, opioids, barbiturates, and general anesthesia, concurrent with withdrawal of CANH. Agitation and distress may last from several days to weeks because of the slow dying process from starvation and dehydration. The potential problems of this end-of-life care pathway are similar to those of the Liverpool Care Pathway. After an independent review in 2013, the Department of Health discontinued the Liverpool Care pathway in England. The guidelines assert that clinicians, supported by court decisions, have become the final authority in nonconsensual withdrawal of CANH on the basis of “best interests” rationale. The authors posit that these guidelines lack high-quality evidence supporting: 1) treatment futility of CANH, 2) reliability of distress assessment from starvation and dehydration, 3) efficacy of pharmacologic control of this distress, and 4) proximate causation of death. Finally, the authors express concerns about the utilitarian-based assessment of what constitutes a person’s best interests. The authors express their dismay at the level and the role of medical authoritarianism institutionalized by these national guidelines when deciding on the worthiness of life in PDOC. The authors conclude that these guidelines are not only harmful to patients and families, but they represent the means of nonconsensual euthanasia. The latter would constitute a gross violation of the public’s trust in the integrity of the medical profession.
Spanning our differences: moral psychology, physician beliefs, and the practice of medicine
Ryan M Antiel, Katherine M Humeniuk and Jon C Tilburt
Moral pluralism is the norm in contemporary society. Even the best philosophical arguments rarely persuade moral opponents who differ at a foundational level. This has been vividly illustrated in contemporary debates in bioethics surrounding contentious issues such as abortion and euthanasia. It is readily apparent that bioethics discourse lacks an empirical explanation for the broad differences about various topics in bioethics and health policy. In recent years, social and cognitive psychology has generated novel approaches for defining basic differences in moral intuitions generally. The authors propose that if empirical research using social intuitionist theory explains why people disagree with one another over moral issues, then the results of such research might help people debate their moral differences in a more constructive and civil manner. The authors illustrate the utility of social intuitionism with data from a national physician survey.
Ebola, epidemics, and ethics – what we have learned
G Kevin Donovan
The current Ebola epidemic has presented challenges both medical and ethical. Although we have known epidemics of untreatable diseases in the past, this particular one may be unique in the intensity and rapidity of its spread, as well as ethical challenges that it has created, exacerbated by its geographic location. The authors look at the infectious agent and the epidemic it is causing, in order to understand the ethical problems that have arisen.
Long-term ill health and the social embeddedness of work: a study in a post-industrial, multi-ethnic locality in the UK
Kaveri Qureshi, Sarah Salway, Punita Chowbey and Lucinda Platt
Against the background of an increasingly individualizing welfare-to-work regime, sociological studies of incapacity and health-related worklessness have called for an appreciation of the role of history and context in patterning individual experience. This article responds to that call by exploring the work experiences of long-term sick people in East London, a post-industrial, multi-ethnic locality. It demonstrates how the individual experiences of long-term sickness and work are embedded in social relations of class, generation, ethnicity and gender, which shape people’s formal and informal routes to work protection, work-seeking practices and responses to worklessness. We argue that this social embeddedness requires greater attention in welfare-to-work policy.
Increasing longevity and prevalence of long-term conditions contribute to older adults being the greatest users of health services. However, relatively little is known about the health and illness beliefs of the oldest old or how they decide to seek help in response to symptoms. Through analysis of in-depth interviews with day center attendees aged 80–93, we find that a moral, hierarchical approach to health problems and help-seeking exists; similar to Cornwell’s (1984) findings among 50–60 year-olds of a similar social group 30 years ago. However, when acting independently, those in their eighties and nineties report modifying their health and illness beliefs and behavior, in response to their own perceived old age. Some health problems are ‘demedicalized’, being increasingly attributed to age and by being self-managed. Others are perceived as potentially more serious, leading to increased consultation with medical services. When obliged to act outside their moral belief–behavior framework by others, the participants expressed feelings of disempowerment, yet resisted modifying their moral beliefs. This may represent resistance to adopt the ‘sick role’, while seeking to maintain control over uncertain health as functional dependence and frailty increases. This study furthers theoretical understanding of the health and illness beliefs and behavior of the oldest old, with important practical implications.
Inquiries in the UK into mistreatment of older people by healthcare employees over the last 30 years have focused on introducing or supporting employee whistle-blowing. Although whistle-blowers have made an important contribution to patient safety it remains a controversial activity. The fate of whistle-blowers is bleak, often resulting in personal and professional sacrifices. Here we draw on the views of healthcare and social care employees working with older people to explore perceptions of whistle-blowing as well as alternative strategies that may be used to raise concerns about the mistreatment of patients by co-workers. Whistle-blowing was perceived as a negative term. Managers said they promoted open cultures underpinned by regular team meetings and an open-door ethos. Others described workplace norms that were somewhat at odds with these open culture ideals. Whistle-blowing was considered risky, and this led to staff creating informal channels through which to raise concerns. Those who witnessed wrongdoing were aware that support was available from external agencies but preferred local solutions and drew upon personal ethics rather than regulatory edicts to shape their responses. We argue that the importance of workplace relationships and informal channels for raising concerns should be better understood to help prevent the mistreatment of vulnerable groups.
This article discusses men’s transition to first time fatherhood, with a focus on the way they recognise various in-tension moral demands and negotiate an appropriate role for themselves. The findings are taken from a longitudinal study, drawing on elements of grounded theory, comprising a series of face-to-face and telephone interviews with 11 men over a 9-month period from the 12th week of pregnancy to 8 weeks after the birth. The analysis focuses on men’s feelings and experience of exclusion and participation, and their response and reaction to that experience. The findings present two descriptive themes, ‘on the inside looking in’ and ‘present but not participating’, followed by third theme ‘deference and support: a moral response’ that exposes the dilemmatic nature of men’s experience and explains the participants’ apparent acceptance of being less involved. The discussion explores the concept of moral residue, arguing that while deference and support may be an appropriate role for fathers in the perinatal period it may also be a compromise that leads to feelings of uncertainty and frustration, which is a consequence of being in a genuinely dilemmatic situation.
For young adults with inflammatory bowel disease (IBD), perceived stigma has been found to be a salient concern. Drawing on interviews with individuals with IBD aged 18–29 (n = 16), this article uses rhetorical discourse analysis to explore how stigma is discursively constructed by young adults, with a focus on the moral underpinnings of the participants’ talk. Their representations showed both felt stigma and enacted stigma; principally related to the perceived taboo surrounding the symptoms of their condition, which often led to the non-disclosure or concealment of the condition. The different ways in which stigma is manifested in the accounts present a challenge to recent arguments questioning the relevance of this concept in chronic illness research, though it was found that it is not adequate to look at stigma alone and, given the unstable nature of IBD, negotiating stigma in relation to possible charges of deviance is a pertinent issue for these young adults. For instance, non-disclosure because of shame could result in individuals experiencing blame. Accounts were constructed through a range of discursive strategies, allowing the participants to present themselves in morally appropriate ways throughout. Suggestions are made about future directions in addressing stigma and deviance in relation to this cohort.
African American women’s preventative care usage: the role of social support and racial experiences and attitudes
Erin Pullen, Brea Perry and Carrie Oser
Research suggests that African Americans are less likely to utilize preventative care services than Americans of European descent, and that these patterns may contribute to racial health disparities in the United States. Despite the persistence of inequalities in preventative care utilization, culturally relevant factors influencing the use of these gateway health services have been understudied among marginalized groups. Using a stratified sample of 205 low-income African American women, this research examines the predictors of receiving a physical exam, with a particular emphasis on how differing levels of social support from friend and family networks and experiences of racial discrimination and cultural mistrust shape utilization. The findings underscore the importance of traditional predictors of utilization, including insurance status and having a usual physician. However, they also indicate that supportive ties to friendship networks are associated with higher predicted rates of having an annual physical exam, while social support from family and sentiments of cultural mistrust are associated with lower rates of utilization. Broadly, the findings indicate that even as traditional predictors of help-seeking become less relevant, it will be critical to explore how variations in discrimination experiences and social relationships across marginalized groups drive patterns of preventative care utilization.
Habitus of home and traditional drinking: a qualitative analysis of reported middle-class alcohol use
Lyn Brierley-Jones, Jonathan Ling, Karen E McCabe, Graeme B Wilson, Ann Crosland, Eileen FS Kaner, and Catherine A Haighton
There is evidence that alcohol consumption among those in middle-class occupations consistently exceeds safe levels, yet there has been little research into why this occurs. This article explores the meanings associated with alcohol use among professional, managerial and clerical workers. Qualitative data were collected from five focus groups of male and female employees aged 21–55 (N =49: 32 male, 17 female). Each focus group was conducted on the premises of a medium-scale or large-scale employer, four public sector and one private sector, in the north-east of England. Using Bourdieu’s concepts of ‘habitus’, ‘capitals’ and ‘fields’ we found that, among these middle-class occupational groups, alcohol use was associated with two habitus: a ‘home drinking’ habitus and a ‘traditional drinking’ habitus. Those of the home drinking habitus particularly used wine as a source of cultural capital and a means of distinction, whereas those in the traditional habitus consumed lager, beer and spirits to have fun in social settings. A small minority appeared to belong to a third, omnivorous, habitus where a wide range of alcoholic drinks were consumed in a variety of contexts. Existing public health initiatives to reduce alcohol consumption may require modification to accommodate a range of drinking cultures.
Mental health trajectories and their embeddedness in work and family circumstances: a latent state-trait approach to life-course trajectories
Stéphane Cullati, Delphine S. Courvoisier, and Claudine Burton-Jeangros
In this article we adopt a Bourdieu-based approach to study social inequalities in perceptions of mental and physical health. Most research takes into account the impact of economic or social capital on health inequalities. Bourdieu, however, distinguishes between three forms of capital that can determine peoples’ social position: economic, social and cultural capital. Health research examining the effects of cultural capital is scarce. By simultaneously considering and modelling indicators of each of Bourdieu’s forms of capital, we further the understanding of the dynamics of health inequalities. Using data from a large-scale representative survey (N = 1825) in Flanders, Belgium, we find that each of the forms of capital has a net effect on perceptions of physical and mental health, which persists after controlling for the other forms of capital and for the effects of other correlates of perceived health. The only exception is that the cultural capital indicators are not related to mental health. These results confirm the value of a Bourdieu-based approach and indicate the need to consider economic, social and cultural capital to obtain a better understanding of social inequality in health.
The importance of economic, social and cultural capital in understanding health inequalities: using a Bourdieu-based approach in research on physical and mental health perceptions
Wouter Pinxten and John Lievens
In this article we adopt a Bourdieu-based approach to study social inequalities in perceptions of mental and physical health. Most research takes into account the impact of economic or social capital on health inequalities. Bourdieu, however, distinguishes between three forms of capital that can determine peoples’ social position: economic, social and cultural capital. Health research examining the effects of cultural capital is scarce. By simultaneously considering and modelling indicators of each of Bourdieu’s forms of capital, we further the understanding of the dynamics of health inequalities. Using data from a large-scale representative survey (N = 1825) in Flanders, Belgium, we find that each of the forms of capital has a net effect on perceptions of physical and mental health, which persists after controlling for the other forms of capital and for the effects of other correlates of perceived health. The only exception is that the cultural capital indicators are not related to mental health. These results confirm the value of a Bourdieu-based approach and indicate the need to consider economic, social and cultural capital to obtain a better understanding of social inequality in health.
Challenging the field: Bourdieu and men’s health
Mark Robinson and Steve Robertson
This article considers how understandings of health promotion with men may be assisted by engagement with Bourdieu’s theoretical work. The article outlines leading concepts within Bourdieu’s work on ‘field’, ‘habitus’ and ‘capital’; considers subsequent critical debates among gender, feminist and sociological theorists around structure and agency; and links these to discussions within men’s health. A particular focus concerns structural disruption of, and movement of social actors between, ‘fields’ such as family, work and leisure settings. The article examines, through Bourdieu’s critical legacy, whether such disruption establishes conditions for transformative reflexivity among men in relation to previously held dispositions (habitus), including those inflected by masculinities, that affect men’s health practices. Recent work within Bourdieu’s heritage potentially facilitates a re-framing of understandings of men’s health practices. The article specifically explores masculine ambivalence within accounts of reflexivity, identities and practice, and considers how social and symbolic (masculine) capital are in play. Implications of Bourdieu’s leading concepts for theorizing settings-focused approaches to men’s health promotion are exemplified with reference to a men’s health project in a football stadium leisure setting. The article considers the benefits and challenges of applying gendered critical insights drawing on Bourdieu’s work to men’s health promotion, and discusses emerging theoretical dilemmas.
The debate about psychiatric nosology was reignited last year when the fifth edition of the Diagnostic and Statistical Manual (DSM) was published to widespread criticism. Critics cite a number of problems with ‘psychiatric diagnosis’, though it is sometimes unclear which classificatory practices are included under this broad heading. Although it may be possible to avoid the problems inherent in the DSM system, other difficulties associated with classification (labelling, stigma) may prove harder to escape. The first part of this article argues that some form of psychiatric classification is made inevitable by the communicative, epistemic and ethical pressures on psychiatry. In the second half it is suggested that there are ways to think differently about our relationship to psychiatric classification, and that these could play a role in mitigating the harms outlined by diagnosis’ critics.
Food industry and public health representatives are often in conflict, particularly over food labelling policies and regulation. Food corporations are suspicious of regulated labels and perceive them as a threat to free market enterprise, opting instead for voluntary labels. Public health and consumer groups, in contrast, argue that regulated and easy-to-read labels are essential for consumers to exercise autonomy and make healthy choices in the face of food industry marketing. Although public health and food industry have distinct interests and objectives, I argue that both contribute to the creation of the food label as a governmental strategy that depends on free-market logics to secure individual and population health. While criticism of ‘Big Food’ has become a growth industry in academic publishing and research, wider critique is needed that also includes the activities of public health. Such a critique needs to address the normalizing effect of neoliberal governmentality within which both the food industry and public health operate to reinforce individuals as ‘healthy consumers’. Drawing on Michel Foucault’s lectures at the Collège de France, I examine the food label through the lens of governmentality. I argue that the rationale operating through the food label combines nutrition science and free-market logics to normalize subjects as responsible for their own health and reinforces the idea of consumption as a means to secure population health from diet-related chronic diseases.
Relocation, realignment and standardisation: Circuits of translation in Huntington’s disease
Jamie Lewis, Jacki Hughes and Paul Atkinson
Based on complementary ethnographies of a biomedical laboratory and a clinic – both working on Huntington Disease (HD) – we discuss the circuits of translation evident in biomedical and clinical research. By examining a recent epistemological shift from understanding the disease as genetic to understanding the disease as a problem for neuroscience, as well as documenting the multiple framings of the disease that migrate between the laboratory and the clinic, we emphasize the complexity involved in the movement of biomedical science into clinical work. We stress that this is not a one-way flow from the colloquially known bench to bedside, but is dependent on a cluster of contextual activities and local actors. We also stress the extent to which global collaborations, standardization and regulatory frameworks can facilitate such framing and migration by aligning local practices and different disciplinary outlooks. We take a sociological perspective on translational processes – or rather to an expanded understanding of translation – to capture the material flows and conceptual transformations that are involved in the complex relationships between fundamental and clinical research.
Recently, A. David Napier and colleagues published their executive summary from The Lancet Commission on Culture and Health (The Lancet, Volume 384, Issue 9954, pp. 1607-1639, 1 November 2014). They write:
“This Commission is the first ever detailed appraisal of the role of culture in health, bringing together voices from different fields, including anthropologists, social scientists, and medics. Experts review health practices as they relate to culture, identify and assess pressing issues, and recommend lines of research that are needed to address pressing issues and emerging needs. The Commission examines three overlapping domains of culture and health: cultural competence, health inequalities, and communities of care. With reference to these domains, the Commission shows how inseparable health is from cultural perceptions of wellbeing.”
In the short time since the release of the report, four related initiatives have emerged from the publication. The first is an endorsement from the WHO, which the commission intends to take up strategically in January 2015. The second is an initiative to sponsor an NHS event to present and discuss the Commission’s 12 key findings and related recommendations. Third is to build a platform for the production of outputs such as white papers on each of their 12 findings. And fourth, to launch the first European Forum on Culture and Health in Ascona, Switzerland at the end of November––there, they will design a European strategy to guarantee sustained attention to the needs identifies in the report.Culture and Health Commission Members: A David Napier, Clyde Ancarno, Beverley Butler, Joseph Calabrese, Angel Chater, Helen Chatterjee, François Guesnet, Robert Horne, Stephen Jacyna, Sushrut Jadhav, Alison Macdonald, Ulrike Neuendorf, Aaron Parkhurst, Rodney Reynolds, Graham Scambler, Sonu Shamdasani, Sonia Zafer Smith, Jakob Stougaard-Nielsen, Linda Thomson, Nick Tyler, Anna-Maria Volkmann, Trinley Walker, Jessica Watson, Amanda C de C Williams, Chris Willott, James Wilson, Katherine Woolf You can download the full report here:
Image credit: Heather Lewis, Pay-per-view, 2011 (no coin), (McColl Center for Visual Arts) Mirrors, coin meter, light
by Élisabeth de Fontenay (trans. William Bishop)
University of Minnesota Press, 2012, 168 pages.
In the opening paragraph of Without Offending Humans, Élisabeth de Fontenay describes the first time she saw her mentor Jacques Derrida speak at the Collège de philosophie:
I reacted, all things being relative, as Malebranche did upon reading Descartes’s Treatise on Man: “His beating heart sometimes forced him to stop his reading,”…. From that moment on, I did not take leave of this work nor of this man, even if it would often cause me distress to place myself in certain of his footsteps. (1)
Besides its recursivity, which hints at the almost pathological dependence on citation that is to follow, such a reverent opening primes the reader to question whether a work so firmly situated in Derrida’s project can deliver an argument original enough to warrant its book-length runtime. The author does nothing to defuse this growing fear when, some pages later, she introduces her key intervention in the book’s first chapter as certainly the only point where she feels she is in disagreement with Derrida, adding that “it is not without a certain amount of anxiety that I wish to formulate these reservations, now that he does not have the time to explain himself further” (14).
As it turns out, de Fontenay’s cautious critique is an important one. In his writings on animals, Derrida observes that with few exceptions philosophers from Aristotle onward have built their conceptions of “the human” on an unexamined set of foundational assumptions that reduce nonhuman life to a single homogeneous category, “the animal.” Between the category of the human and the category of the animal—or l’animot, as Derrida playfully dubs the latter category—philosophers have presumed the existence of an abyssal rupture that serves to assure humans of their own uniqueness. In an interview with Jean-Luc Nancy in 1991, Derrida refers to this kind of thinking as a “sacrificial structure” that links the human domination of nature with the acceptance (and meaningfulness) of animal sacrifice. De Fontenay points out that for Derrida’s argument to work, he must treat all the diverse cultural and historical instantiations of sacrifice as tokens of a single transhistorical type, whereas anthropologists have shown us many different kinds of sacrificial functions that cannot be reduced to a single catchall category.
Unfortunately, this intervention into Derrida’s thinking does not lead to anything like a sustained thesis for de Fontenay. Lacking a coherent framework on which to hang on its many observations, Without Offending Humans instead reads like a series of riffs on a set of topics related to the animal question in philosophy. This is a familiar danger for academic volumes based on independent essays, but the problem is amplified here by the fragile internal coherence of each entry. Derrida’s inimitable style makes for some notoriously impenetrable prose, but there is a sense in his essays that even the throwaway moments will reward a careful reading. Not so with Fontenay, who writes with a complexity that seems only to distract. Most intrusive is her unrelenting use of quotation and paraphrase, a ventriloquism that at its worst—and I can think of no other way to say this—amounts to vapid name-dropping. For instance:
We know that after having displayed a strong interest in physiognomic research, Goethe distanced himself from Lavater, and that Diderot, at first tempted no doubt by the monism underlying the enterprise, ended up refusing to participate in the translation of texts by the illustrious Swiss pastor, and that Hegel was ferociously critical of him in the Phenomenology of Spirit…(79).
Such passages are characteristic—this one is taken from a paragraph that also mentions Lichtenberg and footnotes Proust—and after a while the effect is dizzying.
Among the most frustrating ambiguities of Without Offending Humans is whether de Fontenay herself wishes to give said offense or avoid it. I suspect that part of the allure of the book’s title, at least to some, is its apparent suggestion that the cause animale has not gone far enough. Has the animal rights movement held in reserve some fundamental anthropocentrism, some respect for humans and human sensitivities that limits the scope of its possible achievement? At least one previous reviewer concludes that the title in fact has the opposite (and much plainer) intent, signaling de Fontenay’s desire to critique animal rights without disturbing the species boundary.
Perhaps, however, there is a puckish element in de Fontenay’s choice of title after all. Someone like Peter Singer, whom de Fontenay takes to task for his ahistorical assertion of the natural rights of animal and man, courts mainstream backlash as a rhetorical strategy. But Singer does so recklessly, and for this his provocations often find the wrong target. Eva Kittay, a philosopher and the mother of a severely mentally disabled child, bristles at Singer’s assertion that if chimpanzees are not deserving of rights, then reason dictates that neither are severely disabled humans (Singer’s intent, clearly, is to argue for the rights of chimpanzees and not against the rights of disabled children, but for Kittay that is beside the point). De Fontenay’s criticism seeks out narrower and safer targets, but it would be unfair to call her efforts inoffensive or trite. Her denunciation of “banal, quotidian, and legal” forms of cruelty indicts anyone who has eaten factory-farmed meat or shopped at a pet store. The mass slaughters that followed from the “mad cow crisis,” traceable to the decision to feed meat and bone meal to herbivores, works, according to de Fontenay, “as a way of not having to point at the madmen that we have become” (129).
There is more than enough here to inspire and to provoke thought, especially for fans of deconstruction and perhaps also for fans of the Posthumanities series edited by Carey Wolfe, of which this book is a part. The book’s memorable moments are mostly disparate, however, and that lack of coherence is likely to limit the endurance of its appeal. Heavy use of citation, coupled with the absence of an organizing theme, makes the entire work feel like a kind of annotated bibliography, and perhaps that is how this book is best appreciated.
Les Beldo is an anthropologist and a postdoctoral lecturer in Comparative Human Development at the University of Chicago. He received his PhD from the University of Chicago in August 2014. His research interests include animal studies, environmental anthropology, and the anthropology of morality.
Derrida, Jacques. 1991. “‘Eating Well,’ or the Calculation of the Subject: An Interview with Jacques Derrida.” In Who Comes after the Subject?, edited by Eduardo Cadava, Peter Connor, and Jean-Luc Nancy, 97–119. New York and London: Routledge.